Hankies were optional when the news hit that Blue Cross Blue Shield of North Carolina lost money again in 2015 because of Obamacare. CEO Brad Wilson told The News & Observer that BCBSNC may stop selling policies under the Affordable Care Act if losses continue, as Wilson predicted they will despite an average 32.5 percent hike in the company’s ACA rates.

Well, I certainly hope this doesn’t put a dent in Wilson’s compensation, already reduced to a mere $2.8 million for 2014.

There is a problem, however, beyond whether the BCBSNC brass can keep up their mortgage payments. In many parts of North Carolina, people looking for coverage under the ACA have exactly one choice of insurer: BCBSNC.

Are we missing the public option yet?

Which brings me to the debate between Hillary Clinton and Bernie Sanders over whether a single-payer system of the kind Sanders supportshe calls it Medicare for allis realistic.

Clinton says it isn’t. Not now. Not ever. “It’s an idea that will never, ever happen,” she said in a recent debate. I hope she’s wrong.

But what really confounded me was what Clinton said about why single-payer is impossible. “Even during the Affordable Care Act debate,” she said, “there was an opportunity to vote for what was called the public option. … And even when the Democrats were in charge of Congress, we couldn’t get the votes for that.”

I don’t think “we” really tried.

The public option was the idea that, if we wanted private insurers like BCBSNC to get serious about holding down costs, we should confront them with a government-run competitor, a “public” insurer that could offer lower rates for comparable coverage.

A variety of public-option plans were offered during the 2008 presidential campaign. Some called for a public insurer in each state. Others wanted a national insurerperhaps by expanding Medicare, which has a track record of holding down rates by limiting payments to hospitals, drug companies, and doctors. Medicare doesn’t take anything off the top for profits, either.

The three leading Democratic candidatesBarack Obama, Hillary Clinton, and John Edwardsall espoused a version of the public option. Then Obama was elected, and he didn’t get it done.

I wrote about it a lot back then. The bottom line was that Obama thought he could get some Republican votes for the ACA if he dropped the public option (he got zero GOP votes), and at least three of the sixty Senate Democrats Obama needed to push the ACA past a Republican filibuster were against it.

We’ll never know whether a determined Obama could’ve persuaded the likes of Joe Lieberman and Max Baucus to get behind the public option.

We do know, from reporting by The New York Times and the Huffington Post, that Obama cut a deal with Big Pharma and the for-profit hospital chains to jettison the idea long before the Senate voted.

Obama also rejected the idea of folding the ACA into the 2009–10 budget reconciliation process, which would’ve allowed it to passwith the public option, if the president wanted itby a simple majority in the Senate.

The upshot is that we have the ACA, and more Americans than ever have health-insurance coverageabout 88 percent, according to the Congressional Budget Officealbeit at an enormous cost.

Many with ACA coverage, even if they’re among the eight in ten whose premiums are subsidized, can’t afford to use it because the deductibles and copays typically run $3,000 or more per person per year. Meanwhile, U.S. spending on health care exceeded $3 trillion in 2014, the first year of the ACA, an increase over the prior year of 5.3 percent. That’s $9,253 per person.

That’s also 50 percent more than the next most expensive countryFranceand twice what the British spend.

Draw your own conclusion about the wisdom of Obama’s tactical decisions. What’s not in question is that the extended battle over the ACA, which dragged into 2010, led to Democrats losing their majorities in Congress in the 2010 elections. Republican obstructionism has dominated since.

So the question is, where now for health care reform?

One way to build on the ACA would be to renew the fight for the public option, taking the issue to the voters once again.

Another would be to allow people over fifty-five to buy into Medicare, and then over forty-five, and then thirty-five, until it does indeed become Medicare for all. Believe me, as a newly eligible Medicare recipientI’m sixty-fivenobody with a choice is going to pick BCBSNC over Medicare.

But under Obamacare, no one under sixty-five has that choice.

I wish Bernie would spell out how we get from Obamacare to single-payer, either with the public option or Medicare buy-ins. I imagine he doesn’t for fear that Hillary would label him disrespectful for questioning Obama’s handiwork, costing him critical support with black Democrats.

But what’s more disrespectful than leaving the ACA the way it is, half-finished?

And what’s sadder than believing, as Clinton apparently does, that the only way to achieve 100 percent coverage is under the thumb of insurance companies like Blue Cross Blue Shield of North Carolina?

This article appeared in print with the headline “Bowing to Blue Cross”