On October 1, 1996, I was one of three speakers who appeared before fourteen Minnesotans selected to participate in a "citizen forum" on healthcare reform sponsored by the Minneapolis Star Tribune and KTCA-TV, Minnesota's public television station. I made the case for a "single payer" healthcare system; the director of what was then called the HMO Council of Minnesota made the case for "managed competition"; and a third speaker made the case for "medical savings accounts" (MSAs). A single-payer system is one in which one payer (the government) reimburses doctors and hospitals. Managed competition is a theory that assumes that competition among HMOs can reduce healthcare costs without damaging quality of care. MSAs are traditional insurance policies with huge deductibles (typically $2,000 per person). After three and a half hours of discussion, eight of the fourteen citizens voted for single-payer, three voted for managed competition, one voted for a hybrid of single-payer and managed competition, and two abstained.

This vote strongly suggests that a sizable majority of Americans would support a single-payer solution to the healthcare crisis if they were ever exposed to a real debate about it. Other data support this conclusion. For example, a 1991 Harris poll found that 68 percent of Americans preferred Canada's single-payer healthcare system, compared with only 29 percent who favored the US system; a 1999 survey of professors and students at US medical colleges, reported in the New England Journal of Medicine, found 57 percent of students and faculty members of America's medical schools "thought that a single-payer system…was the best health care system," while only 22 percent were willing to say the same about managed care. But despite the public's preference for a single-payer system, and despite solid empirical evidence that single-payer would provide higher-quality care for less money than an HMO-dominated system, managed competition was elevated to de facto US health policy during the early 1990s, while single-payer proposals were kept off the public agenda by big business and its allies in Congress.

In California, the single-payer movement forced a debate–a very lopsided debate, as it turned out–about the single-payer proposal by collecting a million-plus signatures to put the proposal on the November 1994 California ballot. From July until Election Day, the anti-single-payer forces, led by the insurance industry, bought $11 million worth of radio and TV advertisements and financed a direct-mail campaign. Our "good neighbor," State Farm, spent close to a million dollars in October 1994 alone on letters personally signed by State Farm agents urging their customers to vote against the single-payer initiative.

The defeat of the single-payer proposal is one of three examples of corporate agenda-setting told by Barry Casper in an absorbing book titled Lost in Washington. Casper, a professor of physics at Carleton College during the years he wrote this book and, for the first eight months of 1991, Senator Paul Wellstone's policy adviser, also describes two other battles between public interest groups and wealthy special interests–the effort to defeat the National Energy Security Act, a bill promoted by the auto industry and the nuclear and fossil-fuel industries, and the battle for campaign finance reform.

Just as polls indicated a majority of Americans would support a single-payer program, so polls indicated majorities of Americans endorsed the positions the public interest groups took in the energy and campaign finance reform debates. Casper cites, for example, a 1991 poll showing that 86 percent of Americans supported increasing the average fuel efficiency of the nation's automobiles from 27.5 miles per gallon to 40 by the year 2000, a policy opposed by the auto industry and a substantial portion of Congress, including, notably, Senator Bennett Johnston, Democrat of Louisiana, then chairman of the Senate Energy and Natural Resources Committee. "We now have a political system in which a public policy proposal can have enormous popular support and the potential to garner an electoral majority," Casper concludes, "but it may not even get a fair hearing, much less a vote, in the Congress or anything approaching adequate coverage in the media."

Because Casper was a participant in the health, energy and campaign finance reform fights, his recounting of these battles is full of details, many of which have appeared nowhere else. The rich detail of these histories helps the reader to comprehend the myriad ways that big money sabotages democracy. These histories also prepare the reader to understand and evaluate Casper's proposals for reviving democracy. Many books have been written about the causes of and solutions to the corruption of democracy. But Lost in Washington, with the exception of William Greider's extraordinary Who Will Tell the People?, is the only book I know of that combines a detailed analysis of multiple public-versus-special-interest battles with a wide-ranging review of the solutions to the corruption.

As most readers of The Nation know, the corruption that afflicts American democracy is not the old-fashioned kind–the kind that occurs when politicians agree to cast aye or nay votes on particular bills in exchange for cash delivered in suitcases by shady characters wearing sunglasses. If big money were literally a disease, it would more closely resemble cancer than a knife wound–it attacks the body politic slowly, it weakens not just one but numerous systems (elections, committee hearings, the media, etc.) and, because the disease works slowly on many fronts, it is difficult to diagnose and explain thoroughly to the public. The histories of the health, energy and campaign finance reform fights told in Lost in Washington illustrate in disgusting detail how the money cancer has metastasized throughout America's democracy.

We learn, for example, the variety of tactics that Senator Johnston (recipient of gobs of cash from the energy industry) employed to make it very difficult for Senator Wellstone and other members of the Senate energy committee who opposed the National Energy Security Act (S. 341) to prepare for hearings on the bill. These tactics included giving opponents little time to study the bill and short notice on when hearings would be held and what the agendas of these hearings would be. Because the bill dealt with so many topics, Casper (Wellstone's chief adviser on this bill) needed five days in seclusion in order to comprehend the entire bill. But senators and their staffs are busy, and those five days did not become available to Casper until the Senate took a short recess early in spring 1991. But by then, Senator Johnston had held seventeen hearings on S. 341. The environmental groups with which Wellstone and Casper were allied were similarly disadvantaged.

We learn, to take another example, that Pacific Gas and Electric, a California utility with much at stake in the debate over S. 341 (and in the headlines these days because of California's blackouts) wined and dined Casper and eighteen other Congressional staff members at expensive hotels and restaurants in California over a four-day period in March 1991. During those four days, PG&E lobbyists and top officers, including its CEO, had access to the legislative staff that public interest groups can only dream about. The Sierra Club, Public Citizen and other groups that opposed S. 341 did not sponsor similar junkets.

How do we excise the money cancer from our democracy? The last three chapters of Lost in Washington sketch an answer to this question. Casper endorses a half-dozen reforms, including full public financing of elections, the "none of the above" option on election ballots, proportional-representation elections (instead of the current winner-take-all system), free or low-cost access to the media and third-party participation in debates. He devotes considerable attention to what he calls a National Citizens Agenda-Setting Initiative under which citizens could, if they were sufficiently organized, force Congress to hold hearings on proposals despised by big business and the Congressional pooh-bahs who set the legislative agenda.

Note how this proposal differs from the initiative process we know today. The initiative Casper is proposing would not establish a law but would, rather, force a vote in Congress on a proposed law. Casper, who was intimately involved in the unsuccessful 1994 citizens' campaign to pass a single-payer system in California by initiative, is well aware of the difficulties citizens' groups encounter in the traditional initiative process. The health insurance industry and other opponents of the single-payer initiative vastly outspent the advocates of the initiative, which lost 73 percent to 27 percent.

"The basic concept [of the National Citizens Initiative] is a simple one," Casper explains: "If a designated percentage (say, 3 percent) of registered voters in a designated fraction (say, one-third) of Congressional districts signed a petition saying they wanted a certain proposal considered and voted on, Congress would have to hold full and fair hearings and both houses would have to vote on it."

In order to assist citizens' groups in participating in this new process, Casper proposes that all citizens be given $50 vouchers annually that they could contribute to any initiative they choose. (Casper credits Greider for this idea. In Who Will Tell The People? Greider proposed an annual tax credit worth $100-$200 to each citizen that could be used for a wide variety of political purposes, not just initiatives.)

As someone who has spent the past twenty-five years organizing for underfunded citizens' groups, I am attracted to both parts of Casper's proposal–a national mechanism for forcing Congress to vote on issues of public interest and the proposed voucher. One can immediately think of a dozen reasons why the national initiative and voucher proposals might not work well. These reasons all boil down either to the maldistribution of money–big business simply has more of it than citizens groups do–or to the ineluctable fact that a small but substantial number of human beings are bigots or worse. We may ask, for example, whether the seed money needed to organize enough citizens in enough Congressional districts to contribute their signature and $50 to an initiative campaign will be more available to "astroturf" groups (fronts for big business) than to truly grassroots citizens' groups. Once an initiative forces hearings and a vote in Congress, what will prevent big business from buying the votes (indirectly, of course) needed to secure the outcome it wants? Won't bigots of all stripes get more access to Congress?

But similar objections can be made to virtually every other proposal for reviving democracy currently under discussion by small-d democrats. Forcing the media to give all candidates free exposure, for example, helps bigots and fools at the same time that it helps ordinary people with good hearts and functioning brains. One could argue that efforts to pass clean-election laws of the sort enacted in Maine, Vermont, Arizona and Massachusetts will soon be thwarted by big-business groups as they figure out that controlling candidates elected with the help of public money is a lot harder than controlling candidates who took big-business bucks to get elected.

There is no perfect or obviously best solution to the big-money cancer. I share Casper's belief that the solution to our anemic democracy is more democracy, not less, and that an effective solution will be one that embraces multiple proposals, including clean-election laws and Casper's national agenda-setting initiative proposal.