It seems a grim possibility that Congress will pass some kind of tear-down of the Affordable Care Act. The resistance, the visceral anger that this is provoking across the country is evidence that the ACA, for all its omissions, did something right — in subsidizing premiums, providing access to care and spreading risk. But, health care continues to be too expensive, and the system is “janky”, confusing and awkward.
The combination of dissatisfaction at the ACA — and pushback at GOP mischief — is giving progressives hope that single-payer might truly be on the table in the next administration.
Personally, I’d be delighted if that came to pass. Single-payer works, where it’s been implemented: It’s just and fair; it’s relatively efficient; it’s really universal, cradle-to-grave.
As much as I am convinced of its substantive merits, I remain a respectful skeptic of the political prospects. (By “skeptical” I mean just that: I’m not saying, It’ll never happen. I’m saying, Show me.)
So as someone who supports single-payer, but who fears there simply aren’t enough people like me, I have some advice for advocates. You didn’t ask. But here it is:
First: Those who do not learn history are doomed to repeat it. May I suggest Paul Starr’s 400+ page volume “The Social Transformation of American Medicine” for a … sobering historical perspective? People have been pushing for universal health care in the US for over 100 years now.
- Teddy Roosevelt supported government insurance as a “Bull Moose”, and his loss led to it being shelved for 20 years.
- FDR’s administration considered it and it caused (stop me if you’ve heard this one) an uproar from the AMA.
- Truman attempted it, with a similar result: The AMA opposed it bitterly, and Dems got absolutely walloped by the GOP in the next election. But LBJ referred to Truman as the “Father of Medicare” when he signed it into law.
- Nixon proposed a national health program that resembled the ACA, except it was more generous. Ted Kennedy opposed it, proposing single-payer instead. Both plans failed, to Kennedy’s enduring regret that he had failed to take Nixon up on his offer.
- The Clintons proposed a national health care system. Hillary probably botched the politics. The insurers hated it. The AMA hated it. A fictional couple named Harry and Louise hated it, and well, so goes America, huh? And the Dems got horribly, structurally obliterated in 1994.
- … and then there’s the ACA. Simultaneously too-bold and not-bold-enough, and — please, let’s not discount this — crippled by cynical, bad-faith, spiteful opposition from Republicans, in the courts and at the state level.
The long history of struggle is not a reason to give up pursuing single-payer. Maybe this time is different! Advocates point to intriguing poll evidence that it is, and post-ACA (one way or the other) perhaps we’ve moved the Overton Window sufficiently. You’ll never know if you don’t try.
This leads to #2: It’s not Festivus, so ease up on the recrimination. Don’t assign nefarious “corporate” motives to Democrats, advocates, and people on the left or center who are skeptical of the political prospects. Some Dems are corporate-friendly, more tepid; but skepticism on the political prospects is not ipso facto a sign of betrayal. There are those who have been in the advocacy and wonk trenches, who have been through the Ted Kennedy/Nixon, HillaryCare, S-CHIP, Medicare Part D, and ObamaCare wars; who have taken the bullets; who have done the work and suffered the consequences; who knew that The Wages of Goodness are Not Assured … by their long experience they have been given reason to be skeptical that there is political will to accomplish single-payer. Show Sisyphus some respect please, before you tell him he’s been pushing that boulder all wrong.
Just being right on the merits counts for very little. You need power, and that means coalition-building. There are ways to make the push in a constructive, positive way; or one can assert one’s righteousness, alienate people, and continue the circular firing-squad mentality on the left.
Bernie Sanders offers a fine example of how to proceed: He never fails to mention single-payer Medicare for All, but doesn’t tear people down, dutifully supports incremental improvements, doesn’t let the perfect be the enemy of the good — given the alternatives at the time. That’s why Bernie gets respect: He lives in the real world.
Three: Say Medicare For All, not “single-payer”. Never mind that I used the wrong name above. Leverage the Medicare brand. People know Medicare. They’re on it, or their parents or grandparents are; it’s popular and familiar. “Single-payer” sounds wonky and exotic. Let’s have Medicare, just more of it. And Medicare is expandable: Surely an incremental expansion of Medicare down to age 50 would be good and helpful. Success builds upon success.
Four: Be forthcoming about the tax increase — even as you correctly note that it replaces private premiums and will very likely save money overall. Vermont passed an intent to go single-payer, but couldn’t accomplish the actual lift of raising the taxes to fund it.
“It is not the right time for Vermont” to pass a single-payer system, Shumlin acknowledged in a public statement ending his signature initiative. He concluded the 11.5 percent payroll assessments on businesses and sliding premiums up to 9.5 percent of individuals’ income “might hurt our economy.”
I know and you know that it replaces insurance premiums, overstuffed and featherbedded with “executive salaries and shareholder value”. And if you get insurance through your employer, the premiums are indeed a part of your total compensation. You and I might be comfortable with that trade; but it’s a leap of uncertainty for some that there are savings in moving from private to public funding. You’re proposing moving money out of compensation in the form of health insurance, which employees often can’t see — to a shared payroll tax, which they surely can.
Don’t hide from this uncertainty. Address it head-on, and say absolutely it’s a price you’re willing to pay and a risk you’re willing to take.
(I’ve always been baffled as to why large corporations and organizations wouldn’t prefer to hand off this responsibility to the government, at some considerable savings and probably with some benefit to employee health and productivity. How much time, personnel and money are spent on fussing over employee health plans — particularly when inflation is high and we’re trying to squeeze the cost balloon?)
Five: Be forthcoming about cost controls. This is yet another big political fight, and by no means is it limited to just the much-reviled health insurers, or even the PhRMA industry. The health care system is one-sixth of our entire economy, and you’re messing with a vast thicket of parochial business interests. It’s putatively sympathetic “stakeholders” like doctors and hospitals, which are among the cost drivers that give us less/worse care for more money. Even our own Liberal Lion Elizabeth Warren voted to ditch the medical device tax in the ACA. Why? It’s the hometown industry. As much as “everyone” wants reform, everyone has an ox to be gored as well.
When Obama ran for office, his aides contacted [Stuart] Altman, a key architect of the Nixon plan, and asked him to serve as an adviser. By this time, Altman was a battle-scarred veteran of four decades of health care wars. Indeed, policy wonks even coined a term — “Altman’s law” — to describe the stalemate that sets in when everyone wants reform, but only if they get their own way.
So you’d have to state explicitly that you intend for the government to use its heavy hand to keep costs down — that that’s what it’s for. Even Trump, in a shockingly lucid moment, called for the government to negotiate drug prices. And MA’s own Don Berwick — former CMS chief, single-payer guy, and onetime BMG gubernatorial endorsee — made a career of studying inefficiencies in health care delivery.
Good luck and have fun, folks. Maybe this time is different.