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.
stomv says
Medicare for pregnant women, the unborn, and the just born.
I’ve written it here before, and I’ll write it again. Medicare for babies and mommas. Everybody loves mom. Everybody loves cute little babies. So force the issue. Point out that every American newborn deserves the chance to get started. Every rural poor baby, every urban poor baby, every baby of a working class family between jobs, every baby of a two-working-parent household with high deductible insurance.
GOP? You love the unborn, right? Prove it. Dems, you’re desperate to win back working white voters, right? Prove it. Put all pregnant women, all post-partum women, and all infants on Medicare. Once the kid is one year old, POOF, mom and baby are back in the for-profit system. But you gave them a good start. You gave them help. You helped women choose to keep their babies, or at least to deliver them. You gave every single American a good start in life.
Know what else you did? You just created a giant middle class of 20s and 30s who will demand Medicare for all once they’ve enjoyed the benefits and had them stripped, indeed ripped away.
We don’t have to expand Medicare to all people all at once. We can do it incrementally, to allow the economy to shift naturally. Pregnancy is a major medical care wildcard for people in their 20s and 30s. Put it on Medicare, ensure all babies get a good start in life, and build a constituency of pre-65 year olds who know first hand how much better Medicare is. And if it isn’t, well then, at least we’ll know that too.
jconway says
We could call Stomvs proposal the Jimmy Kimmel Act and it would get 70/30 support in the polls. I’d also add Midlife Medicare is a great way to expand the program in a way that appeals directly to Trumps base.
My wife’s pointed out to me that maternity deaths are skyrocketing in the US and this is another policy area where we could win back the Sams Club moms who defected to Trump.
Lastly, we don’t need to get nearly as wonky as Charley does. Medicare for All is simple and easy to understand for a campaign and we can leave the details to when we govern. Voters don’t care about details. This could be the lefts build the wall.
hesterprynne says
Points for your wife for pointing out the increase in maternity deaths.
jconway says
She’s a newly minted RN as of last weekend and the Boston job hunt begins.
Charley on the MTA says
The devil is in the details and the lobbyists will make sure that everyone sees the devil. To try to anticipate objections is only smart. Failing to do so, well, you can imagine. At least I can.
It’s fine to say that people vote for broad themes — with which I completely agree — but let’s not get too patronizing. People will want to know how it’s paid for.
jconway says
Half right Charley. I think the business and financial sector will want to know how it affects their bottom line-I disagree voters will care how it’s paid for. They certainly weren’t skeptical about Trump’s proposals nor have they seemed to care about deficits or the debt. They are unenthusiastic about entitlement reform of any kind and polls show broad majorities support entitlement expansion.
I think the post-Trump playbook for progressives have to be keep it simple and go for the top. We saw how the right treated ACA-Heritage Foundations own neglected step child. So push for a big plan and compromise it into piecemail increments like the kind you and stomv discuss.
I think pre-emptively negotiating ourselves away from single payer by arguing it’s too hard or impossible to implement or assuming the political environment around social democracy is the same as it was during the Cold War are mistakes.
I also think naively assuming it will succeed like VT did is a mistake-I’m absolutely with you on implementation. But you don’t campaign in wonkery if you want to win.
JimC says
A couple of points:
I agree generally. “Single-payer” as a label is tough. Medicare is better, BUT
That does not mean “Medicare for All” would be popular.
I think we might overrate single-payer. If we actually do the math on it, and then consider the follow-on effects of its existence, do we still believe it will be great? I’m not trying to argue one way or the other; I just sometimes feel like we take single-payer on faith. I for one have no idea what it would mean in reality.
johntmay says
Yup, Most people in support AND against “single payer” – or whatever you want to call it haven’t the foggiest notion of how we got here.
Why do we have health insurance now when we had no need for it 100 years ago? In 1900, the average American spent $100 (In today’s dollars) a year on health care. Today we spend $8,845 a year. The reasons for this are the same that 100 years ago, the average citizen spent less on air travel and the Internet.,……it was either very rare, or had not been discovered. Prior to the late 1800’s and early 1900’s there was no such thing as anesthesia, vascular surgery, antibiotics. In the 1800’s, a surgeon carried a saw, a strap, a cauterizing iron, and a bullet for you to bite down on if you had a badly injured leg as he would simply cut it off. All those supplies can be purchased at a hardware store and the skills to carry it through do not take years of med school. Times have changed.
Why do so many of us get our insurance through our employers? That was the unintended consequence of wage freezes during WWII.
Most wealthy people who are against single payer have no clue that if went “full market solutions” to this, most people could not afford modern health care and as such, the hospitals would close and the rich people would have no place to spend their money. In fact, the first health insurance policies were sold by a hospital in Texas that was in danger of closing because of this very fact.
Education and knowledge of how we got here are the keys to changing the minds of people on this subject.
jconway says
Keep it simple-affordable health care for all. How we get there is a matter for the policy makers-that we get there and move from where we are is a message for campaigns.
johntmay says
No, No, No…..drop the “affordable”. Affordable means private sector markets.
Donald Green says
When women fought for voting rights, when Afro-Americans wanted just deserved rights, they started from behind the 8 ball. We are a little ahead of their time table since polls show a majority of voters want universal health insurance.
Tommy Douglas started SP in Saskatchewan, a province of only 1.6 million. It was not an overnight success, but the tide turned when a national royal commission decided to study the issue in detail. The result, SP was the way to go.
The time frame went from 1947 to 1961, so it takes time and leadership. During these years there was awful propaganda from doctor organizations and insurers, even a doctors’s strike. So this movement is not for the faint of heart. Those who were on the forefront did not shrink because of “political reality”, but believed in their cause, and fought what they thought meant a better nation.
As Churchill noted, “You can count on Americans to do the right thing, but only after they have tried everything else” We need Single Payer because it is the right thing to do.
jconway says
Martin O Malley and my old boss Evan Falchuk also campaign on cost controls and breaking up provider monopolies. I think this is a component that is both populist anti-big business trust busting and the kind of fiscal controls we will need to win over moderates like CMD.
John Oliver had a great segment on dialysis which is actually the only out patient procedure fully covered by the state. As he put it-single payer for one organ. So it’s already covered by the costs have gone up 40x since the mandate was first implemented and it’s because 70% of the market share for the service is controlled by just two companies both of which have routinely settled in the billions for Medicaid fraud. So-setting prices has to be a component of the transition to eventual single payer or even a public option. And this will drive costs down and solve some of the existing issues with ACA as well as create buy in for more.
Donald Green says
Adding up Medicare, Medicaid, the VA, state, local, and federal government, untaxed employer health insurance adds up to 60+% of the health care expense that is paid by the tax payer. We already pay, but under private sector rules that has increased the price. With the money spent in these areas we could cover everyone by expanding Medicare For All. Doing the right thing is a struggle. If one studies Canadian Medicare it is quite enlightening.
http://www.historymuseum.ca/cmc/exhibitions/hist/medicare/medic01e.shtml