Why Not Single Payer Now?
By Jon Kingsdale
Democrats and moderates spent the last decade building support for, developing, and then defending the incrementalist Affordable Care Act. It has (narrowly) survived eight years of vicious, distorted attack.
Now, a resurgent progressivism would abandon it. Sixteen Democratic U.S. Senators (a record number) have co-sponsored Bernie Sanders' Medicare-for-All bill, and Washington, D.C.'s influential Center for American Progress, recently rolled out Medicare Extra for All.
The policy arguments for a single-payer system have long been clear—universality, simplicity, administrative and (potentially) other savings. Even Taiwan, that bulwark of capitalist resistance to "communist" China, settled on Canadian-style Medicare as the best model for universal coverage.
And there's an emotional factor as well behind the Democrats' swing left: incrementalism seems to have done nothing to mollify the right. After withstanding repeated efforts at "repeal and replace," resurgent liberals might take pleasure in dropping their unrequited efforts at compromise in favor of more fundamental change. Sweet revenge, indeed, on all those Republicans who mouthed sympathy for the uninsured before 2010, only to viciously attack the very moderate, market-oriented ACA!
However, a Democratic push for single-payer is exactly the wrong move now. It would be wrong for three reasons.
First, the ACA is working: The uninsured rate for legal residents has been cut in half. Expanding Medicaid and private coverage is associated with greater access to prevention, primary care and prescription drugs, higher rates of diagnosing and treating chronic conditions, and improved control of hypertension. Its reach is also growing. If Virginia expands Medicaid, as seems likely, two-thirds of the states (and the District of Columbia) will have done so under the ACA. More will likely follow if Democratic wins insulate it from repeal.
Second, the ACA can be improved. This can be done simply by reversing Republican efforts of the past 15 months to undercut it, plus relatively modest increases in the tax subsidies to encourage direct enrollment. Massachusetts Senator Elizabeth Warren has introduced The Consumer Health Insurance Protection Act to do just that.
With its growing popularity, the ACA offers a sturdy platform on which to build. It is now more popular than at any time since its passage, and most voters think Democrats and Republicans should work together to improve it. (See figure.) Independents, who will decide the next elections, can be turned by Republican strategists against single-payer "socializing medicine." But 59% support fixing the ACA, as do 70% of Democrats. Promoting single payer would allow Republicans to switch from defending their record on Obamacare to attacking "spend-and-tax" Democrats.
Third, re-taking Congress in 2018 and the White House in 2020 is more important to Americans' health than any healthcare financing reforms. To cite just one among many issues, the health benefits of arresting this administration's attack on the environment far outweigh the benefits of insuring another 5-7 percent of Americans (the legally resident, uninsured). There are many such issues – food insecurity, education, public housing and income inequality – where halting this administration's policy trajectory would confer health benefits beyond the most optimistic expectations for single-payer.
So, NOT giving Republicans a big fat ideological target in November is crucial to our public health. Single-payer is so easily labelled a government takeover of medicine demanding massive tax increases. It has failed ballot initiatives in liberal California and Colorado by margins of 3-to-1. Even Senator Sanders' home state of Vermont, having enacted single-payer in 2011, reversed course after calculating the tax requirements.
Trump's Republicans have made a colossal mess—gutting reasonable restraints on pollution, cutting health programs, raising annual deficits into the trillions, and sabotaging the norms of decency and informed debate that are essential to representative government. Liberals should not allow them to evade the electoral consequences by scaring voters about a government "takeover" of healthcare. If Democrats do, we may yet snatch defeat from the jaws of victory.
Graph from Kaiser Health Tracking Poll – February 2018: Health Care and the 2018 Midterms, Attitudes Towards Proposed Changes to Medicaid, Ashley Kirzinger, Bryan Wu, and Mollyann Brodie. Published: Mar 01, 2018.
Feature image: Victor Moussa/Shutterstock
Jon Kingsdale
Jon Kingsdale is Associate Professor of the Practice, Health Law, Policy & Management at Boston University School of Public Health. He has 40 years of experience in health care financing and policy. In 2006, he was appointed by Governor Mitt Romney to organize and lead the Massachusetts Health Connector, the model for health insurance exchanges under national health reform. After starting and running the Connector (four years), he spent the following six years consulting to the federal government, state-based marketplaces and private clients on the implementation of the ACA.
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