SINGLE-PAYER HEALTH INSURANCE:

NOT SO FAST

Bernie’s for it.  So is Elizabeth Warren.  So are Cory Booker, Kirsten Gillibrand, Kamala Harris, Jeff Merkley and the House Democratic caucus.  Is it too soon to say that the ayes have it and declare single-payer to be the policy, a litmus-test issue even, of the Democratic Party and of those, like Bernie Sanders, in its orbit?

Yes, it is.  Much too soon.  We know less about single-payer—how it would work, what it would cost, how politically popular it would be—than we knew about that Graham-Cassidy bill they tried to frog-march through the Senate a week before the deadline for simple-majority passage.

What don’t we know about single-payer?

  1. With so many millions of people’s needs now met by existing programs, shouldn’t we see first to the needs of those who are currently not covered?  Proposals for college for all and Medicare-for-all suffer from the same flaw: they propose that the federal government, i.e., taxpayers, should absorb the costs of those who can already afford, and are in fact already receiving, health care or a college education.  In an era of tight budgets,* shouldn’t we look after the have-nots first?
  2. We don’t know enough about how it might work.  We especially don’t know what we don’t know.  An example from our Medicare experience, reported by NPR in connection with the program’s 50th anniversary in 2015:  A congressional staffer, I think it was, recalled that Great Society policy makers assumed that under Medicare, the costs of medical care for senior citizens, previously borne by private insurance, patients’ savings, or patients’ grown children, would henceforth be paid by Medicare.  But a few years in, policy makers realized that before Medicare, a sizable share of seniors’ medical costs had not been paid for at all; they had been provided gratis, eaten by the doctors or folded into the doctors’ overhead to be paid for by their paying patients.  Once Medicare took effect, those costs were billed to the new program, resulting in costs significantly higher than had been anticipated.  Our experience with every major federal program should prepare us to assume that there will be surprises as coverage is expanded: costs may be—almost surely will be—higher than projected, not all providers will accept the lower payments provided for by the new program to control costs, there may be serious glitches in the enrollment and payment systems.  Remember the enrollment foul-ups that almost sank Obamacare before it left the harbor?  Wouldn’t it be better to adjust to those surprises in smaller groups rather than with the country’s entire population?
  3. Politically, it ain’t gonna happen.  Working with a Democratic Congress, Barack Obama barely got Obamacare passed, even without a public option.  For that matter, working with a Republican Congress, one pledged in blood to repeal and replace Obamacare, Donald Trump has so far been unable to end it.  The chances of the kind of political earthquake that would install a Democrat in the White House, a Democratic majority in the House, and a liberal, filibuster-proof Democratic majority in the Senate are close to zero.  The Republicans are now slogging through the self-inflicted, entirely deserved pit of misery that awaits those who make promises on which they cannot deliver.  Why would Democrats want to join them by committing themselves—as a litmus test, no less—to a program that will not pass, would be booby-trapped with unintended consequences if it did pass, and would likely be hugely expensive?
  4. There’s a reason that Obama didn’t propose to include single-payer in Obamacare.  Obama said that if we were starting from scratch we’d go single payer.  But he likened navigating through the health insurance landscape to looking for a parking place.  On a block with no other cars parked, it’s a cinch to find a space.  In a parked-up block, though, with just a few spaces open, it can be a challenge to find one large enough for your car and to back into it without dinging the cars ahead and behind.  That’s our health insurance “system”: Tens of millions without insurance.  But hundreds of millions of people with coverage, albeit a patchwork of coverage–employment-connected insurance–Medicare, Medicaid, veterans’ insurance, health savings accounts and flexible spending accounts—that is far from perfect but that its beneficiaries may not like being jerked out from under them and replaced by the devil they don’t know.
  5. Single-payer is a radical solution at a time when the electorate may be looking for incremental change.  The emerging Democratic consensus for single-payer reflects a way of thinking much in vogue on the left: that the defeat of a centrist candidate like Clinton is evidence of a national hunger and thirst for a true-left candidate, like Bernie Sanders. Please.  Sanders lost to Clinton, who, we now know, was no political juggernaut. What makes us think that the national electorate wants a candidate, not somewhere between the two 2016 choices, Clinton and Trump, but further left than Clinton and further left even than Obama?  And what makes us think that the American people, whose representatives in Congress and the White House rejected even the public option in 2009 will go for a program in which the public option would be the only option?

Single-payer could work.  Or, as Cassidy-Graham would surely have been, it could be a disaster–operationally, financially and politically. But the way to find out is not to stampede it into litmus-test status for any liberal candidate for Congress or the presidency. Put it through what passes for regular order for parties out of power: Get detailed proposals out on the table.  Figure out how much they would cost and who would pay.  See how they play, first on Sunday talk shows and the PBS NewsHour, then in primary and general elections.  See if they can take a punch.

And above all, proceed with caution.  There’s time till 2018 and 2020, and more yellow and red lights flashing than green.

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