At The Plum Line, Paul Waldfman’s “‘Single payer’ is becoming Democratic Party consensus. Here’s the danger to avoid” identifies some lessons learned about health care politics. “So what lessons can we take from the experience of the ACA that might help Democrats as they move toward another enormous health-care reform?,” asks Waldman. “Here are a few”:
It’s going to take years. There’s a certain amount of wishful thinking in some quarters that goes like this: Medicare-for-all is an idea people find attractive; single-payer systems are simpler than what we have now; so all that’s required to get it done is the proper application of will. But it’s never that easy. It’s going to require lots of detailed policy work and lots of political work to prepare for the moment where Democrats control the presidency and Congress and can make it happen. We all laughed at President Trump when he said “Nobody knew that health care could be so complicated,” so liberals need to keep that in mind.
Disruption is frightening. The fact that people don’t want to lose what they have — and can easily be frightened into thinking they might — is a political reality that will always need to be dealt with. It helped defeat the Clinton plan, it helped undercut the ACA, and it helped defeat the Republican repeal effort. You can’t wish it away. If you’re going to change the insurance millions of people now have, you’d better have a darn good plan to overcome their fears.
We need to think about the transition from where we are now to where we want to go. Other countries with universal systems had an easier time putting them in place than we will, because health care was less complicated decades ago when they did it. We now have an exceedingly complex system in place and transforming it won’t be easy, so the plan we decide on has to be one we can get to from where we are now. The implementation of the ACA was hard enough; implementing a single-payer plan would be even harder. The design of your favored plan should include an understanding of what will happen in the first months and years.
Republican demagoguery is a certainty. Republicans will have legitimate critiques of any universal plan, but they will also tell insane lies about it. Remember “death panels”? Expect that times 10 in the case of single payer.
Beware the interest groups. Some on the left look with scorn on Obama’s decision to co-opt those groups, but if you don’t do that, you’d better be ready for a vicious fight. Insurers, drug companies, medical device makers, hospitals, doctors — they all have a lot of money at stake, and whatever plan you come up with, you’re going to have to deal with them.
There will be winners and losers. Democrats can reasonably claim that many more people will be better off if we move to a universal system, and that everyone has something to gain. But that doesn’t mean that there will be no one who winds up with something worse than they have now, and acknowledging that fact can help you prepare for the backlash.
You have to be able to explain it to people. This was one of the major liabilities of the ACA: It was a complex solution to a complex problem, and few ordinary citizens understood what it did. Single-payer systems start off with an advantage in this area; you can say “Everyone gets Medicaid,” and that’s easy to understand. But if that’s not your preferred plan, you need to find a simple way to describe it.
Waldman argues further that the term “single-payer” may be asking for trouble because it is too narrow. The term “suggests that the only system they’d accept is one in which there is one government insurer and no private insurers. That’s one possibility, but there are many other ways to get to universal, secure coverage that have multiple payers.” Further,
I happen to think the best and most achievable system given where we are is one in which there’s a basic government plan that covers everyone — an expanded Medicaid, perhaps — plus private supplemental insurance on top of it, a hybrid system of the kind that works well in countries such as France and Canada. The point is that it would be much better to speak of “universal coverage,” which allows for a number of different designs as long as they achieve the same goal.
Waldman concludes by repeating his first point, that it’s going to take years. It’s going to require phases, incremental reforms and hybrid public/private policies to move America toward universal coverage. Democrats have to accept that it’s all up to them, since the modern Republican Party is uninterested in building a bipartisan consensus, and seems wholly devoted to obstructing any forward progress on health care. That’s why the 2018 midterm elections are a critical priority for better health care in America.