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The Democratic Strategist

Political Strategy for a Permanent Democratic Majority

Toward Single Payer Reform — Step by Step

It’s hard to find anyone inside the D.C. beltway who actually believes single payer health care reform can be achieved in this session of congress. The majority of progressives seem to have settled for the “public option,” which can be seen as a step toward achieving a single-payer system down the road, make that way down the road.
The public option does seem to be the most promising proposal for achieving a progressive consensus for this session of congress. But I do hope the single payer warriors will keep the heat on as the ‘scary left’ that makes the publlic option seem like a moderate alternative.
I applaud incremental reform as generally a more practicable approach than “big package” reform. By providing a smaller target and a simpler policy, precisely defined incremental reforms have a certain edge in winning hearts and minds. Incremental reforms have less baggage than “big package” reforms and they reduce the opposition’s ability to use red herrings to distract voters. Republicans, for example, had an easier time of it trashing ‘Hillarycare’ than they would in fighting a bill that forces insurance companies to do one simple thing — cover pre-existing conditions.
The oft-cited advantage of big package reform is that you can build a broader coalition. Well, that’s true. But it gives a well-organized opponent plenty of targets for mobilizing opposition. The right is very good at distracting voters with specific objections to proposals that offer otherwise beneficial reforms. See our staff post yesterday on William Galston’s New Republic article to get a sense of how complicated are public attitudes toward various health care reforms.
Incremental reforms are often portrayed as a ‘sell-out’ of progressive principles because they invariably leave some constituency out. The pre-existing coverage requirement, for example, still leaves millions without coverage. But if there is an understanding that other specific reforms to broaden coverage will be strongly advocated shortly after pre-existing coverage is enacted as part of a coalition commitment, then it could become possible to achieve something resembling universal coverage in fairly short order. Voting on highly specific health care reforms one by one in rapid succession may be a quicker way of getting to universal, comprehensive reform than having a grand battle over a highly complicated health care reform bill with many moving parts that have to work together in synch.
Incremental reform is not a new idea. Governor Howard Dean proposed insuring all children first, which is a good example of a politically-attractive initial reform. I like the idea of first guaranteeing catastrophic coverage to everyone — codifying the principle that no one loses their home or retirement assets because of an illness. It would be politically-popular by providing a huge sense of relief to millions of voters and it could be financed through a single-payer mechanism, sort of a partial single-payer reform. Let the private insurer reforms and the public option address other coverage issues — for now. A comment by Daniel Bliss in response to an Ezra Klein post on health care reform at The American Prospect made the argument nicely:

The key thing, as I see it, is that a final plan will not be successful in the long run unless it has a single payer component. Note the qualifying word, “component.” It merely has to share the risk and streamline the core of the system, but does not have to be single-payer in its entirety, and indeed probably shouldn’t if we want the best possible system. There is after all a great deal of difference in how applicable a market is to something that people simply won’t do without (e.g. accident and emergency) compared to something that is relatively more discretionary (non-urgent care administered in relatively small and affordable increments, such as chiropractic treatment). It’s worth noting that the top-rated health care systems in the world, according to the World Health Organization, tend to embody this concept of mating single payer for catastrophic coverage with supplemental insurance taking care of more discretionary parts of health care. France is the outstanding example.

If the Obama Administration can say 3 years from now, “We eradicated the fear of ruinous health care costs for all American families,” that’s a hell of an impressive achievement to run on on 2012.
Given the complexity of attitudes toward health care proposals, I’d prefer to see a series of specific health care reforms debated, voted and enacted in succession, each piece standing on its own merits, rather than having them all linked together and inter-dependent on each other. It would bring more clarity — and simplicty — to the debate over health care reform, and my hunch is consumers/voters would welcome it.

One comment on “Toward Single Payer Reform — Step by Step

  1. Len Charlap on

    There are several things wrong with the above analysis.
    1. Medicare for All IS an incremental step. Step one was Medicare for the highest risk pool, old fogies like me. Step 2 is Medicare for everybody else which is actually easier because it does not cost any more (see below). Step 3 would be more efficient medical practice.
    2. The main reason that it is far better to extend Medicare to everyone is cost. Private insurance companies waste about $400 Billion each year in high overhead and unnecessary requirements on physicians. There is another $100 Billion wasted on high drug prices to companies that spend 3 times as much on “marketing” as on R & D. This $500 Billion each year can be used to pay for the extension of Medicare to everyone.
    If you simply add a public plan, you are leaving the $500 Billion on the Table. You are simply adding cost. This is just stupid.
    3. In addition, there are tecnical reasons just adding a public plan is foolish. If it has to take everyone while private cos can pick and choose , it will wind up with another high risk pool–the sick and the poor. While the idea of creating another pool is bad, if it is a high risk pool, it will be very expensive. The Repubs will seize on this and progress will halt.
    Also if it covers preexisting consitions, then it will greatly expand the pool of the self insured which is terrible from an efficiency point of view. After all, why pay premiums when you are well?
    Finally as to the attidues of the public, if the magic word “Medicare” is mentioned in the questions, a huge majority is in favor of Medicare for All. Here is a question from a Washington Post – ABC poll:
    “Which would you prefer: the current health insurance system in the United States, in which most people get their health insurance from private employers, but some people have no insurance, OR, a universal health insurance program, in which everyone is covered under a program like Medicare that’s run by the government and financed by taxpayers?”
    62% favored Medicare for All; 33% were opposed. That’s pretty decisive. And this is with the facts suppressed. Other questions in the poll show that the 62% supporting the universal program mostly believe it will cost more when it will cost less. They believe they won’t be able to pick their doctor when Medicare allows much more freedom than most private plans. They believe there will be long waiting times when this is a myth. And still they support a universal plan like Medicare for All by 2 to 1.


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