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The Democratic Strategist

Political Strategy for a Permanent Democratic Majority

Toward Single-Payer Reform–Step by Step

This item by J.P. Green was originally published on June 5, 2009
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.

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