Single-Payer Healthcare

SINGLE-PAYER HEALTHCARE….Ed Kilgore responds to my angry post about the DLC’s wonkish 7-point healthcare plan with this:

As recently as 2004, John Kerry, John Edwards, Howard Dean, Dick Gephardt, Wesley Clark, and Joe Lieberman offered health care plans that would take the country pretty damn close to UHC without embracing a single-payer system at all….Were they all compromising wimps? Did they all privately acknowledge that single-payer was the goal, and just cringe from saying it publicly?

Here’s my guess: in private, I’ll bet all of these gentlemen do acknowledge that a simple single-payer national healthcare plan is the best policy. But for tactical political reasons, they think it’s more effective to talk about incremental solutions.

I disagree. It’s true that Hillarycare failed in 1994, but incrementalism has failed too. There have been a few minor improvements in the healthcare scene over the past couple of decades, but the only move in the direction of expanded healthcare that you could describe as even modestly significant has been the Medicare prescription bill, and that was enacted by Republicans. At this rate, we’ll achieve universal coverage by about 2100.

The historic failure of incrementalism is not just a coincidence, either. Rather, I think it’s basic politics: conservatives fight against it as hard as they fight against big reforms, but because the benefits are small there’s no constituency to fight hard for it. Because of this, incrementalism doesn’t work. What’s more, it sounds mushy, it’s not very good policy, and it doesn’t make Democrats sound like they’re standing up for something important. Do you see why I’m not enthusiastic?

The alternative, I think, is to continue supporting improvements to the current system but to make it absolutely clear that our goal is single-payer national healthcare. (For those of you who don’t know what “single-payer” means, it’s simple: it means that healthcare itself is provided by private doctors and hospitals, but it’s paid for by the government. Medicare is a single-payer system, for example. Rich people can continue to pay privately for services that aren’t covered by the government, of course.) It’s true that single-payer will attract huge opposition from conservatives, but unlike incremental solutions it has at least the potential to attract equally passionate support from a very large constituency that would benefit from it. It’s not a fundamentally impossible political proposition.

My guess is that we’re a minimum of ten years away from single-payer UHC, and to get there we need to shift public opinion. Here’s the argument in favor of focusing on that:

  • Single-payer is a simple plan that can be explained in short, compelling phrases. If you lose your job, you still have healthcare. If you’re poor, you have healthcare. If you get a new job, your preexisting conditions continue to be covered. No matter what, you always have access to high-quality healthcare from the doctor of your choice.

  • It’s good policy. Single-payer UHC is the only solution that gets rid of America’s bizarre and accidental (and wildly inefficient and expensive) hodgepodge of private insurance, employer insurance, government subsidies, inner city clinics, and overworked emergency rooms. Single-payer is simple, and experience around the world shows that it works, it saves huge amounts of money, and it reins in skyrocketing costs.

  • It gives Democrats a branding tool. Democrats, for example, are already clearly viewed as the pro-choice party, but in the healthcare arena they’re viewed as being vaguely in favor of “more,” but not much else. Single payer gives us something to stand up for.

  • The political landscape is slowly moving in our favor. Big corporations are tired of healthcare and are increasingly receptive to the idea of offloading their problem to the government. Funding alternatives like VATs could reduce opposition from small businesses, who are afraid of proposals that would raise their costs drastically and disproportionately. Insurance companies will fight against this like crazed lemmings, of course, but there’s not much we can do about that. No proposal is ever going to have the support of everyone.

  • It’s possible to win this battle. From a public opinion standpoint, our biggest obstacle is fear. As soon as you open your mouth about UHC, conservatives start screeching about waiting times for hip replacements in Canada or the number of MRI machines in Belgium, and everyone suddenly starts wondering if the solution is worse than the problem. But we have reality on our side: good single-payer systems (France, Sweden, Germany ? not Canada, Britain, or Italy) work great and people love them. If we can introduce the public to real world examples of how well those systems work, we can gradually overcome their fear of the unknown. This is probably the single biggest thing we can do to persuade people that single-payer healthcare is not the bogeyman the right makes it out to be.

But here’s the thing: none of this will happen if Democratic politicians are afraid to fight for it. We don’t have to give up incrementalism in the meantime, but we do need to make it absolutely clear what goal we’re working toward. It’s good politics, good policy, and good branding. But it’s a long fight, and the sooner we get back in the saddle and start fighting it, the better.

POSTSCRIPT: Matt Yglesias has more on the same subject. And the review of healthcare by Paul Krugman and Robin Wells in the current issue of the New York Review of Books is excellent.