Single payer debate heats up: Don't say I didn't warn you

Why is single payer popping up now?

The Affordable Care Act (aka Obamacare) was a sincere attempt by Democrats to write a bipartisan bill that would attract the support of moderate Republicans. It preserved the employer-based system of private insurance, added market-based approaches such as the insurance exchanges, and enforced personal responsibility through the individual mandate. The Republican leadership made a political decision to attack the bill rather than to support it, and the GOP-led Congress and now a GOP-led Administration have tried their best to undermine the law by spreading misinformation (death panels, government takeovers), defunding key aspects such as the risk corridors, and creating uncertainty (e.g., not committing to funding cost-sharing reductions). States have done their part by suing over the law’s constitutionality.

I’ve warned since 2014 that if Obamacare fails or is repealed it will make single payer more likely. (See If Obamacare fails are we on to single payer? and One more way Obamacare may lead to single payer and Goodbye Obamacare? More like hello single payer!)

Suddenly the political ground is shifting as leading Democrats embrace single payer. The Washington Post (The dam is breaking on Democrats’ embrace of single-payer) reports that there are four co-sponsors of a single-payer bill in the Senate. Max Baucus, former chairman of the Senate Finance Committee and an Obamacare architect, has also come out in favor –something that was unfathomable until recently.

There a few reasons this is happening right now:

  • After seven years of shouting “repeal and replace” Republicans have revealed that they actually don’t have a plan for addressing problems in the healthcare system and that their real intention is to cut Medicaid and throw millions off of coverage
  • President Trump has called Republicans on their subterfuge, so now everyone is aware that there never was a plan
  • Experience with the Affordable Care Act has changed the conversation. For example, no one wants to go back to worrying about whether pre-existing conditions will keep them from getting coverage or that they’ll hit an annual or lifetime cap on benefits

Most importantly from a political standpoint, Democrats realize that the complexity of the ACA –which was needed in order to keep it a moderate bill that built on the complexity of the existing system– has worked against them. I’m a healthcare expert and I don’t understand every aspect of Obamacare. How can the average citizen be expected to do so?

“Medicare for All” is a simple and powerful rallying cry. Everyone knows what Medicare is. Those who have Medicare like it and want to keep it. There is no stigma attached to it. Unlike the ACA, a Medicare for All bill could be simple and elegant. And it wouldn’t require an individual mandate to function.

The health wonk in me says that Medicaid would actually be a much better vehicle for universal coverage than Medicare. (See Could Medicaid for all be the answer?) It would do a better job of bending the cost curve and addressing drug pricing, and would give the states more freedom to innovate. But it might be less appealing politically.

Those who want to preserve capitalism and private innovation in healthcare –and I put myself in that category– should embrace the Affordable Care Act and look for ways to improve it. The alternative is to fight a rear guard action against single payer.

By healthcare business consultant David E. Williams, president of Health Business Group.


September 12, 2017

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