It is paradoxical and rash, but understandable, that some have reacted to the stalled Trump-Ryan health care bill with renewed hopes of going further on health: Nancy Pelosi (D-CA), Angus Deaton (Nobel Prize winner in economic science)—respectable people, maybe even a few Republicans. It would be a blessing if this conversation could be liberated from the stale, moralizing politics that surrounded it during the Democratic nomination fight and other similarly static and unproductive framings in the past.
Conspicuously missing from the Democrats’ arguments with each other over the future of health care is much of a concrete picture of what the magical words “single payer” actually mean. The definitional problem is not new. At the time of the Clinton administration reform efforts of the 1990s, the left wanted a “Canadian-style” single-payer system, until the reality that Canada has a provincial system finally sank in. Medicare for all is the current paradigm, but it has not been closely examined. Most crucially, the place of Medicaid in the post-repeal environment has not been imagined by single-payer advocates.
Unfortunately, the term “single payer” has acquired talismanic significance for many to whom it appeals, discouraging disinterested critical scrutiny. The embarrassing resemblance here to conservatives’ unquestioning faith in market forces is just one reason to steer clear of any such magical thinking. If a single-payer solution is to be argued as anything but a pipe dream, advocates must map out a clear and realistic path forward. This includes recognizing and addressing a number of factors that single-payer dreamers have long been loath to acknowledge.
First, a move to single payer would not only punish everyone’s favorite bogeyman, the insurance industry, it would also strip employers and employee groups of the ability to make their own purchasing decisions. Is it fair and wise to move these decisions further away from the consumers of services?
Second, the insurance industry performs several essential functions, albeit at too high a price for moderate tastes. It manages actuarial risk and payment methodologies, and contracts with provider organizations. Is government to acquire such skills, build that capacity from scratch, or leave the industry in place and regulate it as a public utility? How will employers’ share of the costs of care be recaptured if the government takes over payment? What taxes will employers pay instead? In the current system, the line between employer and employee contributions is often blurred, and the balance between the two is delicate and sensitive. How will it be recalibrated? The advocates need to be able to answer these questions in practical terms, not by accusing the unpersuaded of bad faith.
Third, proponents of Medicare for all must address themselves to the facts that fully a third of Medicare beneficiaries now choose to receive their care from private plans; that Medicare claims are processed and coverage decisions often made by contracting intermediaries from the private insurance industry; and that Medicare itself was cloned from a private insurance model. Why should it be assumed that “public option” plans run by government agencies with no experience in organizing the actual finance and delivery of care could be expected to do a better job than Geisinger or Kaiser Permanente? As to the all-important assumption that a single payer could control cost growth through the blunt expedient of budget caps and price controls, does our fractious political system have the muscle, intelligence, and will to assume the responsibility of improving efficiency and effectiveness at the sharp edge of care, the point of service?
Finally, one cannot ignore Medicaid. Whatever is going to happen next has to start with what is happening now, and the biggest thing that’s been going on lately, arguably, is the apparently irrepressible spread of Medicaid expansions into the states that initially rejected it. The new administration’s comfort with expansion waivers, albeit under conditions that many find objectionable, provides an opening for sustaining the momentum that the expansion of expansions has generated. This is not a trend that anybody in his or her right mind should want to interfere with.
Ideology drives fuzzy thinking and bad behavior on both left and right. In reality, health care in the United States has always been a hybrid of public and private payment and provision. No such marriage can survive winner-take-all attitudes on either side. A certain kind of payment system isn’t an end in itself. Universal coverage, quality care, and reasonable costs are the goals. What’s the best way to get from here to there? That’s all that matters. Let’s have an adult discussion. Check your pet peeves and preconceptions at the door. Bring evidence. Think hard, and speak clearly.