Single Payer Still Matters

 /  Nov. 5, 2017, 4:42 p.m.


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As reality TV clichés percolate into nuclear diplomacy and the United States edges closer to Republican single-party rule, it may seem strange to care about a bill in the Senate that is too far to the left to pass in Canada. This bill—Senator Bernie Sanders’s Medicare for All Act, which aims to establish a universal health care system administered by the government rather than by employer-backed insurers—is in itself far from monumental. The independent from Vermont has introduced similar acts throughout his career, with the most recent coming to the Senate floor two years ago. The details of Sanders’s plan have changed a little, and he has a new following since his 2016 presidential campaign, but this Medicare for All Act, like its previous iterations, still essentially has a zero-percent chance of becoming law.

But unlike all the previous bills filed into various Senate folders, this bill has no less than sixteen co-sponsors. Even if the Democratic leadership in the Senate itself is not on board with the bill, nearly every Democratic senator whose name has been floated as a 2020 presidential candidate is on board, including everyone from progressive icons like Sanders and Elizabeth Warren to more moderate leaders in the party with perceived ties to the financial industry like Cory Booker and Kirsten Gillibrand. That’s not to say the Democratic Party is guaranteed to nominate a single-payer supporter in 2020, but the party’s left is clearly making single-payer a central issue, and most of the Democrats obviously vying to replace Trump seem to be focused on checking off the single-payer box, whether or not it is a main policy priority for them.

On its surface, this might seem like a perfectly natural move from the party that passed the Affordable Care Act in 2009 and that has been fighting towards some idea of universal health care since the days of the New Deal and the Great Society. But this Medicare for All Act does something more fundamental than just striving toward universal coverage. It declares that health care is something too basically important to be left to the private sector and market forces, even with government tinkering.

Sanders and his sixteen co-sponsors are thus asking the nation to treat health care like we treat education—as a right that requires the government to directly administer a service through public education—as opposed to something like the provision of food—where SNAP and other programs subsidize the buying of food and farm subsidies subsidize the production of food, but the government runs neither supermarkets nor farms. On the surface, these two approaches—securing a right directly and indirectly making it more accessible—may seem similar. But in practice there are meaningful differences. Direct provision—for example, having the government directly pay for everyone’s health care plan—allows individuals to simply think about what health care they need and pursue this care, whereas the indirect market approach asks people to consider both what they need and what is financially efficient.

Perhaps, if everyone were a health care economist robot, the indirect approach would be clearly better: by pursuing health care in an economically efficient way, people would maximize society’s well-being to dollar ratio, which would allow any health care program to get the most bang for the buck. But given that most people don’t understand health care economics well, the reality is that this indirect method will, at least in some instances, cause people to be led astray from their well-being due to financial anxiety. Consider, for example, a check-up which seems to the average person to be overwhelmingly likely to be a waste of money but which could nevertheless end up saving a life. Single-payer allows individuals to simply go get the check-up and the care they generally think they need, regardless of expense. This not only potentially saves more lives in the aggregate, but also addresses the inherent worry all of us have when we think we or someone close to us is in medical peril. It prevents individuals—particularly poor individuals—from feeling like their well-being amounts to numbers in check-books. Though we all must learn to live with the small risk of terrible disease that is inherent in living, some reasonable, even if not economically rational, fears—like dying of an easily preventable illness—simply shouldn’t be necessary in the wealthiest society in history. And when we do have overwhelmingly irrational medical fears, we need human-to-human connection, whether that means spending time with family or speaking with a psychological professional, more than simply being cut off if we happen to be too poor.

Hence, even a world in which Hillary Clinton were president, the Democrats controlled Congress, Medicaid expansion continued, and further subsidies made health care affordable to essentially everyone, would be importantly different from the sort of world Sanders and the Medicare for All Act envision. Hillary-world with its universally affordable health care would be better than the one we live in with its constant health care cuts and climbing premiums, but individuals would still have to think about their health in terms of cost. The bodily and mental well-being of people would still not be a guaranteed end; instead the cost of health care would dictate what sort of jobs people end up taking and would attach a dollar-sign to every potential accident we face.

The alternative offered by the Medicare for All Act—where health care is a right that should be secured independently of the market, rather than a good that is available on the market—nevertheless has some downsides. With no cost-sharing mechanisms or significant investments in expanding the supply of health care, there are major questions about how we can ensure that everyone has as much health care as they perceive they need, in which case, rationing seems inevitable. Yet, while it certainly is not good to be denied a treatment because of some government regulation about prioritizing treatment for those who need it the most, at least in this instance the denial of treatment is grounded in some more fundamental care for humans (even if it happens to be other humans who need something more), rather than care for pieces of green paper.

Green paper certainly matters: until the question of how this single-payer health care system will be financed is firmly answered, it still remains in the land of wishlists. But the fact that single-payer is the vision of a critical mass—if not an outright majorities—of the next generation of liberals, is by itself incredibly important. Over the last century, health care, perhaps second only to white supremacy, has been the defining political story of the meandering path of American democracy.

The fact that activists on the left are shifting in their demands—from a focus on indirect market structuring to direct ways to provide for people’s fundamental needs—is emblematic of a broader shift in political philosophy. Progressives are getting invested in helping people beyond abstract, though impactful, notions of economic efficiency and making choices marginally less harmful. They are beginning to look into fundamental insecurities individuals face in an increasingly alienating world. This shift is perhaps the best possible answer to the question of what comes after Trump, and, even if the Medicare for All Act remains tucked away in a Senate file drawer for a while longer.


Josh Kaufman


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