How Can We Achieve Single Payer?


So presidential candidate Bernie Sanders announced his health care plan last week with significant response. Those like myself, who have been advocating for a single payer plan, rejoiced. We finally have an candidate who is speeking our language. More practical liberals, on the other hand, had characteristically well thought out objections.

All right. First the giddyness. During the 2008 presidential campaign health care was a central issue. Families were seeing their premius increasing while their wages continued to stagnate. It seemed that insurance companies offered fewer benefits, charged hidden costs through misleadingly described “coinsurance.” Insurance companies could deny coverage for almost anything under the guise of pre-existing conditions. Over 45 million Americans were uninsured. Harvard Univsity reported that over 45,000 people a year died as a result of inadequate insurance coverage.  Health insurance PR man Wendell Potter turned whistleblower reported on his conversion after a visit to a health care expedition held at a local fairgrounds. “It was absolutely stunning. When I walked through the fairground gates, I saw hundreds of people lined up, in the rain. It was raining that day. Lined up, waiting to get care, in animal stalls. Animal stalls.”

In the meantime, insurance companies raked in obnoxious profits.

It was in this context that then Senator Obama proposed introducing a public option as his health care reform. If someone could not afford insurance in the private market, they could sign on to a quality public insurance plan that they could afford. If they had private insurance that they liked, that was fine, but the public option was there if they needed it. It was a simple plan that was missing some details. For instance, what would stop people from waiting until they were sick to sign on to the public insurance program?

In truth, it was a rather tepid reform proposal. However, to be completely honest, health care activists went crazy over it, and frustrated insurance consumers, again like myself, jumped into the fray. We signed on to the Obama pubic option, rolled up our sleeves and prepared for battle.

And let’s face it, Obama’s public option is nowhere near as bold as Bernie’s single payerish program. Yes, there is a profound lack of detail in Sanders’ plan, admittedly. But that was also true of the public option. Health care is a huge issue requiring a nuanced hammering out of almost endless details and particulars. That’s for legislators to figure out. Campaigns are not won on matters of practical reality. Campaigns are about vision, and Sanders’ vision is not only offering “puppies and rainbows“, but offers enough detail to convince activists that it is doable. About its credibility, Mother Jones’ Kevin Drum claims, “his sums might not add up perfectly, but they’re pretty close.”

See. Pretty close. That works for me. Let’s do this!

Okay. So let’s slow down a bit. Let’s face it, we’ve been down this road before. If there’s one thing that I’ve learned from my time as a health care activists it’s that we are going to get the shit kicked out of us. In 2010 we emerged from fighting for the public option bruised, bloody and baffled–and didn’t get the public option. Instead, we got Romneycare! An improvement, yes, but hardly the vision we started with. It cost us. The president left us with little leadership, and ultimately abandoned us to his politics of the possible. Health reform became a form of political profanity.

And this was the public option, a tepid, admittedly flawed little squeek of a reform. How do you suppose the establishment is going to respond to Bernie’s plan?

So we better take the criticisms seriously. These are best articulated by’s Ezra Klein and Paul Krugman at the New York Times. After all, we’ve been to the ball before and were stood up.

As much as we hate to admit it, Klein, Krugman and others have some good points. A President Sanders will be up against an entrenched insurance institution with deep financial roots tangled throughout a bought and paid for congress. He will have the responsibility of trying to convince millions of Americans, most of whom have health insurance that they like despite the costs. Bernie will have to convince them to give up plans and a provider process that they know, that is secure, for a foreign, unfamiliar system. As Krugman points out, “single-payer would impose a lot of disruption on tens of millions of families who currently have good coverage through their employers.” Americans with better than average coverage today will have certainly not be on board.

Then we are going to raise their taxes! Bernie admits that his plan would require a 2.2% increase in taxes. Bernie is trying to define this as a “premium”, but come on. It’s a tax. And Americans don’t like taxes. True, even if Bernie’s calculations are off, it is likely that Americans would be paying much less for Bernie’s plan than they are currently paying for premiums, though the $466 claim is probably wildly understated. Regardless, this constitutes a huge increase in federal spending relatively quickly.

Getting the American people on board with this plan would require the Sanders Administration to effectively communicate the benefits of his single payer plan. It would also have to deal with the inevitable minutia of health care policy that will become front and center in the legislative process and educate the public on these rather mundane policy pieces. All of this against the headwinds that will whip through the country as an endangered insurance industyr fights potential extinction by dumping unlimited millions of dollars into a public relations blitzkrieg the likes of which we have never seen, with the Republican Party as a sounding board. Cue Sarah Palin and the death panels. “Bernie Sanders wants to pull the plug on Grandma!”

Let’s face it. Our experience with successfully communicating these ideas is…well…not good.

Krugman is correct. If we could start from scratch, a single payers system would be a no brainer.

But we are not.

So there must be a way of making this transition that is workable. I hate to say it, Bernie’s is certainly not practical.

I think there is.

We need to incrementally expand Medicare over time. Medicare is something that people are familiar with, so we will not be replacing their insurance with some strange, almost certainly clunky system that scares people. We will not be asking people to sacrifice. People can get behind the plan, and the hyperbolic voices of our opponents would be muted. It’s easy to talk about death panels when it comes to a new commodity like Obamacare or Berniecare, but not Medicare.

We start with a .5% payroll tax increase. Yeah, we don’t like taxes, but half of a percent is something that even Americans can live with. Then Medicare expands to cover people from 55 or 6o years of age and over. Insurance companies are not as likely to complain because this decreases the average age of their insurance pool, controlling costs. The following year we do the same, a .5% (I’m no expert on health care tax policy, so the actual numbers may have to be determined by folks who actually know this issue better than me) increase and cover 50 years olds…and so on and so forth.

Ultimately, there will be pushback from the insurance industry as younger, more profitable consumers are shifted into Medicare, but by that time the expectation will be set. Insurance companies, to survive, will have to shift their focus to supplemental coverage (let’s face it, Medicare for all would have some holes). Campanies unwilling, or behind the curve on making the transistion have time to divest and liquidate. Within a few years a Medicare for all scenario would be perfectly doable and reasonable with relatively few disruptions.

As exciting as Bernie’s plan is in vision, it is lacking in practicality. Vision is great! I would certainly rather have a dedicated visionary at the helm than a devotee of “politics of the possible.” However, this visionary, and those working for him, will have to face political reality. At some point it becomes time to get to work and accept the fact that the vision is not going to come to fruition in quite the way imagined. The best we can hope for is something better than what we have.

We got that with Obamacare, as disappointing as it was at the time. This reform has improved the lives of millions of people, but obviously did not go far enough. Americans are still struggling with health care. That Sanders can propose such a radical change and still maintain his popularity is testament to how much Americans continue to struggle. I think the plan I suggested would have offered the same vision that Bernie is presenting, but with much more practical implications.


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