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About That Single Payer Boomlet

On many levels this made perfect sense. The Affordable Care Act represented a would-be grand bargain in which the left achieved its century-long goal of universal health care coverage in exchange for using the policy prescribed by the right. In response, the right went to war with the idea and decided it was unconstitutional. And if the mandate/exchange model were found unconstitutional, there'd be no point in doing anything other than pushing for single payer since there'd be no other policy approach left. So why not go all in for single payer? Especially since it likely would have taken another 20 years until any president actually tried to solve the issue.

For myself, I find it hard to say whether I'd be for single payer largely because in my own mind I find it very difficult to separate policy in the abstract from political economy and politics. Frankly, I'm not sure we should really try. It's a good way to fool yourself. If I could just rewind history and decide for everyone that we should have a system like France or Canada? Absolutely. It works vastly better than what we have by every studiable measure. Do I think this is remotely possible? No. Not particularly.

And this is what I wanted to discuss when I grabbed my laptop to write this post. I'm seeing various folks now saying that the ACA will end up as a disaster and Obama was foolish not to get behind a really workable system like single payer or 'Medicare for All' while he had the chance. Marcia Angell says the ACA will simply end up as a confection of half-measures that accomplishes nothing more than discrediting its advocates. And I know enough about health care market failure to have some fear she may be right.

But this is a good moment to pierce the liberal delusion that single payer was out there for the taking -- even possibly out there for the taking -- had President Obama or any other president simply set his mind to it. After the 'public option' hit the brick wall that it did, it's difficult to believe that anyone could really believe that single payer was even remotely possible. It was virtually impossible -- with massive majorities in both houses -- to push through a bill that left the mammoth health insurance industry intact and forced no one with their current private care plan to give what they know in exchange for something they don't. So surely it would have been possible to push through a reform which essentially abolished the health insurance industry and forced big change on the overwhelming majority of the population who already has private coverage. To believe that you have to be totally submerged in the lethal progressive/liberal purism of loving defeat.

It's proved incredibly hard to lasso this horse. So ... fuck it, I'm just going to lasso a unicorn instead.

But it's more than just that. Single payer supporters do themselves a disservice by imagining that the only or even the main obstacle to single payer is the money power of the health insurance industry. That's obviously a big obstacle. It was a huge issue in 2009. But the biggest is the simple fact that the overwhelming majority of people, especially most people who vote, have health insurance coverage. And even though most don't like it and hate their insurance companies, in most cases, they're easily scared off by being told they're going to lose what they know, lose access to their doctor and get something new that they don't know. This is a fact. Anyone who's ever tried to run a political campaign tied to health care reform will tell you this. I've been shown various polls showing support for fairly self-serving descriptions of single payer that are totally divorced from how the rhetoric would actually play in the political wild.

The claim -- probably true -- that most people would end up liking the other system better doesn't make it any less of a fact. Why it ended up this way may have something to do with deep-rooted anti-statism in the American political tradition. More likely it's tied to historical accidents described in this piece in today's Times.

Grounding yourself in the policy essentials is critical. And pushing for policies you believe are workable and right even if public opinion is against you and you're looking at a long fight into the future is the bedrock of most deep political change. But there's no honor or credit for totally deluding yourself or others about what was at all in the range of politically possible in 2009 or now.