A Note to Single-Payer Advocates

by: David Sirota

Wed May 13, 2009 at 15:51


Here are some facts:

- I am an advocate of single payer health care. In fact, much of my chapter on health care in my first book, Hostile Takeover, advocated for single-payer health care.

- Most progressives, and many millions of Americans, support the concept of a single-payer health care system.

- Those in Congress, like Sen. Max Baucus (D-MT), who refuse to consider single payer in the debate over health care are the enemies of single payer.

- Those in the United States, like me, who support single payer, but also would support a robust public option in a non-single payer universal health care system, are not the enemies of single payer.

- Just because public option plans haven't been structured or implemented well in the past, doesn't mean they can't be structured or implemented well in the future.

- There is dual value in pushing hard for single-payer: It can get us close to (or perhaps even immediately achieve) a single-payer system. It can also make sure that if we don't get single-payer, we get something that's still very good like a robust public option that will ultimately lead to single payer.

The second-to-last point is particularly important: I've found in my work on health care that professional advocates of single payer seem to believe their biggest enemies are those who support single payer, but short of that, would also support a robust public option in a non-single payer universal system. These advocates seem like they actually want enemies, rather than wanting to build as broad a coalition as possible.

I'm not really sure why this is, other than the fact that some people just need to feel like they are in a fox hole with the entire world against them. While I agree that much of the political Establishment is against single payer, I don't believe that there has to be some sort of mutually exclusive situation whereby you are either "for it or against it." You can be for single-payer, but also, short of single-payer, also for a public option - and you can simultaneously support the vigorous, uncompromising push from single payer advocates as helpful to moving the country in the right direction on health care.

In sum, those who are working their asses off to create real, meaningful and progressive health care reform - whether single payer, or a robust public option - have enough enemies as it is, without having to create more enemies amongst themselves unnecessarily.

David Sirota :: A Note to Single-Payer Advocates

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agreed -- but i'm not really sure where this is coming from... (0.00 / 0)
the whole post comes across as something of a straw-person, especially if you aren't linking to anything or quoting someone to make your case about what 'some' single payer advocates say or do.  

that said, it seems to me that the most pertinent question is whether reform w/ a public option makes single payer more or less likely.  i happen to think it makes it much more likely, for a number of reasons, but i recognize that there are possible arguments on the other side.  but from where i sit, i can't see single payer being passed in the near future short of one of two things happening: 1) a robust public option is established this year, and then gradually expanded in the following years in the face of high demand, until single payer becomes all but inevitable, or 2) we have a general strike for single payer.  short of a general strike that actually shuts business in america down, i don't see single payer passing through congress.  


A public option is the ONLY (4.00 / 5)
way single payer ever happens in this country. You aren't going to get rid of the insurance cpmpanies with one piece of legislation, it would be too easy for it to be characterized as social medicine and by the the time the smear campaign is over, 70% of democrats will be voting against it. However, the one critique republicans have made that is probably true, is their assertion that a good public option would ultimately marginalize private insurers and put the country on the path to single payer, or at least a majority covered under a public option.

I will go one step further and say that while we should fight for the strongest public option possible, getting one to begin with would a big victory. One thing we know is once a public option is law, it basically becomes impossible to get rid of and much easier to improve. The tougher part of the legislation is actually getting the public option as law, strengthening the public option once it's already providing coverage is a hill much easier to climb. Of course, as I said earlier, we should fight hard for the strongest public plan possible.  


[ Parent ]
agreed 100%. that is why i said the only way (0.00 / 0)
we would have single payer is a general strike.  if everything is shut down and the economy is on the brink, congress might reconsider.    

[ Parent ]
Yes, but (4.00 / 1)
WHERE ARE THE DEMOCRATS who are not for Single Payer but are strongly for the Public Option?

They should be screaming from the rafters that the private health insurers are afraid of competition.  But they're silent.

And what is Howard Dean doing saying that the public option IS single payer?  Isn't that blurring the more moderate message of the public option?

Can't anyone here play this game?


sTiVo's rule: Just because YOU "wouldn't put it past 'em" doesn't prove that THEY did it.


[ Parent ]
Not a straw man; you get this a lot from SP advocates (0.00 / 0)
Many strong advocates of single payer assert that the insurance companies will always find a way to dump the expensive policy holders onto the public plan, ultimately guaranteeing  their failure. This same argument is used against other forms of step-by-step reform, to the point where "incrementalist" is used as an insult.

It is true that insurance companies are powerful, but I do not agree that they are omnipotent. If that were the case, then how the hell could you achieve the more radical step of eliminating them?

There are a number of mechanisms for slowly transitioning to single payer:
- Age bands (elderly, then children, then college, then ...)
- Occupation categories (farmers, auto-workers, self-employed...)
- Service strata (primary care, catastrophic, dental, chronic condition...)
- Income groups (poor, middle class, unemployed...)
- State-by-state

The strongest argument for permitting people to buy in to the public plan is that it is voluntary. 90% of the opposition to single payer is fear-based. The other 50% (yeah, there is lots of overlap) is that most people have a system that works for them, so they don't want to rock the boat until they see if the new system will work for them.

Significant progress towards health care financing reform will surely benefit from involvement of the unions, and not just because unions have led on so much progressive legislation. Historically, insurance has been a benefit delivered/negotiated by the union, so unions are loath  to give up such a critical demonstration of their value to the workers. With all the take-backs around health-care issues, this may be changing.


[ Parent ]
David, I basically agree with you (0.00 / 0)
I believe single payer is easily the best system to employ for universal healthcare coverage. The numbers bear that out and the american people support it. Furthermore, I completely hate that congress and the administration have marginilized single payer advocates while the insurance companies are present. Even if single payer is not achievable right away, it sure as hell would tilt the level of discourse to the left.

However, I completely disagree with single payer advocates who decry anything short of single payer as not really healthcare reform. If we got a bill this year with a good public option and with all the cost saving measures needed for true reform, then it would asinine for progressives to not be gleeful. It would arguably be the biggest progressive victory in many of our lives, short of the civil rights movement. So I think we need some perspective here, it was only a couple years back where privatizing SS seemed more likely than healthcare reform.

Now, I don't like Obama's hands off approach with the legislation, particularly him telling members of congress to push for a public plan when in private meetings but not doing so in public for fear of losing the insurance companies too early, I understand the calculas, (i.e. the later the opponents of healthcare reform jump into the game, the more likely it will pass) I just don't like it. I do appreciate the time and attention he's given to this. I was really skeptical that he would actually try to work on healthcare early, I thought he would stick with token victories like SCHIP, but he seems to at least genuinely want to get this done.  


David, I basically agree with you (0.00 / 0)
I believe single payer is easily the best system to employ for universal healthcare coverage. The numbers bear that out and the american people support it. Furthermore, I completely hate that congress and the administration have marginilized single payer advocates while the insurance companies are present. Even if single payer is not achievable right away, it sure as hell would tilt the level of discourse to the left.

However, I completely disagree with single payer advocates who decry anything short of single payer as not really healthcare reform. If we got a bill this year with a good public option and with all the cost saving measures needed for true reform, then it would asinine for progressives to not be gleeful. It would arguably be the biggest progressive victory in many of our lives, short of the civil rights movement. So I think we need some perspective here, it was only a couple years back where privatizing SS seemed more likely than healthcare reform.

Now, I don't like Obama's hands off approach with the legislation, particularly him telling members of congress to push for a public plan when in private meetings but not doing so in public for fear of losing the insurance companies too early, I understand the calculas, (i.e. the later the opponents of healthcare reform jump into the game, the more likely it will pass) I just don't like it. I do appreciate the time and attention he's given to this. I was really skeptical that he would actually try to work on healthcare early, I thought he would stick with token victories like SCHIP, but he seems to at least genuinely want to get this done.  


Oops..double post..ignore (0.00 / 0)


[ Parent ]
Interesting point David (4.00 / 4)
and one I have some sympathy for myself, but it may not matter as much as you think.

The classic statement of the "Public Option" came in Paul Krugman's "Conscience of a Liberal"(2007).  Basically, Krugman argued that we could finesse the bad name of "Socialized Medicine" that even "single-payer" had by simply creating a government option like Medicare.  This would be better than most if not all private insurance and would lead to single-payer over time.

Well, the Health Insurance racket is not stupid.  They can read the handwriting on the wall.  Just like Southern slaveholders who were not mollified by Lincoln's "gradual die-off" of slavery, the private Health insurers want no part of a competition they will probably lose.  And so they've put forth the utterly ridiculous argument (coming from them) that competition is great unless it's against the government, in which case it's unfair.  

Of course there's a big contradiction here.  "Government can't do anything right" but there's no way private health insurance can hope to compete against it.  This should open the private Health Insurance racket up to withering scorn from the entire Democratic party, but the argument is barely heard.  The bullshit of the health insurers has been allowed to stand virtually unopposed.  

The Democrats aren't fighting for the "public option".  They are, as in so many other matters, afraid of their own shadow.  The only ones who are fighting are the single-payer crowd.

(I must also mention the weird angle of Howard Dean here, who is trying to conflate the two plans, in a somewhat dishonest way, saying the public option IS single payer, but I don't think he's convincing anyone.)

Ultimately, Democrats MUST stand up for the idea that government has a legitimate place in the Health Insurance industry which is a natural monopoly.  Competition in the Health Insurance industry only wastes money.  Health Insurance is not a service, it's a way of paying for a service.  (Note: it is important to differentiate the Health Insurance industry from the Health Care industry, which is a service).

So YES, it is important for single-payer advocates to respect public-option advocates, but it would sure be helpful if the latter were not afraid of their own shadows and paid some respect to their single-payer comrades in arms.  Allowing single-payer advocates to be arrested without protest in the Senate chambers is no way to show that respect.

 

sTiVo's rule: Just because YOU "wouldn't put it past 'em" doesn't prove that THEY did it.


single payer in the states (4.00 / 1)
there is a good chance of passing single payer systems in Maine, Pennsylvania, and several other states. The most important thing is that Congress pass no plan that prohibits the states from passing their own single payer systems. No plan is better than a plan the blocks the states from enacting their own systems.

i'm not sure i agree with your final sentiment (4.00 / 1)
since it is not more plausible to me that all of the states, let alone half of them, would actually pass single payer.  you know, a bird in the hand and all that.

that said, yes of course, we should fight to prevent the bill from foreclosing state 'experimentation' with single payer.  


[ Parent ]
single payer/public option (0.00 / 0)
The Edwards campaign did the same trick of trying to make a public option the same thing as single payer. I was an Edwards supporter, but I thought a lot of his supporters were way over the line with their "support" (worship). But, that's over and done.

My question now is, where's Dennis Kucinich?? I haven't heard anything out of him in weeks, and nothing about single payer! I thought he'd be on all the shows that would have him to advocate single payer.  

I vote Democratic, I think Independent


Edwards said that (0.00 / 0)
his public option plan could eventually "evolve" into single-payer.  He never said they were the same thing.

[ Parent ]
I agree (4.00 / 4)
As someone who enjoyed single-payer healthcare in the UK for 8 years, I STRONGLY support it here. It can and would work... for everyone except insurance companies, of course.

No one is saying private healthcare insurance would be BANNED if we had single-payer (why does that side have to be so EXTREME?); indeed there is private insurance in the UK too. We can surely have both here.

But while I want single-payer and have many years of nothing but good experiences with it, I do understand that we may not get it, so yes, I also support a public option as a reasonable compromise... as long as it's NOT what we have now, i.e. copays, deductibles, networks, high prescription prices etc. I want to be able to go to any doctor, anywhere. I want no paperwork, nothing out of pocket besides the premium that comes out of my paycheck, and most of all, no wondering if what my doctor says I need will be covered. I no longer want to face bills of thousands of dollars if some bureaucrat decides I didn't really need that MRI.

Basically I want things to change. I want options. REAL ONES. I want single-payer, but if I can't have that, I STILL WANT OPTIONS. And if the option to be on Medicare is the best I can get, than fine. I'll take it. It's better than this. I'm just sick of THIS.


we are not talking about socialized medicine (0.00 / 0)
like you have in the UK, we are talking about a Canadian style medicare for all where there would be NO private health insurance. Private providers would bill the gov't which would pay for everything.  

[ Parent ]
That's not what I've heard (4.00 / 2)
From all I've heard, no one would be forced to use the proposed govt healthcare plan. Everyone would still have the option to get their healthcare privately/through employer if they choose. There is private health insurance in the UK too. It's not like private healthcare is eliminated entirely. Believe me, rich folks in the UK don't go NHS.

I haven't heard anyone saying private health insurance would be eliminated; after all, the whole idea of healthcare reform is to provide options instead of forcing everyone to use something that may not suit their needs. The best thing would be what they have in the UK... a government healthcare system for the masses, coupled with private healthcare for those who prefer that and can afford it.


[ Parent ]
Choice is important, but the public plan needs to be well-funded (0.00 / 0)
I never agreed with the idea that private insurance companies should be eliminated or outlawed or whatever.  Yeah they suck, but people should still have the option of buying shit if they so choose.

The problem is that if we have both private and public plans, what may happen is that the cheaper public plan will attract the poorest/sickest people, and be overwhelmed financially.  Without a solid funding base, the public plan will not do well for long.

As I understand it, the NHS is funded by all taxpayers, including those who also buy private insurance, thus the complaint of "paying twice" (a similar complaint also exists for private school consumers).  IMO, this is the way that health care should be: everyone pays into a public government system, but can buy a private one as well if they so choose, just like in education.  That way, the public system won't be constantly jeopardized by a lack of a funding base.  The public plan as being discussed right now, though, will not enjoy the financial support of all citizens, as I understand it.


[ Parent ]
What's The Goal? (0.00 / 0)
I think that single-payer advocates are VERY justified in their with us or against us stand.

Policy: The public option can be the bridge to single-payer healthcare, but it can also be the elitist tool that finally kills single-payer.

Politics: You won't win a negotiation by pushing for the already compromised position.

Most people on the left, including bloggers, are not pushing for single-payer healthcare. Whether they are supporters or not, they are pushing one of several already compromised positions. The few politicians that have come out in favor of the public option use the phrase "buy into" which is a signal to single-payer advocates that even the public option will have loopholes. With regressive democrats like Max Baucus writing the legislation, there is a big possibility that the public option rules could be written in such a way to steer Americans back to private insurers or to continue to go uninsured.

I am totally in favor of health care reform.
I am diametrically opposed to health insurance reform.


RE "pushing for the already compromised position" (4.00 / 1)
While bang makes some VERY important points that I agree with (particularly those in the last paragraph of bang's comment), I think the "already compromised position" argument doesn't hold up.

I've come to agree strongly with the many reasonable, committed, experienced progressive activists who include folks at MoveOn, US Action, ACORN,  HCAN, etc... who've concluded that at this point in time--with the US Congress being who we have now and the campaign finance laws being what we have now--that it's not possible at this time to pass and enact full single-payer/aka improved Medicare-for-All reform in one step, but IT IS POSSIBLE (not by any means guaranteed, espl'y if there's infighting among the left, but is possible) to pass and enact legislation that includes a strong public insurance option modeled on Medicare along with new and stringent rules & regs on the private insurance industry.

There's an imperative to acknowledge that if we don't focus our collective energies and efforts on the Left on pushing forward, together, NOW, toward the goal of public health insurance (being either "pure" single payer, or being one option along with strict new industry regs) then it's very likely that we'll not even get a strong public insurance option in the final legislation.

This post is really important in sounding a warning bell and spelling out the dangers of arguing and infighting amongst the Left. That's just what the Right wants and needs us to do, so let's make every effort to not give it to them.

Civil disobedience becomes a sacred duty when the state has become lawless or corrupt. And a citizen who barters with such a state shares in its corruption and lawlessness.  --Gandhi


[ Parent ]
It Holds Up VERY Well (0.00 / 0)
Uniting under the already compromised position will not steer negotiations in our favor.

We already have more than enough votes to pass whatever kind of legislation we want. It's just that some politicians think that they are entitled to their position of power. The irony is that in order for us to get what we want these self-serving democrats are going to have to lose an election (the better democrats theory). Since they are going to lose an election anyway, they might as well get everyone covered under the only plan (public or private) that let's us choose our own doctors. There's nothing reasonable about MoveOn or ACORN. They are establishment organizations that don't understand politics is a negotiation. Even the president knows we have everything we need to get this done.



I am totally in favor of health care reform.
I am diametrically opposed to health insurance reform.


[ Parent ]
I somewhat sympathize with the single payer-only crowd, for two reasons (4.00 / 1)
1.) Passage of a health care plan that gets us 70 percent of the way to perfection means that it'll be a long time before we get to 100 percent.  Or put another way, passing major health care reform - with or without a public plan option - will take a lot of the wind out of the sails of the single payer movement.  "We don't need single-payer - we just passed this big health care reform!"

You could argue that Medicare, as great a program as it is, has delayed passage of universal health care.  Sure, lots of seniors are pushing for UHS, but imagine if there was no Medicare and ALL seniors were pushing for UHS.  It'd be unstoppable.

2.) Having a choice between public and private plans is great, but the problem is that that because people who don't choose the public plan don't have to pay into it, the cheaper public plan will attract the poorest/sickest people, and be overwhelmed financially.  Without a solid funding base, the public plan will not do well for long.

The perfect solution, IMO, is where everyone pays into a public government system, but can buy a private one as well if they so choose, just like in education.  That way, the public system won't be constantly jeopardized by a lack of a funding base.  The catch, of course, is that under such a system many people will have to give up the health insurance plan they have now, which violates President Obama's principle of allowing people to keep whatever they have.

The public plan as being discussed right now, though, will not enjoy the financial support of all citizens, as I understand it.  That may lead to financial jeopardy, especially if (per the compromise that Chuck Schumer proposed) the public plan will receive no government support beyond start-up costs.

Of course, I still support the public plan option and I think it's far better than no public plan option.  What concerns me, though, is that the public plan will fail and then not only will tons of people lose health coverage, but conservatives will predictably squawk, "See!  Government never works!"


Insurance companies have to add their profit to the bill (0.00 / 0)
I think the public would not care whether single payer or multiple choices, so long as the net result is what the Baucus' blueprint sounds good:

Goals Of Baucus' Plan:
·         Achieve universal coverage
·         Reduce health care costs
·         Improve the quality of care our system provides
·         Baucus' vision for achieving these objectives includes an individual responsibility to hold health insurance - once quality, affordable, care is accessible to all.
·         His plan seeks to reach that point through measures to shore up the employer-based system, through a one-stop insurance marketplace for individuals and businesses, and through limited expansions of public programs.

Baucus' plan also includes a number of insurance reforms to make the market work better for American health care consumers, and delivery system reforms that emphasize better quality, primary care for more patients, and a stronger focus on preventive care.  Baucus also suggests potential savings and efficiencies that can be found in a remade health care system to reduce the cost of reform.

 

But even if the net result is plausible for the consumer, participating insurance companies would have to calculate their premiums to include probably a 20% profit. The government would have to pick that up, and where does the money come from to pay corporations, and the banking community?

The ambiguity in the italicized portion sounds pretty much like PR, and will turn out to control how much comes from people's pocket.  

A National Progressive Alliance, is the only viable solution.

http://www.openleft.com/diary/...


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