Yesterday I wrote that I didn't know how to pass single-payer into law. Upon reflection, I think I spoke too hastily. There is, I believe, a viable, if long-term, strategy to bringing about single-payer. Passing a certain kind of public option is key to this strategy. If a public option meets four specific criteria--accountable to Congress, guaranteed existence, supported only by premiums, and available to everyone--it could very well serve as a gradual, slow implementation of single-payer.
Here are the four criteria a public option needs to start us on a slope toward single-payer:
I know that public option advocates are not supposed to talk about it being a slope toward single-payer, but speaking only for myself that is what I want. Unfortunately, at least from where I stand, it seems highly unlikely we are going to get a public option which meets that accomplishes that goal. Still, if the public option meets the first three criteria--and if health care legislation doesn't ban single-payer at the statewide level--it would at least make it possible to fight for universal availability later on.
- Accountable to Congress. A co-op would not be accountable to Congress, and thus could not be altered by Congress in the future. If the bill cannot be altered by Congress, it cannot be expanded by Congress. As such, unless the competitor to private insurance is accountable to Congress, we are not on the slope.
- Guaranteed existence. The existing public option proposals would not be available until January 1, 2013. While that is a long time from now, it still isn't a trigger because its existence is not conditional to market conditions. As long as we have a public option that is guaranteed to come into existence, instead of one that is conditional based upon Congressional review of market conditions, then we are still on the slope.
- Funded only through premiums. While I would greatly prefer a public option that is subsidized by federal funds, in the short-term it is necessary that the public option is funded only through premiums (and it still counts as only funded through premiums if individuals are given subsidies to pay for those premiums). There are two main reasons for this:
If a public option doesn't exist, it can't be gradually leading us toward single-payer. In order to exist, it needs to be solvent and funded only through premiums after 2014.
- A public option is going to have to pass through reconciliation. As such, in order for it not to survive after 2014, it has to be both deficit neutral and not losing money. This means it has to be funded only through premiums
- Public options funded only through premiums are the only type of public options passed through committee. So, we really don't have much choice right now.
- Available to everyone. The public option has to be available to the entire country if it is going to gradually take the entire country toward single-payer. This is one area where the public options currently proposed by more than one Congressional committee are not adequate. The public options currently being offered will not be available to anywhere close to all of the country, or even a majority of the country. So, even if a public option passes into law, and meets the first three criteria detailed above, it will still be necessary to make it available to everyone before we are truly on a slope toward single-payer.
Then again, I don't really know why we are supposed to be afraid of talking about a slope toward single-payer. For one thing, the only poll I have seen directly asking people about single-payer shows plenty of support:
Time Poll conducted by Abt SRBI. July 27-28, 2009. N=1,002 adults nationwide. MoE ± 3 (for all adults).
"Would you favor or oppose a health care bill that provides for the following? . . ."
"Creates a national single-payer plan similar to Medicare for all, in which the government would provide health care insurance to all Americans."
Secondly, a gradual shift toward single-payer through a public option would be less of a shock to the overall economy, making implementation much easier. Really, there shouldn't be anything wrong with talking about gradually and prudently achieving a reasonably popular, and entirely rational, long-term goal on health care.