Millions of people breathed a sigh of relief when Donald Trump and his Republican cronies failed to repeal the Affordable Care Act (ACA) signed by Barack Obama in 2010 and replace it with their disastrous and deeply unpopular American Health Care Act (ACHA).
The victory has been made sweeter by the revival of public discussion and debate on the reform we actually need: single-payer health care, rather than the compromised ACA.
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Vermont Sen. Bernie Sanders, who is currently the most popular politician in the country, has announced his intention to introduce legislation to “move toward” a national “Medicare for all” system. Sanders’ new proposal falls short of his previous advocacy for single-payer, but it can present opportunities for health care activists across the country.
Another opportunity to advance single-payer is in California, where the Healthy California Act (SB 562) has been introduced. SB 562 would provide universal health care for all state residents regardless of immigration status and take private insurance companies out of the health-care equation.
SB 562 is supported by the Healthy California Coalition, which is led by three longstanding single-payer advocates — the Campaign for a Healthy California, the AllCare Alliance and Labor for Single Payer — along with other organizations such as the California Nurses Association, Physicians for a National Health Program and the San Francisco Berniecrats.
After the full text of the bill was released, Don McCanne of Physicians for a National Health Program gave it a strong recommendation:
It calls for comprehensive health care coverage for all residents of California with no premium, copayment, coinsurance, deductible, nor any other form of cost sharing, for all covered benefits. “Resident” means an individual whose primary place of abode is in the state, without regard to the individual’s immigration status. It’s the real thing.
What is single-payer health care? It’s a system in which a public agency — in this case, the state of California — organizes the financing of health care, thought it is still carried out by various public and private providers. The “single payer” public agency gains the ability to define benefits, negotiate medical costs, including drug prices, and pay all medical bills.
Under a single-payer system, people fund the general insurance plan through their taxes rather than buying policies and paying premiums, deductibles and co-pays, or getting an insurance through an employer who does these things. Medicare, the federal health insurance program for people 65 years or older and people with certain disabilities, is funded and administered in this manner.
The system allows for a freer choice of providers and patient/provider autonomy in medical decision-making, and the simplicity of a universal plan massively lowers administrative costs. Billing and administrative costs in the US health care system totaled an estimated $471 billion in 2012 due to the complex, fragmented insurance system.
Most importantly, a single-payer system transforms health care from a privilege to a social right.
The US is the only wealthy, industrialized nation without some type of universal health care program. Canada, Britain, France and Sweden are among the many countries with national health care programs independent from the private health insurance industry.
These countries pay far less in health care for far better health outcomes. In 2013, health care spending accounted for 16.4 percent of the gross national product (GDP) in the US, compared with an average of 8.9 percent in other industrialized countries.
Despite this dramatic spending difference, among other industrialized countries, the US has the lowest life expectancy, highest infant mortality and significantly higher incidence of chronic diseases such as diabetes and hypertension.
It isn’t difficult to grasp the pressing need to radically rethink the American health care system.
The ACA had positive impacts on people’s lives, and its gains should not be dismissed. The expansion of health insurance coverage due to the ACA reached an estimated 20 million people. Medicaid was expanded to cover more of the poor, at least in states where Republicans didn’t resist it. Insurance companies are prohibited from denying coverage based on “pre-existing conditions” and must provide coverage for a list of 10 essential health benefits under all new individual and small group health plans.
But the ACA failed to provide affordable coverage to millions, further entrenched the for-profit insurance industry and in general didn’t significantly alter the dysfunctional structure of free market health care.
Today, over 28 million people remain uninsured. In California, an estimated 3.8 million people under 65 are uninsured, and millions more lack access to necessary health care.
The cost-sharing (what a person pays out of pocket after premiums) of marketplace plans remains exorbitant for many individuals and families. Deductibles and premiums are on the rise while wages continue to stagnant.
Means-tested benefits, instead of universal benefits, unnecessarily complicated the process of enrollment while curtailing national support for the program. Plus, undocumented immigrants are excluded from coverage under the ACA, though some states provide basic coverage for children or in cases of emergency.
The positive aspects of the ACA ultimately fail to redeem its underlying logic. The goal of the ACA was to restructure the health care system along neoliberal lines by preserving the private health insurance industry, while expanding coverage and mandating that every individual purchase insurance.
Federal subsidies for the premiums of private health insurance plans transfer hundreds of billions of dollars from public hands into the private sector. The Congressional Budget Office estimated in 2013 that $250 billion in federal tax revenue had been lost due to subsidizing private health insurance.
The ACA, which was modeled after Republican Gov. Mitt Romney’s plan in Massachusetts, was from the very beginning a concession to the right and created the path towards Trump introducing an even more regressive health care bill.
With Trump’s drive to strip most of the positive aspects of the ACA while magnifying its negative ones is stalled, the left should embrace the opportunity to put forward single-payer as a real alternative — and reject all demands to concede on this vision.
In California, the fight for single-payer isn’t new. Since the 1990s, a grassroots single-payer movement has been growing, and the history of the fight provides valuable lessons for today.
In 2006 and then again in 2008, a bill similar to SB 562 passed the legislature, making California the first state where lawmakers okayed single-payer legislation. But these were somewhat hollow achievements. Each time, Democratic legislators could pass the bill knowing that it would be vetoed by the Republican governor at the time, Arnold Schwarzenegger.
In 2010, a single-payer bill passed the full Senate and Assembly committees. But that same year saw the federal passage of the ACA. With the Democrats defending their new and far more limited health care system under Obama, California’s single-payer bill was off key with the national message, and the state legislature never put the bill to a vote in the full Assembly.
The bill was reintroduced in 2011 and passed all the Senate committees, but failed by two votes on the Senate floor, with two Democrats voting against the bill and four abstaining. The pressure to implement the ACA combined with a massive state budget deficit made Democrats anxious about supporting an “expensive” bill.
After that, single-payer was sidelined by efforts to defend the ACA — until this year’s Trumpcare fiasco cracked open the conversation once more.
Jerry Brown, California’s Democratic governor, is opposed to single-payer. “You take a problem and say I’m going to solve it by something that’s even a bigger problem, which makes no sense,” he told the Los Angeles Times.
Brown had a different view back in 1992 when he was running for president as the more liberal option. In a debate with other contenders, including the eventual winner of the nomination, Bill Clinton, Brown effectively explained the logic of single-payer:
You cut out all the private health insurance, you have one single payer… And since you have only one source of income in the whole medical establishment, you can drive down the costs. With the holding down of the cost, you can eliminate the intermediary, the middle man, the bureaucracy.
Since his election as California governor in 2011, Brown has retreated from his earlier position and fallen in line with the Democratic leadership’s line on health care, as expressed by Hillary Clinton in last January’s presidential primary debate: “I want us to defend and build on the Affordable Care Act and improve it.”
Following the defeat of Trumpcare, Bernie Sanders tweeted, “Right now we need to improve the Affordable Care Act and that means a public option.”
A public option would create a government-run public health care plan to compete with the private insurance plans when consumers by policies through the ACA’s “exchanges.” This proposal wouldn’t expand the choice of providers, wouldn’t be universal and wouldn’t threaten the insurance industry.
Furthermore, it offers none of the cost-saving benefits of a single-payer system. The expansion of Medicaid under the ACA demonstrated that the sickest people end up in public plans while the healthiest people are scooped up by private insurers.
So why would Sanders push a public option instead of single-payer?
“I believe in a Medicare for all single-payer program, but it ain’t going to happen right now,” Sanders told CNN’s Anderson Cooper at the end of March.
“We don’t have the support in the Congress for that,” he continued. “So while we continue that long-term struggle right now, we need to improve the Affordable Care Act. That means a public option available in every state in this country which gives people a wide variety of options but makes sure that there is competition in every community in this country.”
Last October, Don McCanne of Physicians for a National Health Program laid out the problem with this reasoning:
The tragedy is not so much that on this path we will end up with a public plan that will be only one more feeble player in the dysfunctional market of private plans, but rather that we will, once again, have walked away from single-payer, perhaps for decades, because of this meme about lack of political feasibility.
As the debate over single-payer grows, the task of building a lasting grassroots movement for health care is paramount. A Gallup poll from 2016 showed majority support for replacing the ACA with a federally funded health-care system that provides insurance for all.
With the Trump administration slashing federal health care spending, the moment is ripe for building broad public support for health care as a social right — and pushing single-payer efforts at the state level as a first step toward fixing our broken health care system.