Wayne O'Leary

Health Care’s Line in Sand

Nothing sets apart the Sanders and Clinton presidential campaigns like the question of health care, specifically the candidates’ opposing positions on the desirability of a single-payer insurance plan — what proponent Sanders calls “Medicare for All.” It’s only one issue among many, but it symbolizes the fault lines in the Democratic party separating the progressive antiestablishment from the centrist establishment.

The crux of the matter is whether the US can any longer think big in a political sense, or whether Americans will henceforth have to settle for smaller objectives — whether grand national aspirations are still achievable, or a thing of the past. In this campaign, Bernie Sanders is the visionary, challenging his fellow citizens to set goals in an expansive manner; Hillary Clinton is the incrementalist, urging lowered expectations and a curbing of excessive enthusiasm.

The Sanders message is upbeat, although his critics label it impractical. The Clinton message is decidedly downbeat; it implies that, however desirable it may be in the abstract to have truly progressive government, government demonstrably operating for the general public benefit without kowtowing to private economic interests, that’s not possible in America where private interests and private money appropriately rule. President Calvin Coolidge said it best for all establishmentarians nearly a century ago: “The business of America is business.”

So, in the case of health care, the best we can do is a system incorporating the prerogatives of profit-making insurance companies, pharmaceutical firms, and other interested parties, and guaranteeing their collective piece of the action. If it’s too costly, both in terms of overall spending and individual outlays (family health-insurance premiums rising at triple the overall rate of inflation, for example), that’s just the price we pay for avoiding “socialism.” There’s another price paid that’s harder to quantify: the 29 million still uninsured, who have fallen through the cracks of Obamacare because medical coverage in the US remains a privilege and not a right of citizenship.

Opponents of a comprehensive single-payer plan continue to live with a little white lie to rationalize their diehard adherence to the Affordable Care Act; it’s the disingenuous claim that the 2010 law fulfills the decades-long quest of social reformers and progressive presidents for a universal health-care system, and thereby completes a key part of the Democratic party’s unfinished business.

Actually, Presidents Franklin Roosevelt and Harry Truman visualized something very much like the Sanders single-payer proposal, initially as part of Social Security. Presidents John Kennedy and Lyndon Johnson wanted something similar, but in the face of organized medicine’s opposition, settled for pursuing a single-payer system for seniors alone (Medicare), which LBJ signed in 1965. The late Ted Kennedy, too, worked for an all-inclusive single-payer throughout most of his Senate career.

In fact, until the advent of Hillarycare in the 1990s, and later Obamacare, support of a tax-funded, government-run health entitlement was the official position of the Democratic party. It never occurred to earlier generations of Democrats to build the profit motive into their health initiatives, much less make the individual purchase of health coverage mandatory; these were the bitter fruits of obsessive bipartisanship, the borrowed privatization theories of Republican think tanks, and a desire to keep medical “stakeholders” politically on board.

Contemporary critics of the Sanders plan (most prominently economist Paul Krugman) have undertaken a spirited defense of quasi-private Obamacare, comparing it favorably to the similar non-single-payer systems of some European countries. It’s true, as Krugman points out, that a few successful EU programs rely (like Obamacare) on private insurers, but there are crucial differences.

In Switzerland, which Krugman cites approvingly, insurers can’t make a profit on basic care, and in Germany, the competing private “sickness funds” that provide coverage are also nonprofit. Where private medical-insurance systems exist in Europe, they operate for all intents and purposes as health cooperatives. Moreover, virtually all European governments tightly control drug prices, either through negotiations with pharmaceutical firms, or by setting prices outright as the Swiss do; Obamacare can do neither by law.

Even as Bernie Sanders is demeaned for proposing an “unaffordable” public health plan — alarmist critics decry its $1.4 trillion annual cost without pricing in the enormous offsetting savings realized by eliminating private-insurance premiums — the question remains of how Western Europe has managed to socialize health care and retain viable, indeed flourishing, economies despite gross domestic products a fraction of our own? The answer: its health-care programs are not ruled by the marketplace; they’ve been removed from the profit system.

The US spends 17.9% of its GDP on health care compared to 10.7% for the entire Euro area. The United Kingdom, which has outright socialized medicine (as opposed to socialized insurance), spends 9.4%. Even aforementioned socialist-lite Switzerland spends just 11.3%. And neighboring Canada, one of the models for the Sanders single-payer, checks in at a mere 10.9%.

Regardless, spurious charges continue to be made claiming the Sanders approach, like his agenda at large, is “fiscally unsound” (e.g. USA Today, 1/20/16). The accusation of budgetary ineptitude, a favorite mantra of the establishment media, is without foundation. Sanders pays for his plan in full; opponents just resent how he goes about it — namely, through new taxes, mostly (two-thirds) on corporations and the wealthy in the form of an employer payroll tax and higher marginal estate- and income-tax rates at the top end.

Critics of the Sanders single-payer plan are right about one thing: his proposal will be a heavy lift in Congress; it certainly won’t happen overnight, as he acknowledges. The Vermont senator is an aspirational candidate, and he’s hoping to build a movement and generate a conducive political sea change in the years ahead. It may or may not happen, but the effort is nevertheless worth making.

Here, a historical reminder is in order. We’ve realized only limited, market-oriented health reform to date because both in 1993 with Hillarycare and in 2009 with Obamacare, single-payer was off the table from the start; it was considered “unrealistic” and never accorded a fair and serious hearing. In retrospect, the best way to achieve meaningful reform would have been to aim high while retaining a worthwhile default position. Suppose a Sanders administration pushes hard for a single-payer and fails. The consolation prize might be ... a public option.

Wayne O’Leary is a writer in Orono, Maine, specializing in political economy. He holds a doctorate in American history and is the author of two prizewinning books.

From The Progressive Populist, April 1, 2016

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