Wayne O'Leary

Single-Payer and Its Enemies

There seems to be little doubt that, given their druthers, Americans would prefer to have their health care delivered through a publicly funded, government-administered single-payer system, or what has come to be widely known as “Medicare for All” after the legislation introduced in Congress by Sen. Bernie Sanders (I-Vt.) and Rep. Pramila Jayapal (D-Wash.), and endorsed by numerous Democratic co-sponsors. The concept, initially popularized in the US by the 2016 Sanders presidential campaign, has consistently polled in the 55% approval range since then, and even higher (up to 63%) among Democrats.

Reasons for the continuing attraction of single-payer are not hard to comprehend — universality, comprehensive coverage, the elimination of premiums, deductibles, and co-pays — and they’ve been undiminished by the existence of the Affordable Care Act (ACA), or Obamacare, the slow-motion train wreck of a reform generally viewed as “better than nothing” in recognition of its protections for those with preexisting conditions.

Obamacare actually added only about 20 million Americans to the nation’s insured rolls through Medicaid expansion and the ACA exchanges; far more workers and their families, roughly 150 million people or half of all US health-care beneficiaries, are privately covered through an employer. Another 60 million or so are retired and on Medicare, our single-payer system for seniors. A comparison of the premiums applied to these categories of health coverage is instructive in understanding single-payer’s appeal.

As of 2019, most Medicare recipients were paying $135 in monthly premiums, compared to $1,000-$1,100 per month for typical midlevel (or “silver”) private plans found on the ACA exchanges. Around the same time (2017), a Kaiser Family Foundation study revealed that family plans provided by American companies cost their employees, who paid a third of the premiums, an average $476 per month, and family plans offered by some small businesses cost workers even more — up to $700 a month.

Whereas Medicare premiums have been inching up slowly to match rising medical expenses, the price of private plans has been soaring, annually outstripping both worker earnings and overall inflation; average premiums for employer-provided plans, Kaiser reports, rose 63% from 2001 to 2006, 31% from 2006 to 2011, and 20% from 2012 to 2016, while in Obamacare’s individual market, average plans jumped 20% in 2017 alone.

The price difference between public and private insurance results from widely varying administrative costs: 1.1% of total spending in traditional Medicare (7% if subsidized, quasi-private Medicare Advantage plans, one-third of total Medicare, are factored in), compared to 13% for fully private, profit-making insurer plans. Clearly, public Medicare is an all-around better deal.

But premium costs are only part of the story; there’s also a little matter of annual deductibles. Medicare has only a nominal deductible (under $200 for outpatient services). By comparison, a 2016 Kaiser foundation survey of 1,900 employers nationwide discovered four-fifths of their insured workers carried annual deductibles on their company plans averaging $1,500, a 50% increase over 2012 and triple the outlay of a decade earlier; the remaining fifth, employed at small firms, paid $2,100 out of pocket on average. A year later, Kaiser found employees of some small companies facing yearly family deductibles as high as $9,500, deductibles that would disappear altogether under the Medicare for All legislation now before Congress.

Counterintuitively, two-thirds of those with employer-provided plans, we are told by opponents of single-payer, register happiness with their market-based health coverage. Considering the economic burden, I doubt it, but even if true, that leaves a third who are not enthralled. To these must be added the thousands employed by smaller companies increasingly providing no coverage at all. In 2001, 67% of firms with 50 or fewer workers offered health plans; today, it’s down to barely 50%, as small businesses, intent on cutting expenses, allow the struggling ACA exchanges to pick up the slack — at a higher cost to employees.

Regardless, moving away from private insurance toward a public system, which one New York Times columnist sarcastically characterized as “a fever dream,” violates what some regard as the American way — basically, the accidental, jerry-built, job-based system begun during World War II as a way to compensate workers unable to receive salary increases due to wartime wage-and-price controls. Health insurance tied to employment (and therefore vulnerable to economic downturns) has achieved preferred status among Republicans, centrist and conservative Democrats, and corporate America generally, the coalition comprising single-payer’s sworn enemies.

The coalition has mobilized its think tanks: the Koch-funded Mercatus Center for absolutist free-market Republicans and the Center for American Progress (CAP) for centrist Democrats, each dedicated to undercutting any health-care plan associated with populist Bernie Sanders. The CAP, staffed by Clinton and Obama retreads, is particularly insidious; its funding, heavily corporate, consists of money from banks, insurance and pharmaceutical companies, the tech sector, and retailers like Walmart.

On the political front, the enemies of single-payer include (unsurprisingly) President Donald Trump and (somewhat surprisingly) House Speaker Nancy Pelosi. Trump, like Ronald Reagan before him, considers single-payer socialism; Pelosi, dedicated (along with her caucus’ New Democrat Coalition) to shoring up the ACA, which she considers sufficient, won’t allow a vote on single-payer.

Other Democratic opponents of Medicare for All in Congress have adopted a CAP brainchild, Medicare for America, or what wags have christened “Medicare for Some” — essentially, an optional Medicare buy-in for those aged 50 to 64, another better-than-nothing proposal that is favored by a number of Democratic presidential aspirants chary of pure single-payer, Beto O’Rourke among them.

Working hand in glove with single-payer’s congressional opponents is the ideologically hostile US Chamber of Commerce (which fought an ACA public option in 2010), as well as a high-powered lobby, Partnership for America’s Health Care Future, representing the insurers, for-profit hospitals, doctors, and drug manufacturers that have thrived under the ACA; it’s led by veterans of the 2016 Clinton campaign and the Obama administration. In a blast from the past, the industry lobby has raised the specter of increased taxes and a Medicare for All bureaucracy coming between doctors and patients. A spokesman for one of the group, America’s Health Insurance Plans (AHIP), vows resistance to any government-run plan, full single-payer or otherwise, as un-American.

That’s what single-payer advocates are up against. They’d better hope progressives in the Democratic Party have the stomach for the fight ahead.

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, May 15, 2019

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