The Nobel Laureate in Economics explores the issues about health reform in his column today in The New York Times. He acknowledges that “Obamacare” is something of a kludge,
a somewhat awkward, clumsy device with lots of moving parts
which will inevitably leave some people out and be more expensive than might otherwise be possible. He then poses the question central to the dispute heard again last night in the Democratic debate:
The question for progressives — a question that is now central to the Democratic primary — is whether these failings mean that they should re-litigate their own biggest political success in almost half a century, and try for something better.
His answer tilts far more to Clinton than it does to Sanders, and given his stature as both an economist and a political commentator, I think it worth our while to examine what he has to say,
Krugman acknowledges that were we starting with a clean slate, most health care economists would argue for a single payer system. But we weren’t, and he points at three reasons applicable at the time the Affordable Care Act was created, reasons he says are not going to go away.
Let me offer all three paragraphs of that part of the column:
First, like it or not, incumbent players have a lot of power. Private insurers played a major part in killing health reform in the early 1990s, so this time around reformers went for a system that preserved their role and gave them plenty of new business.
Second, single-payer would require a lot of additional tax revenue — and we would be talking about taxes on the middle class, not just the wealthy. It’s true that higher taxes would be offset by a sharp reduction or even elimination of private insurance premiums, but it would be difficult to make that case to the broad public, especially given the chorus of misinformation you know would dominate the airwaves.
Finally, and I suspect most important, switching to single-payer would impose a lot of disruption on tens of millions of families who currently have good coverage through their employers. You might say that they would end up just as well off, and it might well be true for most people — although not those with especially good policies. But getting voters to believe that would be a very steep climb.
To these three reasons I want to add a fourth, one I did not hear addressed in the back and forth last night. It is not merely the current players in terms of the insurance industry bigwigs. It is also the hundreds of thousands of people whose employment depends upon the current system to some degree or another. While in an ideal world I would love to see a transition to a single payer system, I have yet to see advocates of such an approach include in their analyses the costs of transitioning those people to other employment, including undoubtedly an extended period where they might need unemployment compensation as well as training for new employment.
That is not offered as an absolute argument against offering a public option, or in attempting to move in such a direction. However, it is possible to offer more complete coverage than we have even under ACA while retaining private insurers, and should we need proof we merely need to examine the health care system in Germany,
There is however a further issue to consider before going down the path of attempting to achieve single payer, and that is the opportunity cost of other progressive initiatives that could not be addressed. Krugman takes this head on in his penultimate paragraph:
There are many items on the progressive agenda, ranging from an effective climate change policy, to making college affordable for all, to restoring some of the lost bargaining power of workers. Making progress on any of these items is going to be a hard slog, even if Democrats hold the White House and, less likely, retake the Senate. Indeed, room for maneuver will be limited even if a post-Trump Republican Party moves away from the scorched-earth opposition it offered President Obama.
And even holding the Oval Office and retaking the Senate, we most likely will, because of gerrymandering, still have the obstreperous House blocking most if not all progressive initiatives.
Where then does that leave us as we consider the current political situation? Krugman thinks Progressives need to be realistic, which as he notes in his final paragraph
it’s really hard to see, given this picture, why it makes any sense to spend political capital on a quixotic attempt at a do-over, not of a political failure, but of health reform — their biggest victory in many years.
I could end here. But even as I strongly agree with Krugman, given whom we honor today, I want to offer a somewhat different perspective from his words:
Cowardice asks the question - is it safe?
Expediency asks the question - is it politic?
Vanity asks the question - is it popular?
But conscience asks the question - is it right?
And there comes a time when one must take a position
that is neither safe, nor politic, nor popular;
but one must take it because it is right.
I believe in those words. And there are those whose purpose is to act upon them.
In offering them I acknowledge and affirm the passion Bernie Sanders has on this issue, among others.
But I would add the following, borne of my experience of teaching in different settings very diverse groups of students.
We must never lose sight of the impact upon persons, short term as well as long term, of the ideals we seek to achieve.
For me that colors how I address those words of Martin Luther King Jr.
For now it is going to take so much effort and political capital to maintain what we have achieved with the Affordable Care Act.
I believe that we will continue to see Republican governors signing on to Medicare Expansion, if for no other reason than the financial burdens it lifts from their budgets.
I offer the Krugman column not so much as a criticism of those seeking something more as a reminder of the need to protect what we have achieved.
That position may be “neither safe, nor politic, nor popular” especially among many Progressives, but when I consider all of the impacts, including the opportunity costs of other initiatives, I believe it is the right course of action.
Peace.