Progressives who favor a single payer program, such as Medicare for All, are frustrated by the current debate. Once again the "pragmatists" dominate the discussion, even though most of their ideas are anything but pragmatic -- absurdly complex, expensive and won't achieve universal health care. Single payer advocates, including physicians, have to commit civil disobedience to have their voices heard in Congressional hearings.
The savior is supposed to be the public option -- a private buy-in to Medicare that would prove the efficacy of public insurance. It's not horrible in theory, although the likelihood of a public option emerging from Congress being a fair test of public insurance is a long shot. Already Senate Democrats in the pocket of the financial services industry, like Chuck Schumer, are giving away the benefits of a real public option. But we shouldn't get too upset about that. The public option is the wrong bottom line. Our strategy needs to change, and we have much more power than we think we do. More below the fold.
There's no reason to make the case for single payer here. Others have done it, including corporate consulting firms that, in order to preserve a modicum of credibility, have admitted that single payer is not only the best way to cover everyone and reduce costs, but the ONLY option that really does both.
So why are we mired in a fight for a "public option?" In theory it's a clever way to trick corporate politicians into voting for something that will ultimately discredit private insurance. But as Steffie Woolhandler and David Himmelstein argue, it's almost impossible to pass regulations strict enough to enforce genuine competition between a real public option and private insurance. Already, Schumer and others are setting the public option up to fail. Consider where the fight for a public option has left us, railing about the need to allow the option to charge Medicare rates. Who cares? The debate has already shifted to meaningless minutiae, a field on which the other side will win.
So we're cooked, right? Another round of health care "reform," with the only options on the table being extravagantly expensive corporate programs that won't actually cover everyone for all their trillions in expenditures. Meanwhile, poor old single payer is the embarrassing cousin locked in the closet when the respectable relatives come to visit. What a shame.
Not so fast. There's a better strategy and a better bottom line. The true test of a single payer system versus private insurance is to run them side by side (of course, this is happening now, with Canadian provinces bordering states that have the US hodge-podge system).
Politically, there are places in the country where progressive forces are strong enough to win single payer at the state level, if the existing legal constraints were swept aside, and the existing sources of public insurance could be folded in.
We should ask House progressives to vote against any bill that does not at least include a waiver option for states to form a single payer system. Under such a system, the states could use all their Medicaid and SCHIP money, and be granted a lump sum equal to the previous year's statewide Medicare expenditures plus any tax revenue the state wanted to raise, be freed of ERISA and other federal pre-emption issues, and allowed to form a single payer system.
This is achievable, if progressive Members of the House have any guts. Because the one thing that President Obama has done is change the political calculus. We just haven't realized it, nor have we challenged our champions to step up.
Right now, the entire health care issue seems to revolve around the usual pack of Senate Blue Dogs. But by setting a deadline for a bill to pass, and making clear that they will use reconciliation to defeat a filibuster, Obama and the Congressional leadership have actually shifted the debate in an interesting way -- it's now much more of a fight within the Democratic Caucus than it is an interparty fight.
The Republicans are essentially marginalized. Primarily they have marginalized themselves by their own ideology -- they are so wedded to market based solutions that they're preparing to say no to anything that involves any more regulation or government expansion of access. But they are also marginalized by the fact that the Democrats are signalling a willingness to go nuclear to defeat the filibuster.
So, what happens when the Party of No is out of the equation?
Well, for one thing, the power balance can shift away from the corporate Senators, if the House Progressive Caucus shows guts and leadership. Since House Republicans will never vote for anything even marginally useful, to summon a majority, Pelosi needs to hold her caucus. For months now, the question has been "can we get the votes in the Senate?" But what if the question becomes "how does Pelosi hold her votes in the House if the Senate bill is too conservative?"
The 75 co-sponsors of HR 676 are more than enough to throw the House Democratic Caucus into gridlock. They can effectively block passage of anything acceptable to Obama, if they're prepared to fight.
Yes I know, I'm sorry. I didn't mean to make you spit your beer all over your screen. I do know that the most progressive members of the House are a bunch of Stockholm Syndrome suffering wimps. They are so used to not winning, that the prospect of achieving ANY more coverage flips their earnest responsible hardworking personality switches.
But it it is NOT a given that a health care bill will pass, at least not a bill that can credibly called a universal coverage bill. So, while we should certainly continue talking about how to make the public option a good one, we should expend our energies trying to get the handful of genuine progressives in the House to stand up on their hind legs and, for once, take aggressive, decisive action. They need to come together and say the following:
No bill without a state single payer option. Period. Sorry Nancy. Sorry Harry. Sorry John. Sorry Mitch. Sorry Barack. No bill. No how. No way. Without this. Period.
We
Will
Vote
No
We will vote no because we think that your approach to health care reform is going to fail. We don't want it to fail. Quite the contrary. We're the ones, more than anyone in Congress, who have fought for decades for universal health care. But every respected academic study of the subject suggests that your approach is going to cover fewer people and cost a monstrously larger amount of money than single payer. In the end, we know we don't have the votes for a national single payer system, and we won't stand in the way of your approach. We'll certainly work on every detail to make it as universal, fair and efficient as possible. But we actually think it won't work, is going to waste literally trillions of dollars and will ultimately discredit the entire notion of universal coverage.
What we want is a fair test. States should have the right to form their own single payer systems if their elected representatives so choose. And then we'll see. We think that any state that chooses single payer will wind up with a massive advantage over other states in terms of job creation, business development and overall tax burden in just a few short years. You may disagree. But let's try it. Because without that, you don't get our votes.
This is just a MUCH better fight than the public option. Simple and clear. There are just too many legislative tricks to turn the "public option" into a useless mess or just another bag of money for the insurance industry. A hard fight for a state single payer option requires many fewer votes, and gives us a classic conservative argument for states' rights.
To understand what we're talking about, here are the basic outlines. A state submits to the Secretary of HHS a plan for a single payer system. Upon certification that the plan meets statutory requirements for comprehensivness of benefits, the Secretary is empowered to grant waivers that allow the following:
- The use of all of the year's Medicaid and SCHIP allotments for the single payer.
- A block grant totalling the past year's expenditures by Medicare for care in that state, plus an annual marginal increase at the Medical consumer price index.
- Freedom from claims of federal pre-emption by ERISA of state
regulation of private health insurance.
Then the state could impose taxes that would make up the rest of the premiums, and set pricing and other policies. This is the very best we could get out of this Congress, and it's a whole lot better than the "public option."