Incremental Health Reform Can Still (Slowly) Work

Henry Waxman, the master of taking advantage of what’s possible in health care, warns against single-payer litmus tests.

One of the big trends in Democratic policy thinking since the 2016 elections has been the ever-increasing ranks of elected officials and advocates supporting single-payer health care. Indeed, in many parts of the country — most notably in the largest state, California — the main remaining question is whether single-payer should become a mandatory “litmus-test” enforced element of Democratic orthodoxy, like support for civil rights, Social Security, or reproductive rights.

The reasons for this gathering force behind single-payer are well-known. The Obamacare experience has shown that less sweeping health-care initiatives tend to be too complicated, too “compromised” in terms of the profit motive in health care, and too limited in appeal. Single-payer is simple, doesn’t involve reliance on private health insurance, and includes every American. Particularly at a time when Democrats (at the national level and in a majority of states) don’t have the power to enact any major health-care legislation anyway, why not go for the gold? The logic is compelling, if not air-tight.

But it’s important to remember that while past health reforms have fallen short of the simplicity and universality of single-payer, they have also over the years made enormous contributions to public health, equal opportunity, and progressive politics. We don’t usually think of Medicare (the primary model for single-payer) and Medicaid as “incremental” steps towards universal health coverage, but they were. And without them, and the many tweaks these and related programs have received over the decades, America would be much further away from the goal of health care as a right.

So it’s appropriate that the person who probably did more than anyone between LBJ and Obama to expand health-care coverage, former congressman Henry Waxman, has offered a Washington Post op-ed warning against the temptation of single-payer-or-nothing thinking in the Democratic Party.

Waxman, who retired from the House in 2014 after an amazingly productive 40 years, is no private-insurance-loving single-payer opponent or professional “centrist.” As his op-ed notes, he sponsored a single-payer proposal with his close ally Ted Kennedy. And he was a California Democrat from a safe Democratic district. But he was also the master of taking what he could get in measures to expand health coverage, particularly via serial expansions (and standardizations) of Medicaid, the 1997 enactment of the CHIP program, and finally passage of the Affordable Care Act during the last phase of his congressional service. And now he’s making the arguments that no single-payer model is really all that pure, and that the political capital necessary to enact single-payer may be lacking for the foreseeable future.

Much as I respect the passion of Medicare-for-all advocates and share their broader goals, single-payer is no panacea. We couldn’t muster the votes for single-payer nine years ago when we had a filibuster-proof 60 votes in the Senate and a 255-179 majority in the House. Even if we recapture control of Congress in 2018, our margins will be smaller. And of course, the Republican in the White House would veto any such legislation.


Just as important, single-payer is no policy panacea. Medicare is hugely successful and popular, but most beneficiaries purchase private supplemental insurance to reduce the burden of large out-of-pocket costs. The most prominent single-payer bill would eliminate all out-of-pocket costs for Medicare, a move whose astronomical costs would require tax increases at politically suicidal levels.


Moreover, most countries with universal coverage, including Germany, France, Switzerland and the Netherlands, do not have what we would define as single-payer, instead relying on private insurance as part of the mix.

Waxman doesn’t just tout past incremental reforms or point out problems with single-payer: he also lays out an ambitious agenda of new incremental reforms, aside from “fixing” Obamacare: expansion of Medicare to cover the long-term care needs of the elderly; initiating the serious cost-containment measures that can make universal health coverage more feasible; and making existing programs more seamlessly compatible to avoid disruptions of and gaps in coverage.

Indeed, one can argue that one of the problems with the rush to embrace single-payer is that it has inhibited fresh thinking on how to expand coverage through other means — which may prove necessary. There are sound progressive reasons for exploring them that have nothing to do with triangulation or corporate campaign donations or lack of courage. As Waxman concludes:

Let’s be united on the goal of universal coverage, pragmatic on tactics and focused most of all on making a positive difference in as many people’s lives as possible.

That’s not as simple as “Medicare for All,” but it’s a strong message nonetheless.

Incremental Health Reform Can Still (Slowly) Work