the national interest

Pretending Single Payer Health Care Is Easy to Pass Doesn’t Make It Easy

Senator Bernie Sanders speaks during a health-care bill news conference on Capitol Hill in Washington, D.C., on Sept. 13, 2017. Photo: Andrew Harrer/Bloomberg via Getty Images

The American health care system developed, like a deformed tree, around employer-sponsored insurance as its core feature. This has made it extremely hard to build a single, simple universal system, because it would require moving people out of health care they have into something new, and require turning their premium contributions into taxes.

If you could sit down face to face with every American and calmly talk them through the numbers step by step, you could probably convince them to feeling comfortable giving up employer-sponsored insurance. Since you can’t do that, the only option is passing a bill in a hysterical atmosphere where the insurance industry and conservatives bombard the public with warnings of massive middle-class tax hikes and tens of millions of Americans losing their current insurance to get moved onto a government plan.

If we didn’t have an employer-based system already, it might be politically feasible to build a single-payer system. But the politics of uprooting that deformed tree are extremely imposing. You can read a history of the struggle for universal health care, like Jonathan Cohn’s Sick, or Paul Starr’s Remedy and Reaction, to understand why most liberals (and Democratic elites) believe the growth of the employer system has tragically blocked the political path to single payer.

Those conclusions, built up over decades of experience and polling data, inform the mainstream liberal view of health care. Since it’s just too hard to convince people they’ll be better off paying taxes instead of premiums, and exchanging their current insurance for a government health care plan, the path to universal coverages lies in working around the existing system. Paul Krugman made this case last year, and so did I.

Ryan Cooper, like many leftists, dismisses the conclusion. Cooper argues that Krugman and I are merely parroting insurance industry propaganda:

But this argument is garbage. Medicare-for-all would mean vastly more people enjoying good health care, and dramatically fewer people getting kicked off their insurance overall.

Their main argument is pretty clearly going to be centered around loss-aversion. “Most Americans support commonsense, pragmatic solutions that don’t interrupt the coverage they rely upon for themselves and their families,” PAHCF spokesman Erik Smith told The Hill. (Jonathan Chait and Paul Krugman have made similar points.)

Well, yes. A well-designed single-payer system would lead to fewer people losing their insurance. I don’t deny that. Neither does Krugman. Both of us disagree with Cooper that it will be easy to convince most Americans to believe this.

To quote the column of mine Cooper links: “Yes, in an imaginary, rational world, people could be reassured that Medicare will be as good as what they have, and the taxes will merely replace the premiums they’re already paying. In reality, people are deeply loss-averse and distrustful of politicians.” Krugman doesn’t deny that either. “You’d have to convince most of these people both that they would save more in premiums than they pay in additional taxes, and that their new coverage would be just as good as the old,” he writes in the other column Cooper links. “This might in fact be true, but it would be one heck of a hard sell.”

It’s possible, of course, that this political analysis is wrong, or that it will change one day. I kept reading through Cooper’s column looking for the part where Cooper either acknowledged that Krugman and I would like single payer in an ideal world, or that we are wrong about the political hurdles. That passage does not exist. The number of words in Cooper’s column devoted to rebutting our actual case about the politics of single payer is zero. Cooper simply concludes “the medical lobby’s argument [is] mistaken,” and driven by “nothing more than greed.” Either Cooper has not bothered to read the columns he is claiming to rebut (they’re short!), or he cannot understand them (they’re quite simple!), or he is intentionally dishonest.

If single-payer advocates can come up with a way to get around the political obstacles in the way of single payer, they should say what they are. (I have seen many such efforts, though none have struck me as persuasive.) More to the point, you’re never going to enact single payer unless you can address the political obstacles. Simply ignoring the obstacles, and pretending the people who are aware of the obstacles are lying shills who hate single payer, isn’t going to get you closer to enacting the policy.

My previous column notes Bernie Sanders’s regrettable habit of avoiding the political obstacles, and pretending the only barrier to enacting single payer is the greed of the insurance industry, and presumably the politicians who are bought up by them. His fans among the intelligentsia have mimicked this unfortunate habit.

Pretending Single Payer Is Easy to Pass Doesn’t Make It Easy