More than a few conservatives are of the opinion that should the Affordable Care Act fail to achieve its goals, it would make the adoption of single-payer health insurance in the United States more likely. The reasonable ones who believe this argue that their side hasn't done enough to come up with ideas to address the very real problems in the health-care system, so if the ACA doesn't work, they don't have much to offer in response. If the question is, "Well now what?" and their response is, "How about making it impossible for you to sue your doctor if he cuts off the wrong leg? And can I interest you in a health savings account?", the American public may well turn to the big-government solution instead. I've spoken to conservatives who think that scenario is a real possibility. Carnival barkers like Rush Limbaugh, on the other hand, are telling the rank and file that the rocky rollout of the ACA was all part of the secret plan: things would go wrong, and then the socialist in the White House would be able to swoop in and implement single-payer before anyone realized what was happening.
And there are plenty of liberals who would say, "Sounds good to me!" Not that they're rooting for the ACA's problems to remain unsolved, but they are trying to make people understand that the difficulties are a result not of the ACA containing too much government, but of it not containing enough (this is a point I've made myself). But a belief that the ACA's failure would make single-payer more likely fundamentally misreads our political history.
First of all, when we talk about the ACA "failing," what specifically are we saying? Well, there's a glitchy website, which I suppose might never work, but that seems unlikely. Despite conservative cries of freedom crushed under government's boot, an ACA failure would in most cases—at worst—mean things stay as bad as they've been. Premiums might not come down. Some significant number of people might still be uninsured. People buying insurance on the individual market might not be all that happy with their coverage. Businesses might face significant costs insuring their workers. All of which describes the status quo.
So even a "failure" of the ACA would likely be greeted with the general sentiment that it didn't help as much as people hoped. Would it then be possible to assemble the kind of political momentum necessary to pass single-payer? That seems all but impossible. Keep in mind that meaningful health insurance reform had behind it an almost unanimous Democratic party for decades before it was finally achieved. What it finally took was a worsening of key trends like premium costs and rates of uninsurance, combined with the momentary possession of big enough congressional majorities to overcome Republican obstruction, combined with the co-opting of the powerful interests that traditionally opposed reform. It wasn't as though Barack Obama woke up one day and decided he'd like to reform health care; the work, including devising the plan he adopted, had been done long before he came to Washington.
So let's say it's five years from now, and the most likely thing has occurred: the ACA is working well in some areas and less well in others, and liberals like me are still saying that single-payer would be better. Even if it was worse than that, could you assemble that same unanimity on the Democratic side to push for it? Almost certainly not. Could you stand up to the fierce opposition of interest groups like insurers and pharmaceutical companies and device makers and doctors? Probably not. Will you have the filibuster-proof majority in the Senate (don't forget, the "nuclear option" only eliminated the filibuster for some judicial and executive branch nominations, but left it intact for legislation) that would be necessary? Odds are exceedingly slim.
If we're going to see something like single-payer in our lifetimes, chances are it will come not from a grand reform but through a series of smaller adjustments to the current system. For instance, under the ACA millions of people will be moving into Medicaid. Perhaps one day we could see some sort of merger between Medicaid and Medicare, which could be justified on efficiency grounds and could get the support of doctors and hospitals if they could get Medicare-level reimbursements for their current Medicaid patients (Medicaid's payments are lower). Then you might be able to find ways to allow people to buy in to Medicare—maybe first people over 55, and if that works, maybe more people. Perhaps you could offer a public option (!) to people on the individual market but not to those with employer plans. Eventually, through a series of incremental steps, you might be able to widen the part of our system that already resembles single-payer and ratchet toward it taking over the entire system.
I'm not saying any of those moves would be easy to achieve, but what I am saying is that this generation has pretty much spent all the ammunition it had for a knock-down, drag-out fight to reform health care. Yes, selling the public on single-payer is in theory easier than selling it on the ACA was, since it's a lot simpler to explain. But the public is only one part—and not even the most important part—of the challenge. The complexity that is now bedeviling the ACA was the answer to a series of political problems, and it's hard to argue that it wasn't politically deft; after all, Obama did what every other Democrat since Truman had failed to do. But the opposition it got was nothing compared to the fight that would ensue if the next Democratic president tried to pass single-payer in one fell swoop, no matter how badly things go with the ACA. It's much more likely that if the ACA is working pretty well, we'd be able to tweak it around the edges to give more people the option of moving into a government plan if they want to. If there's a path to single-payer, that's what it is.
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