Real Talk: Unpacking the Prospect of Universal Healthcare in the United States

It’s time to have a talk about single payer.

Let’s start with clarifying terminology. Although often bandied about synonymously, single payer and universal healthcare are not the same. Think of them as a Venn diagram. Universal healthcare means that everyone has coverage. That’s the ultimate goal. Single payer is one specific mechanism of accomplishing that goal. It’s not the only means of doing so, nor even necessarily the best fit for the United States, given the political conditions we face here today and the reality of the American healthcare system. Single payer could mean universal healthcare, but universal healthcare doesn’t have to mean single payer. A cursory examination of other countries’ healthcare systems abundantly evidences that single payer is far from the sole means of covering everyone, nor is it always the most effective on a financial or human level.

Now is not the first time Americans have toyed with notions of government-sponsored universal healthcare. During the Progressive Era of the early twentieth century, New York state unsuccessfully sought to pass a compulsory method of insurance funded through a combination of taxes and employer and employee contributions. Had it succeeded, it could have served as a model for subsequent healthcare developments in the United States, but that was not to be. Unsurprisingly, it failed because opponents who feared anything that bore the slightest whiff of socialism lined up against it, while a strong lobbying force composed of doctors, employers, and insurers (and, paradoxically, some labor unionists) united to defeat it for their own interests. And naturally, even back in the first decades of the twentieth century, the nature and extent of healthcare that women would receive threw a wrench in the establishment of an all-encompassing healthcare system. Oh, how little has changed.

In all probability, we would see a comparable alignment now to the one that emerged during the Progressive Era, albeit one constituted of different groups, should we attempt to pass single payer. While it should not stop us in our crusade for universal healthcare, it’s reasonable to prepare for pushback from medical device manufacturers and elements of big pharma that certainly wouldn’t be fans of the governmental ability to keep tabs on prices that it would entail.

Had we successfully managed to pass single payer at either the state or federal level at any point in our history, we’d be in a different place at the present day. The reality, however, is that we haven’t. We can’t simply impose the conditions of another country on our own and assume that because single payer works decently in Canada or England (though both of those countries have their own notable healthcare problems systemically and politically, I hasten to add), it will work here. Nor should we cherry-pick the theoretic solutions where the grass appears greenest and overlook other examples, such as the hybrid public/private Dutch system, that suit the current healthcare groundwork we already have instantiated in the United States.

There is no utopian solution to the knotty problem of healthcare. Everyone on the left is of the same mind that healthcare is a human right, full stop, and that we want everyone to have the best possible coverage. The question is how we, in the United States, can arrive at universal coverage. It’s critical that we not conflate one specific method of attaining that aim— single payer — with the aim itself — universal healthcare.

Americans, undaunted as ever, have never ceased trying for single payer. In recent years, we’ve seen failed and stalled efforts in Colorado, New York again, California, and Vermont. Each time, it’s failed for four predominant recurring reasons: America’s (especially the right wing’s) deeply rooted dread of real or imagined socialism, the exponential cost of such a system, the fact that it leaves women’s healthcare out of the equation, and the complexity of administering it.

The American right’s fear of socialism needs no explanation from me. Consider the First and Second Red Scares, McCarthyism, and the Cold War, just to name a few instances of American backlash against actual and perceived socialism in the United States and abroad. Remember how irate people became over the ACA’s individual and employer mandates not that long ago? Multiply that by a hundredfold and you’ll have a sense of the conservative reaction to single payer. And we’re likely not talking exclusively politicians here. Once people realize that single payer would ramp up, not lessen, their taxes and the mandate that they have health insurance, cries of “socialized medicine” will ring from the rooftops yet again.

Cost is another story altogether. People seem to think of single payer as “free” healthcare. Nothing could be farther from the truth. Sure, depending on how it worked, you might pay little or nothing at all in copays when you go to the doctor, but that’s because you’d be paying much higher taxes. Even if you’re not paying copays, should American single payer wind up looking anything like Canada’s, you’d probably have to cover other medical costs (maybe prescription drugs, maybe nursing home care, neither of which are remotely cheap) out of pocket. Senator Bernie Sanders, for instance, dramatically undersold his campaign’s healthcare plan. It would cost trillions more than he estimated, and the federal government would have to get that money from somewhere. Recall people’s outrage over the additional money they had to lay out for the improvements to their healthcare under Affordable Care Act. Single payer makes that look like peanuts. The cost issue is exactly why Sanders’ own home state of Vermont and more recently California failed to pass single payer. Where would the government cobble together the trillions of dollars needed to provide comprehensive healthcare to all Americans? It’s a gargantuan task, and taxpayers won’t be pleased once they realize that they have to foot the bill.

Reflect on HR 676, John Conyers’ single payer bill currently making the rounds. Democrats don’t know how we would pay for the ideal of free healthcare for every American. Undoubtedly, it would require a considerable tax increase at the very least. If Democrats truly want to pass something as radical for this country as single payer, they better do their homework. Republicans will rip them to shreds if they champion an exponentially expensive bill with little to no idea of how they’ll pay for it, and boom, there goes the dream of single payer for who knows how long.

Nor is that the only issue with Conyers’ bill, or indeed any variant of the Medicare for All bills currently floating around the Capitol. Medicare for All is in truth a misnomer, since the Medicare program as we currently know it would disappear, to be replaced with a new federally centralized healthcare system. HR 676 proposes switching everyone from their current coverage in any form to the federally sponsored coverage that the bill would provide. How would we transition everyone without provoking upheaval in our intricately complex healthcare system? How would we ensure that no one falls through the cracks? This isn’t simply adding people to Medicare, but building up an entirely new structure while simultaneously dismantling the ones we have in place. We’re talking millions upon millions of people, vast numbers of whom live with chronic illnesses and disabilities and thus cannot risk losing their health insurance even for the shortest of whiles. What about undocumented immigrants, a particularly pertinent question in view of Trump’s heartless plan to end DACA? What about people who don’t want to give up their current healthcare? They would have no choice in the matter. Imagine the uproar over that, especially since most people like their present health insurance. People hated shifting their coverage once the ACA passed, and they had to do so because their coverage was a mere shadow of what it is now under the ACA’s mandatory essential health benefits. Asking them to do so all over again just a few years later, particularly if Democrats don’t go about it in a thorough and methodical way, is a recipe for disaster. Even when changing for the better, especially when it costs more, people don’t like doing it.

Healthcare represents a fifth of our economy. The idea of uprooting our current structure in one fell swoop will reasonably concern people if we don’t have a detailed plan in place to see it through. Think about people who work in the healthcare industry. What will happen to their jobs and paychecks? What ripple effect will it have on our economy? Given that health insurance is non-taxable income, if people no longer receive healthcare from their employers, how does that impact their wages? What would happen to for-profit hospitals? If they fold, could nonprofit hospitals and community health centers take on the additional patients? These constitute a mere handful of the economic questions we must interrogate if we want to pass single payer responsibly and with as little pain to as few people as possible.

So those are the cost and economic considerations in a nutshell. The women’s health issue is, as per usual, more ideologically dicey. Enter the Hyde Amendment, the 1976 law that bans federal funding from covering abortion except in cases of rape, incest, or imminent danger to the mother’s life. Single payer, of course, would mean that all healthcare spending would filter through the government (hence the terminology “single payer,” as the government would be the sole payer for all healthcare costs), and as such would constitute federal funds. That means that no health insurance could cover abortion under single payer as long as the Hyde Amendment remains law. Nada. Zilch. Nothing. That’s all she (or, more accurately, he) wrote.

While it’s critical to talk about repealing the Hyde amendment, and it’s something we have a moral obligation to do, accomplishing such a feat is a decidedly uphill battle. Take a gander at Republicans’ ramped-up attacks on women’s health and reproductive rights on the federal and state levels since (and even before) Trump entered office. The list of examples is too extensive to enumerate here, but for some highlights (lowlights, really) in no particular order: we’ve got the various Republican healthcare plans that would have undone essential health benefits including maternity care and prevented Medicaid patients from obtaining care at Planned Parenthood; Trump’s measure enabling states to halt Title X funding to organizations that provide abortion; Trump’s new rule in the works expected to emerge any day now that would allow employers to drop birth control coverage; the House’s passage of a bill to codify Hyde; numerous states’ draconian efforts just this year to curtail abortion or render it virtually impossible; and Texas’ rape insurance. In early January, Speaker Paul Ryan declared that he wanted repeal of the ACA to include stopping federal funds to Planned Parenthood, an even crueler assault on women’s health than appears on face value, since no federal dollars pay for abortion under Hyde, period — meaning Paul Ryan was attacking women’s, men’s, and nonbinary people’s preventive care, cancer screenings, and reproductive healthcare. Trump’s 2018 budget basically extends the global gag rule to the United States, barring any institution that so much as offers abortion from receiving federal funds. And, yes, he also reinstated the global gag rule, since his attacks on women’s health know no national borders. Nor should we expect this to cease once Trump ultimately departs from office, since Republicans’ war on women’s health is a long-standing one. Democrats know this a problem, hence Representative Barbara Lee’s EACH Woman Act. We need to see momentum on this bill or a comparable one before we can discuss single payer in any form.

Single payer failed in Colorado for exactly this reason, with major women’s reproductive justice groups such as NARAL pointing out what should be the obvious fact that if a healthcare bill doesn’t cover women’s health, then it’s “not truly universal.” Once again, pursuing single payer in our current political environment not only places women’s health at risk, but back-burners it, telling women that their healthcare needs are unimportant. As should surprise no one who has been paying attention to the healthcare battles of the past seven months (or, you know, ever), the women who would suffer most from passing a single payer law without first repealing Hyde are women of color and low-income women. It’s the age-old trope demanding women sacrifice themselves for the sake of the greater good. That’s misguided at best, and misogynistic at worst. Bodily autonomy is not only vital for women’s lives and health, it’s an economic issue, a racial justice issue, a civil rights issue, a freedom issue. Without control over their own bodies and reproductive futures, women cannot control their health, cannot plan for their (and their families’, if they choose to have families) futures, cannot advance economically and professionally, and are, in practice, second-class citizens. If women aren’t full social, cultural, professional, and economic participants in our country because legislators refuse to trust them with control over their own bodies, we all suffer. None of this is to say that women have to have abortions, but they have to have the right and financial ability to have an abortion should they choose to do so. And realistically, we can expect that Republicans will take their antagonism towards women’s health a step further and refuse to cover contraception as well in any single payer debate.

But let’s say, hypothetically, Congress somehow manages to pass single payer. We’re still dealing with the same incarnation of the Republican party that grounded its campaigns for seven years on repealing the ACA and, at the end of the day, doesn’t believe that the government should be in the business of providing people with healthcare. What kind of strings will they attach? What poison pills will they throw in? That, however, isn’t the most worrisome aspect, as that’s a question we could rightly ask about virtually any bill (although healthcare is a particular concern in this arena, particularly in regard to women’s health — recollect the ACA’s Stupak-Pitts Amendment).

Of primary concern, especially where Republicans come into play, are single payer’s structural and policy implications. Take a step back. What exactly is single payer? It’s centralizing healthcare in the federal government. Given the Republican party’s historic animosity to comprehensive, equitable, and affordable healthcare, the thought of granting them yet more sway over our healthcare than they already possess sends a chill down my spine. Providing them with more power over what kinds of healthcare receive funding and by how much, bearing in mind their track record, is utterly illogical.

Single payer would likely take one of two forms: either it would become an entitlement like Medicaid or Medicare, or it would become part of the federal budget. In either case, we’re placing authority over our healthcare in the hands of the federal government — including the Republican party — rather than our current hybrid public/private model. Should single payer emerge as an entitlement, Republicans could seek to end, cap, or gut it as they spent months striving to do in regard to Medicaid. And we have every reason to believe that they would do so. Their efforts to weaken healthcare went well beyond what we saw in all versions of their cruel healthcare bills. From day one, Republicans sought to undermine and sabotage the ACA, whether that meant refusing to expand Medicaid, limiting subsidies, taking the Obama administration to court over reimbursements to insurers that cover low-income people and thus keep everyone’s premiums down, or spreading false rumors about the law — and that’s just the tip of the iceberg. It’s apparent, then, that Congress not only influences the funding of entitlements, but the administration and determination of what precisely they cover. That should concern us all.

Don’t overlook the threat that the Trump administration imposes either, both in terms of what it could do itself, as well as the enduring damage it will cause to healthcare administration and the precedent it sets for future Republican presidencies. Simply to provide a few instances, the Republican-controlled department of Health and Human Services sent a letter to governors back in March paving the way for them to impose work requirements on Medicaid recipients (which, tellingly, especially targets women); used ACA money to run campaigns against it; diverted taxpayers’ dollars for healthcare to undercut the law; cooked its own misleading score of Trumpcare; halved the enrollment period for 2018 health insurance; and slashed the outreach budget for health insurance enrollment by over 70%. Meanwhile, Trump’s budget explicitly levies such work requirements and guts healthcare spending across the board, strikingly harming women, children, and low-income people. Congressional Republicans want even the bipartisan stabilization bill in the works to provide states greater flexibility in the terms of their healthcare programs (read: cutting benefits).

All told, Republicans haven’t given us any reason to believe that they’d be good-faith actors in any healthcare reform, and we grant them heightened responsibility over determining and administering our healthcare at our peril.

Then there’s option two. Should healthcare become part of the federal budget, Republicans will possess still more pull over it. In light of this country’s long-term and profoundly problematic history of rhetoric surrounding the “deserving poor,” not to mention Republicans’ notorious stance as the anti-science party, this should raise a red flag. They would get to debate which diseases, treatments, procedures, and types of care warrant coverage, as Congress will need to vote to appropriate money annually. How delightful, the thought of adding healthcare yet more starkly to the already-fraught budgetary debates. Healthcare appropriation will compete with such items as defense, and is likely to be one of the first budgetary entries to take a hit in cost-cutting measures as we currently see in England’s NHS. Imagine living with a chronic illness or disability and being forced to stake your life and well-being on Republicans’ healthcare decisions. What happens if Republicans decide not to cover a particular medication, intervention, disease, or research avenue? Our healthcare would become still more of a political football than it presently is, which is saying something. If either England or indeed our own history is any indication, mental health and reproductive health would probably be the first on the chopping block.

Republicans’ antidemocratic process of trying to ram Trumpcare through secretively, as well as the atrocious bills themselves, abundantly prove that they cannot be trusted with our healthcare. Single payer would place women, transgender and nonbinary people, and people with disabilities and preexisting conditions — three of the groups whom Republicans targeted most severely in Trumpcare — at dire risk.

None of this is to say that the ideology behind single payer isn’t laudable. Quite the contrary, as previously stated we have a moral obligation to provide comprehensive, affordable, and quality healthcare to all. The dilemma is how best to go about it, taking stock of our country’s healthcare history and political situation.

In that vein, it’s worthwhile to take a moment to reflect on the major reforms that the ACA brought to our healthcare delivery and system. Very few people, if anyone, think it’s perfect, but it has unquestionably improved quality of life, economic security, and healthcare outcomes for millions upon millions of Americans. It expanded coverage to more people than ever before in our nation’s history, even in the face of Republican sabotage. It dramatically lowered the rate of medical bankrupties. It ended insurance companies’ discriminatory practices of either charging exorbitant sums to or outright refusing to cover people with preexisting conditions. It forbade insurers from charging women more than men for healthcare. It required all insurance plans to offer a meticulous set of essential health benefits, including components that had rarely (if ever) been covered before, like maternity care, mental health care, and preventive care. It removed lifetime and annual caps on coverage. It reduced racial and ethnic healthcare disparities. It sought to supplant fee-for-service care with value-based care, encouraging doctors to work collaboratively as teams and provide optimal treatment for their patients as individuals, rather than throwing as many tests and prescriptions at them as possible. And these few among many instances of improvement arose notwithstanding the flaws in the ACA’s passage and administration, whether we have in mind Democrats’ inability to pass a public option as part of the ACA (thanks, Joe Lieberman), or Republican sabotage of the Medicaid expansion, public confidence in the law, and the individual markets since the very beginning.

It should thus be abundantly clear that the ACA represents a decided step in the right direction. Propelling it through Congress and signing it into law was a true labor of love, one that strove — and remarkably succeeded — to extend affordable, quality, and comprehensive healthcare to all Americans. It fell short of the mark, but that’s hardly a surprise, as revamping something as vital and complicated as our nation’s healthcare system takes time and hard work. There’s no need to throw all the progress we’ve made under the ACA out entirely, all the more so since far from being a failure, if not for the ACA any real possibility of universal healthcare would be no more than a faint glimmer in Democrats’ eyes. Not since LBJ’s Great Society of the mid-1960s did Americans benefit from such a sweeping reform to our healthcare system.

Our energies need to be focused on preserving and strengthening the advances we’ve made under the ACA. Not only is single payer unrealistic at this point in time, it threatens women and people with chronic illnesses and disabilities because of the existence of the Hyde amendment and the heightened power with which it would imbue Republicans who have proven their untrustworthiness in all things healthcare. The good news is that Democratic representatives have introduced precisely such plans to expand and enhance preexisting components of our healthcare system to improve our patchwork public/private approach and get everyone covered that way.

Doing so would require five basic steps. First, we should expand Medicaid to all 50 states, as the ACA originally intended — pretty self-explanatory, albeit not necessarily easy to accomplish. Note, entirely expectedly, that the states that opted not to expand Medicaid are all red ones. Second, we could establish a subsidized public option, whether we allow people to buy into Medicaid as Senator Brian Schatz is championing, or Medicare as Senator Chris Murphy advocates. We even have a state-based precedent in Nevada, which nearly passed a public option during the briefly shining moment of Sprinklecare earlier this year. Third, we must fortify and improve the ACA — which has proven impressively resilient despite sustained Republican sabotage — by increasing subsidies, formally appropriating cost-sharing reductions, promoting competition among insurers, and the like. Fourth, we should lower the Medicare age to 55, which Senator Debbie Stabenow proposed last month. Fifth, until we have a public option up and running in every state, we should allow people to buy into the D.C. exchange where Congress and staffers get their healthcare to address the risk of bare counties, like Senator Claire McCaskill broached back in the crucible of the ACA debate. These senators aren’t alone in advocating for such achievable reforms. The key word here is that they’re achievable. By building on the structure we already have, we could expand healthcare to all Americans without impelling large-scale disruption in our healthcare system, suddenly and astronomically raising taxes, or handing Republicans undue control over our healthcare on a silver platter.

If we’ve learned anything since January, we should understand that healthcare policy and delivery are complicated. Democrats should be wary of not falling into the trap of believing that there’s an easy or swiftly reachable fix, because they’re setting themselves up for severe disappointment. Due diligence, however inglorious, is critical. Propitiously, the initial stages of that due diligence already exist in the form of the research that is the backbone of the ACA, the ACA itself, multifarious studies on the ACA, the legislation indicated above, and policies advanced by organizations such as the Center for American Progress. Equally fortuitously, we have a clear (granted, thorny in pursuit, but clear in policy aims) path ahead of us to advance towards universal healthcare. Senator Patty Murray laid out a variety of steps that she and her colleagues recommend, from reinsurance to cost-reduction programs, that Democrats and Republicans could take on a bipartisan basis this very month. Remember that for universal healthcare to be truly universal, it must incorporate everyone’s needs and voices, including women, transgender and nonbinary people, and people with chronic illnesses and disabilities. Give everyone a seat at the table and a venue to express their needs and concerns. If we want to do this right, we must leave no one behind. Don’t become wedded to any particular means of achieving this ambition, don’t forget to contextualize healthcare policy methodologies in the facts on the ground in the United States, and above all, don’t lose hope or patience. We’ve come a long way against the odds, and we can go still further.