Gradualism and the fight over Single Payer

Back when I was starting out in blogging back in 2009 (before Game of Thrones started on HBO and gave me something way more popular to write about), I was actually a public policy blogger. And with the ongoing fight over single-payer that came out of Hillary Clinton’s positioning of single-payer as an attack on the Affordable Care Act, interventions by Ezra Klein and Paul Krugman and others on the same, and even my esteemed colleague’s contribution to the debate, my policy blogging interests are starting to reawaken.

One of the topics I used to be really interested in was gradualism as it applied to health care. Indeed, one of my very first blog pieces ever was an essay that pointed out that single payer itself gradually emerged through a series of reforms that took place over decades and only gradually became systems like the NHS.

However, Hillary Clinton and her supporters are making a terrible argument for gradualism.

For all that Bernie Sanders has been criticized for not having a detailed enough plan for his single payer proposal, the following is the grand total of Hillary Clinton’s proposals for health care reform on her website:

“Defend the Affordable Care Act and build on it to slow the growth of out-of-pocket costs.”

“Hillary will continue to defend the Affordable Care Act (ACA) against Republican efforts to repeal it. She’ll build on it to expand affordable coverage, slow the growth of overall health care costs (including prescription drugs), and make it possible for providers to deliver the very best care to patients.”

“The average deductible for employer-sponsored health plans rose from $1,240 in 2002 to about $2,500 in 2013. American families are being squeezed by rising out-of-pocket health care costs. Hillary believes that workers should share in slower growth of national health care spending through lower costs.”

“Crack down on rising prescription drug prices and hold drug companies accountable so they get ahead by investing in research, not jacking up costs… Prescription drug spending accelerated from 2.5 percent in 2013 to 12.6 percent in 2014. It’s no wonder that almost three-quarters of Americans believe prescription drug costs are unreasonable. Hillary believes we need to demand lower drug costs for hardworking families and seniors.”

“Protect women’s access to reproductive health care.”

“Transform our health care system to reward value and quality. Hillary is committed to building on delivery system reforms in the Affordable Care Act that improve value and quality care for Americans.”

“Hillary will also work to expand access to rural Americans, who often have difficulty finding quality, affordable health care. She will explore cost-effective ways to broaden the scope of health care providers eligible for telehealth reimbursement under Medicare and other programs, including federally qualified health centers and rural health clinics. She will also call for states to support efforts to streamline licensing for telemedicine and examine ways to expand the types of services that qualify for reimbursement.”

These random paragraphs and bullet points, needless to say, don’t exactly live up to even the basic requirements for a health care plan, let alone the more stringent standards being applied to Bernie Sanders’ proposals. And while Hillary Clinton’s campaign did send out a four page PDF last year, it’s notable that you can’t find it in the health care section of her own website, and even then it’s still rather bare-bones and small potatoes at that: three free annual doctors’ visits, a tax credit for insured Americans with high out-of-pocket expenses, improved transparency in medical bills, and so on. About the only significant element of her proposal is a “fallback process for states that do not have the authority to modify or block health insurance premium rate increases,” and even that’s incredibly sketchy.

What’s missing in all of this is a sense of directionality – how any of these changes will lead to a genuine universal health care system. There’s nothing here about covering the seven million immigrants who don’t qualify for Medicaid or health insurance subsidies, or the four million Americans who are stuck in the Medicaid gap in the red states, or the 7.7 million young people who aren’t getting health insurance from their employers and who can’t afford the premiums on the exchanges, or the 14.4 million other Americans who aren’t going to be covered either. There’s nothing here about expanding the tax credit subsidies on the exchanges to make health insurance genuinely affordable, or increasing minimum insurance standards to make insurance plans provide quality health coverage. And there’s certainly nothing here about improving on the Medicaid expansion by creating a genuine public option – let alone how we could build upon public programs to gradually achieve a single payer system. This is kind of weird when you think about it, because this is all pretty obvious stuff that even a young policy-blogging grad student like me thought of back in 2010.

And I think this is at least a small part of why Hillary Clinton is getting thumped by Bernie Sanders among young voters:

Because whatever else you say about Bernie Sanders’ plan, it at least gives a vision of a better future. And at a time when a lot of young people are graduating off of their parents’ health insurance plans, floundering in a labor market that doesn’t really provide employer-provided health insurance for people our age (personal story here: I’m an employee of the City University of New York and I don’t get health care through my employers for another two semesters. I’ve also been bounced around three different health plans in as many years through the New York exchange), and actually trying to find decent health care in a system that has a lot of holes, his vision is pretty attractive. I’ve got a lot of friends, a lot of them good progressive activists, who’ve found themselves in states that didn’t expand Medicaid or who found that the only health care plans on their state’s exchange don’t exactly provide quality care (mental health coverage and dental health care insurance especially often isn’t worth the paper it’s printed on), or who’ve found themselves making just enough money to not qualify for premium subsidies but not enough that premiums for plans on the exchange don’t hurt. Forget condescending lectures about how Bernie appeals to the heart but not the head; these people are supporting the Sanders campaign because it’s appealing better to their economic interests than Clinton is.

And this brings me to an important topic. There are genuine limitations to the ACA, but the ACA is being used by some Democrats to block further health care reform. We see in in the national primaries, where Clinton and her surrogates argue that Bernie’s proposals for single payer threaten to undo Obamacare. But we’re also seeing it at the state level – for example, in California in 2012, California’s single-payer bill was defeated when six Democrats in the state legislature walked sideways, arguing that the state needed to focus on implementing the ACA instead. In 2014, a Democratic insurance commissioner’s initiative to give the commissioner the power to reject health insurance premium increases was defeated after a campaign that argued that this would destroy the ACA.

And that, combined with a national campaign that’s simultaneously trying to tell me that Clinton is a genuine progressive, no really, and that single payer is never ever going to happen, makes me suspicious that all of this talk about building on the ACA to make a better system isn’t sincere gradualism. Rather, it starts to sound like the ACA is being used as ideological cover to let moderates push back on attempts to push the Democratic Party to the left without having to stand and declare who they really are.

Because while I may be a millennial, I’m enough of a historian to remember what the content of Clinton’s health care proposal was in 1993-4, and that the Democratic Leadership Council’s think tank calls itself progressive too.