The Path to Universal Healthcare II: The Political and Policy Obstacles

Let’s pick up on the discussion we started yesterday. Before we begin, read Charles Gaba’s piece, which is really good. Done? OK. Let’s assume the first can opener, congressional majorities that despite the skew of both the House and Senate towards rural, conservative jurisdictions are open to comprehensive health care reform (whether a single-payer or, more likely, a hybrid model). I’ll leave out some of Gaba’s important points, such as the fact that under universal health care women’s reproductive services will be under-covered or uncovered whenever Republicans win a federal election. There are still some formidable remaining political obstacles:

• Most people like their insurance, and most people covered by employer-provided insurance are likely to get worse insurance in a universal model. Paul Starr’s book is really good on this point, but one paradox of American health care reform is that its gross inefficiency makes reform more difficult — one upshot of spending so much money is that most people who get health insurance through their jobs have insurance that’s pretty good. This may change, but as of now that’s a lot of people, more likely to vote than the uninsured as a group, who have only downside risk from a transition to universal insurance. Meanwhile, people on Medicare — another politically influential group — have nothing to gain at best and are also likely to perceive a downside risk.  Obama wasn’t dumb when he kept repeating the “if you like your plan you can keep it” half-truth-at-best — risk aversion among the public is a major obstacle to health care reform. This is also why the ACA preserved the incentives for employer-provided insurance although virtually no health policy experts think it’s an optimal system.
• Sharply reducing or eliminating the role of the for-profit insurance industry will put a lot of people out of work. In the long term, this isn’t a reason not to do universal health care, any more than coal jobs are a reason not to support green energy. But in the short term it’s a political problem not just because the companies will fight reform hard but because any statute will be most vulnerable in the next two electoral cycles, and anything that makes the economy significantly worse is bad. All things being equal, it is preferable that this transition happen gradually rather than immediately. (Note that this isn’t in itself a dispositive argument for incrementalism, just a point in its favor.)
• Any universal health care program that is 1)worth doing and 2)has a politically viable level of taxation will have to give practitioners a yoooge haircut. People focus way too much on the insurance industry when discussing obstacles to reform. They’re a problem, but not an insurmountable one. (The ACA passed without buy-in from the insurers, after all.) The real problem is doctors. Another way that the grossly inefficient American health care system insulates itself from reform is that doctors make a lot more money in the United States than in countries with truly universal systems.  Medical professionals are a more influential and much more widely admired group than the insurance lobby. As a result, even in contexts with fewer veto points than the American system universal health care has generally passed by offering doctors a better deal than they had before. If there’s a precedent for passing a universal health care statute while sharply reducing payments to doctors anywhere, I’m not aware of it. This is a big, big political problem.

In short, I suspect the question of whether gradualism or a nearly-immediate transition to universal health care is better on the merits will be moot because the latter is politically impossible. But, at a minimum, supporters of universal health care need to be prepared to deal with these obstacles, and they need to be thinking about what intermidiate steps should be prioritized in the overwhelmingly likely event that passing Medicare For All or some variant proves impossible. There are very, very difficult political and policy obstacles involved here. “Having a president who supports single payer give some BLISTERING speeches” is not a plan. The United States doesn’t lack universal health care because the alternative models don’t exist — just throw a dart at a map of Europe and you’ll get a better one — or because politicians are unaware of them, but because there are all kinds of status quo biases that make comprehensive reform massively difficult. Difficult, not impossible — but handwaving the obstacles away doesn’t get you an inch closer to universal coverage.