Passing TrumpCare Would Make Universal Healthcare Harder, Not Easier

There’s a popular line of argument going around that the left of the Democratic Party is to be praised for strongly defending the ACA and opposing BCRA even though passing the latter would make single-payer more likely. The bottom line of the argument is correct, but the reasoning is wrong. In fact, the strategy of the left of the party is perfectly coherent: stopping BCRA is in the best interests of health care policy in the short and long term:

To people who think that the primary barrier standing in the way is the fecklessness or corruption of Democratic Party leadership, a Democratic president who favors single payer is most of the battle. But in reality it’s more like 5 percent of the battle. Rather, the difficulty of getting to something like single payer is rooted in formidable structural barriers. In addition to the basic fact that the large number of veto points in the American system protects the status quo, there are two major factors that make the immediate abolition of all private health insurance an incredibly difficult political lift. And Republicans gutting the ACA wouldn’t make them any less so.

The first is that the longer you wait to do a public system, the harder it is to accomplish. When countries like the U.K. and Canada passed nationalized and single-payer programs, respectively, health-care spending represented a much lower percentage of GDP. This made things easier for two reasons. First of all, these countries were able to overcome strong opposition from medical professionals by throwing money at them. American policy-makers won’t be able to buy off doctors, hospitals, and other vested interests that way; indeed, any viable universal public insurance would have to give them a major haircut. This won’t be easy. And, second, all of the countries that created universal programs decades ago have been able to control costs throughout that period. Keeping costs lower through public cost controls over time is a lot easier than cramming them down once they’ve been allowed to grow, as has happened in the U.S.

The second major barrier to single payer or a similar program is that people who have employer-provided insurance or Medicare generally like it. The ACA’s exchanges don’t present much of a problem; any well-designed public program is likely to give most people getting their insurance through the exchanges a better deal. Employer-provided insurance is a different story — a lot of people will likely to be made worse off (although this will probably be less true over time.) And even if Medicare is preserved as is, people already in Medicare have nothing to gain from a universal program and may perceive a threat. In health care, as in many things, people are strongly risk-averse.

The difficult impediments standing in the way of single payer can be seen in the recently failed California proposal. Some of the problems with the bill were California-specific, but some have national implications. The designers of the program tried to deal with the second problem by offering public insurance with generous benefits that would leave very few people worse off. But this ran the bill straight into problem No. 1 — the bill would have been exorbitantly expensive. The answer to the question of whether the levels of taxation necessary to fund the program would be politically viable is implicitly answered by the fact that the Senate bill didn’t contain a funding mechanism at all.

It should be obvious at this point that passing TrumpCare wouldn’t mean an easy path to universal health care. The Republican bill would make the first problem even worse while doing nothing about the second. Universal public insurance would still be a very heavy lift, and with Medicaid having been gutted the next Democratic government would just be starting further away.

Universal health care based primarily around public insurance is not an impossible goal. But it is far more likely to happen through public insurance expansions and voluntary buy-ins that gradually move more people away from employer-provided insurance (which will be easier as it becomes less generous/more expensive.) Passing TrumpCare would just be a setback in this process.