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Single-Payer and Generational Expectations


Yesterday saw an interesting parallel in the realm of health care politics, as at the same time that Hillary Clinton was giving an interview with Ezra Klein where she explained why she thought that single payer, and especially Bernie Sanders’ version of single payer, wouldn’t work, sixteen Democratic Senators endorsed said bill.

I bring this up not to slam Hillary, but rather because I think it illustrates an important phenomena of recent politics: the pace of political change is increasing and at an increasing rate. Even last year, Hillary Clinton’s 2016 proposal to add a public option and Medicare at 55 to the ACA was squarely on the center-left of the Democratic Party – to say nothing of being squarely to the left of the ACA as written and somewhat to the left of all three health care proposals in 2008 – and Bernie Sanders’ proposal was on the left edge of the Democratic Party. Now, supporting single payer in fact as well as in theory has become a requirement for someone to run for the Democratic presidential nomination in 2020.

And it’s very easy for many politicians or political observers to be wrong-footed when the ground underneath them keeps shifting, especially since perceptions of the politically possible (what I call the policy imagination) are heavily influenced by generational experiences.

Contrary to both the obnoxious over-users of the term neoliberal and those who insist that Hillary Clinton has always been a stalwart progressive, the political history of both Hillary and Bill Clinton was profoundly shaped by witnessing the backlash against George McGovern in 1972, the failure to achieve the left policy agenda in the 1970s, and the repeated electoral victories of Ronald Reagan and Margaret Thatcher. As with many of their generation who started on the New Left and then migrated to the center, the Clintons seem to have come to the conclusion that the American people (or at least the electorate) were permanently hostile to the aspirations of the Left.

And here is where the Third Way comes in. The Third Way has often been seen by scholars like David Harvey as a purely neoliberal project: putting a human face on post-industrial capitalism by using some of the fruits of unregulated capital to compensate for its evils. But I think it could also be seen as a project of people with genuinely progressive sympathies and ideals who believed that their maximal ambitions could never be achieved and that the only way forward was to make peace with the Reaganite/Thatcherite status quo and try to win as many incremental gains as were possible without raising the alarm of the fundamentally conservative electorate. This works out to neoliberalism in practice, but explains why quite a few people in the Third Way keep calling themselves progressive and react with such existential pain when they are challenged from the left.

I would argue that this this lowering of expectations of the possible is a kind of generational “scarring” that never fades. Here, I’m guided by the work of Mark Blyth in Great Transformations, which explores the collapse of economic ideas in the 1930s and then again in the 1970s and the ways in which politicians and administrators found it almost impossible to abandon the ideas they had grown up with, and the work of Sheri Berman in The Primacy of Politics and The Social Democratic Moment, which seeks to explain why some left-wing parties were able to adapt to the Great Depression and why some couldn’t, even when that meant cutting social spending and suffering a massive backlash that helped to revive the fortunes of the Nazi Party, so strong was their commitment to historical materialism and their theories of Marxist revolution.

If generational “scarring” is that profound, it’s not surprising that politicians would find it difficult to respond to rapid and unexpected changes in the realm of possibility. To take one case: despite the fact that the Great Recession had created this swell of anger against the wealthy and the financial sector, center-left parties in the United States and Europe were very quick to move away from the temporary Keynesianism that held sway in 2008-2010, and very slow to move away from the politics of austerity. Even when revolts on the left and right demanding radical change ate away at their base, center-left politicians who had gone through that baptism of fire in the 1970s and 1980s that convinced them that there was no alternative to the Third Way kept offering the same cautious incrementalism.

And so it is with single-payer in the moment, with political change taking place in unexpected ways and in unpredictable bursts. Certainly the backlash against Obamacare had probably convinced a significant percentage of the Democratic causes that something had to be done about exchanges where insurer participation fluctuated, where premiums sometimes increased dramatically, and which contained plans that had quite high deductibles and copays which angered a lot of consumers. But without the 2016 election delivering united control of the Federal government to the Republican Party and then the all-out effort to repeal the ACA being pushed through the House and almost through the Senate, I don’t think we’d see the shift to single-payer that we see now.

Because while the argument that the ACA was a Republican plan is bullshit, I do think it was intended as a compromise that would satisfy both the left and the center of the Democratic Party. In 2007-8, many various forces within the Democratic Party – Families USA, Andy Stern and SEIU, the Center for American Progress, the Economic Policy Institute, the campaigns of Hillary Clinton, Barack Obama, and John Edwards, and eventually the Democratic Congressional caucuses – eventually coalesced behind a plan that combined the mandates, group purchasing, and subsidies from the 1993 Clinton plan with a “public option” in place of single-payer. This compromise fell apart in two ways: first, the “public option” was dropped out of the bill, which left the left without as much buy-in, and second and more importantly, the moderate elements of the bill (the exchanges, the mandates, and regulations) didn’t actually reduce the backlash against the law. Insurance companies and hospitals and doctors stayed on the sidelines, to be sure, but the GOP withheld any support and launched a successful campaign of scaremongering that won them control of the House in 2010 and the Senate in 2014.

While the backlash wave may have broken on the rocks of the failed repeal effort, I think a lot of Democrats have come to the conclusion that if the ACA isn’t going to produce that bipartisan, “non-controversial” security, they might as well go for single-payer and dare the GOP to try to take away health care from 300 million as opposed to 30 million Americans. That movement has happened very quickly, within a matter of months and weeks rather than years, so it makes sense that people of a generation used to the decades-long status quo could miss the signals.

In conclusion, I will be very interested to see what happens once “millennials” (another hated term) start entering into political office and how the clash between their own generational experiences and those of Gen X and the Baby Boom is mediated by the political system in what I am sure will be an entirely frictional process.

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