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The Lessons of Colorado

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Dylan Matthews has a good piece about why single-payer failed badly in Colorado, and what lessons are and aren’t relevant at the federal level:

In some ways, the federal situation is more promising than that in Colorado. While major Democrats in the state resisted the single-payer push, more and more national Democrats and 2020 presidential contenders are endorsing Medicare-for-all. “It came too soon and came without an open dialogue with the Democratic Party and candidates up and down ballot,” Dyar, the ColoradoCare field director, says. “Had this initiative had Democratic Party support in Colorado, it could’ve gone much further.”
The federal effort also doesn’t involve a ballot initiative changing the Constitution. If a real push happens for single-payer the next time a Democrat is in the White House and the party controls Congress, there will be time to negotiate particulars and work out the kinds of problems that emerged with the ColoradoCare language. “It’s important that many progressive and centrist groups have a role from the start in writing single-payer legislation,” Dyar says. “Without that buy-in and without that compromise that comes with that process, there’s always something to make someone unhappy.”

“Colorado may not be the best case study in looking to successes and failures on single-payer,” Wood concludes, given ColoradoCare’s unique set of challenges.

But at the same time, the ColoradoCare debate offered some warnings as to issues a federal single-payer push will have to address.

Abortion is a big one. While the US Constitution doesn’t ban federal funding for abortion, the Hyde Amendment does statutorily ban funds from going to abortions (with exceptions for rape, incest, and life of the mother). That’s just a legislative provision regularly included in federal appropriations bills, and it could be repealed as part of a single-payer push.

But as the 2009 to 2010 fight for Obamacare showed, there are some Democrats who might be on board to raise taxes and expand health coverage, but not if that coverage includes abortion. Former Rep. Bart Stupak (D-MI) nearly scuttled the effort by offering an amendment barring federal funds from being used to subsidize insurance plans covering abortions. He and other anti-abortion Congress members threatened to oppose the bill without the amendment, and abortion rights groups threatened to oppose any bill that included it. Eventually, President Barack Obama was forced to issue an executive order limiting funding for abortions through the insurance marketplaces to satisfy Stupak.

It’ll be hard enough to get 218 House votes and 51 (or even 60) Senate votes for single-payer. If even one or two members of either House take Stupak’s position, Democrats could be forced to choose between single-payer with no abortion coverage (which would greatly restrict abortion access and enrage abortion rights groups) and a system in which literally every abortion is paid for by the federal government, enraging anti-abortion groups and likely greatly increasing the number of abortions performed.

Another obstacle is the tax shock. Bernie Sanders has been fairly vague about how he’d fund his single-payer proposal, and past funding plans he’s put out have raised far too little money to cover the benefits. But when Congress actually debates a single-payer bill, that bill will have to specify pay-fors, or else its advocates will need to persuade colleagues to access a massive increase in deficits and debt.

That will be tough. Running against big tax increases and a “government takeover of our healthcare” is, as ColoradoCare’s opponents demonstrated, very easy…

[…]

Bernie Sanders is, of course, hardly a naif about the immense power of corporate interest groups. But even if there were no corporate opposition, winning over the public would be tough. While the current system clearly doesn’t work for people without coverage, most people with employer-based insurance like it. They like it a lot, in fact. And they tend to be very skeptical of big disruptive efforts to change it, as Princeton sociologist Paul Starr argues in Remedy and Reaction: The Peculiar American Struggle over Health Care Reform.

There’s a reason Obama spent months assuring people that if they liked their health plan, they could keep it. When you tell people you’re going to take away what they have now, they usually tell you to go fuck yourself.

This is why many health reform advocates, starting with UC Berkeley economist Helen Halpin and Yale political scientist Jacob Hacker, have argued for transitioning to single-payer by offering a public option available to employers and individuals alike. If such a plan paid the same rates to doctors and providers as Medicare (rates lower than private insurance), that would translate into lower premiums, which would lead employers to gradually shift into the public plan of their own accord, without a huge, super-visible tax increase.

This is the approach that former Rep. Peter Stark (D-CA) offered in his AmeriCare Health Care Act in 2006, and Sen. Chris Murphy (D-CT) is offering similar legislation this year. The Colorado experience suggests that such an approach could avoid the problems that dog more ambitious single-payer plans — particularly if employers could choose between a public plan that covers abortion and a public plan that doesn’t.

Again, as an opposition proposal Bernie’s is fine — there’s nothing wrong with focusing on end goals when you’re not in a position to enact anything, and we don’t know what the next Democratic majority caucuses will look like and what political context they’ll be operating in. But, as Jon Cohn says, supporters of universal healthcare have to be prepared for the strong likelihood that one-fell-swoop (or even a four-year swoop) single-payer program is unlikely, and also be thinking about what changes would move the needle the most strongly in that direction, while reducing the number of uninsured as much as possible.

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