The fate of the Republicans' health-care bill is unclear — but it's not looking good. The ultra-conservative House Freedom Caucus refused to vote for the American Health Care Act because it wasn't cruel enough, resulting in a hasty rewrite over Wednesday night, and further negotiations between them and President Trump on Thursday. But the changes alienated some more moderate Republicans, and failed to appease the ultras anyway. At time of writing, the vote has been delayed until Friday.
The AHCA is a monstrous bill that would leave at least 24 million more people uninsured by 2026. But whether or not it fails, the Democrats shouldn't sit idly by and wait for Republicans to slowly bleed ObamaCare to death by other means. They need a counter-offer, one that's more compelling than the creaky status quo. They need a single-payer, Medicare for all plan. Here's why.
The first reason is that single-payer is quite clearly the best universal health-care policy option for the United States. As Dr. Adam Gaffney explains, the U.S. model of multi-tiered health insurance has generally lousy and highly unequal outcomes, both here and in European countries with similar structures like the Netherlands. Complicated public-private hybrid systems mean much larger administrative costs, and the fact that markets are extraordinarily ill-suited to deliver health care means tons of difficult regulation.
Indeed, the distance in uninsured people between ObamaCare and single-payer is actually greater than that between ObamaCare and the Republican plan. Complicated, janky programs tend to let people fall through the cracks.
All that is made worse by the singular characteristics of the American government. Whereas the government of, say, Finland is akin to a watchmaker, with a delicate, skilled, and precise grasp, the American government is like a lumberjack, with powerful but callused and rough hands. It does Social Security — a straightforward and extremely large program of tax collection, asset management, and check-writing — very well. But it often struggles with complicated regulations that require a lot of deft rules and bureaucratic finesse.
ObamaCare plays to precisely the opposite of America's strengths. Instead of being a simple, straightforward program to hand out insurance coverage — the policy equivalent of a honking great axe — it's got complex regulations, fiddly quasi-market structures, and mandates everywhere you look — the policy equivalent of the repair box from Toy Story 2. It should be no surprise that many of those regulations do not completely fix the problems they were intended to address, or are effectively ignored. We need simpler, bigger, blunter tools, and single-payer fits the bill.
Now, actually implementing single-payer would be seriously disruptive to the existing insurance arrangements in America.
Just under half of people get their insurance through their employers. Expanding Medicare to that size at a stroke would be a huge administrative undertaking, and worse, it would simply delete many large companies that employ tens of thousands of people. Medicare is much more administratively lean than the rest of the insurance industry (and it could be made even more so), and so lots of people who are essentially engaged in pointless busywork would have to find other jobs. (Importantly, that also means we'd be saving tons and tons of money as a society, which could be used to expand comprehensive coverage without cost sharing.)
There are ways that disruption could be handled, of course. You could couple single-payer with a one-time surge of active labor market policy to shift people into new jobs so that everybody landed on their feet, for instance.
This brings me to the politics. As noted above, ObamaCare did not finish the job of achieving universal health care, and this is a good chance to move the ball forward. The AHCA is extraordinarily unpopular because it takes coverage and subsidies away from people, and a majority believe that it should be the government's responsibility to make sure everyone is covered. Fundamentally, Medicare is very popular, a fact only partially covered up by generations of red-baiting and duplicitous austerian propaganda. If Democrats had simply bulled ahead with a single payer-esque plan in 2009, instead of the complicated and heavily means-tested ObamaCare, they almost certainly would have done better than they actually did in the 2010 election.
And even for people who are skeptical of going full-bore all at once on single-payer, it still makes an excellent opening bid. Start with single-payer for all during the next bite at the health-care apple, and you could end up with a plan of combining Medicare and Medicaid, enrolling all people under 26 and over 55, and putting a Medicare buy-in on the ObamaCare exchanges. (That might begin chipping away at the employer-based system and be a somewhat more gradual route to single-payer.) Just witness the original opening bid for ObamaCare, which was far more generous before it got badly whittled down by conservative Democrats.
It also makes an excellent organizing signpost. Medicare for all is simple, easy to understand, and hard to argue against or distort. Most people know someone on Medicare who can testify to the generally good care, or who is counting the days until they can enroll and have the peace of mind that comes with quality coverage. Fabricated agitprop like the mythical ObamaCare "death panels" will be a much harder sell.
As Republicans do their level best to make sure as many poor people as possible go bankrupt from medical debt or die of preventable diseases, a single-payer counter-offer makes perfect policy and political sense. Even if you think it's a bit hasty on the merits, it's still a splendid way for the Democrats to demonstrate, loudly and clearly, that they are for quality health care for all.