What is Stopping Single Payer Healthcare in America?

This post was originally written on April 9th, 2020

In a HarrisX poll, health care ranked as the highest political priority for 15 percent of Democratic voters. Amid a scattered field that included national security, immigration, and the economy, this 15 percent block was enough to secure health care the top spot. Other data indicate the same. RealClear Opinion Research conducted a similar study and found that for 36% of Democratic voters, healthcare ranked as their biggest concern approaching the 2020 election. In the same wave of research, RCP found that 28% of the voting block believes a “completely new system” is in order, while 39% claim that the “system is not working well” and that improvement is needed. Only a combined 33% of the respondents in this poll described the current healthcare system as “good” or “working well.”

Evidently, the Affordable Care Act was not enough in the eyes of most Democrats and left-leaners. And this shouldn’t be surprising. Despite the leap forward the ACA provided in getting healthcare to underprivileged Americans, its byzantine, corporate-friendly structure artificially pumps up costs, confuses those trying to navigate it, and inevitably leaves out Americans who need it, as any means-tested program will do.

The support among Democrats for healthcare reform is further substantiated by polling done on Medicare For All. We’ve known for a while that Medicare for All is a popular policy, but results from primary exit polls only cement that picture. Despite the hardship Bernie Sanders has faced in the 2020 primary, his flagship proposal performs extremely well within the Democratic base. This is huge for the progressive movement.

But to understand just how much of a win Bernie Sanders and other progressives accomplished through their shifting of the healthcare discourse over the past few years, we have to look at the framing of the exit polling questions. These differ from state to state, but here are a couple examples:

“A government plan for all instead of private insurance? Agree or Disagree?”
“Do you support a single government health insurance plan for all?”

There is no way around it; these questions are delivered in a way that leaves little ambiguity about the proposal suggested. The first example’s use of “instead” differentiates the actual Medicare for All policy from a public option. The second one is slightly more muddled, but “single” implies the single-payer model proposed by only Bernie Sanders and (sort of) Elizabeth Warren. Given the clear-cut phrasing of these questions, their results further prove Medicare for All’s popularity. Even in states where Biden manhandled Sanders, the policy succeeds. Here is an excerpt from a Vox article on the matter:

“Take Florida, where Biden soundly defeated Sanders, winning 62 percent of the vote to the senator’s 23 percent. It was Biden’s biggest win of the day, and one of his strongest showings in the primary so far, but even there, 55 percent of primary voters said they support ‘a government plan for all instead of private insurance,‘”

The thirst for improved, even rebuilt, healthcare is clear as day. But this desire, perhaps surprisingly to some, stretches beyond the Democratic base and those further left of it. When registered Republicans were polled about “Medicare for All,” an astonishing 52% said they support the policy. The framing of this question was more ambiguous; “Medicare for All” has been repurposed so often that it has lost some clarity as an actual policy. The way the question was asked, pollees may assume the question was asking about a public option instead of a pure, private insurance-free Medicare for All policy.

Despite that, having over half of the Republican base support any type of healthcare reform is shocking, especially after its elected officials have worked actively against any type of healthcare change or expansion. This dynamic surfaces in national discourse as well, with the last several GOP nominees vowing to fight against, repeal, or scale back the ACA. (The exception being Donald Trump, who used rhetoric sympathetic or even supportive of a single-payer system at the beginning of his 2016 run).

Of course, 52% support means 48% opposition, and that isn’t a small number. 26% of the Republicans polled “strongly oppose” Medicare for All, and contending with this fact requires acceptance of something obvious — many Americans, especially with right-wing perspectives, are skeptical of government intervention. Medicare for All, and even the public option, are often painted by Republican leaders as “socialist” policies that curtail freedom and choice. Even the ACA, which is comically far from representing socialism in any form, earned Barack Obama the absurd “socialist” tag during his campaign and presidency.

But as with many other issues, the representatives and their constituents are not aligned. An analysis of elected Republicans would suggest that support for Medicare for All among their base is virtually non-existent; try to find vocalized support for M4A from a GOP official, and you’ll see what I mean. But this isn’t the case. Even if we assume an enormous margin of error from the Hill poll cited in the above paragraph, at least 40 percent of the GOP supports some form of increased healthcare, whether that be “Medicare for All” or a public option.

For a large block of the Republican base to support a policy so antithetical to the free-market rhetoric espoused by GOP leaders demonstrates something clear; our healthcare system doesn’t work. Clearly, the pain and suffering that American healthcare causes overrides the Republican base’s inclination against government involvement. Improved healthcare, by any objective metric, is becoming more of a bi-partisan consensus among the American electorate. Evidently, enough Americans have witnessed the horrific consequences of having a healthcare system as deeply privatized as ours.

And this pain isn’t imagined. By most measurements, American healthcare vastly underperforms other countries in the first world. The immediate statistic that jumps out is the number of deaths that arise due to a lack of health insurance. The estimates of this number fluctuate, but generally range between 20,000–60,000. This statistic is often met with disbelief: “No emergency room will turn down a person having a heart attack,” or something similar may the response one makes to hearing it. And this is true; someone on the verge of death is not declined care in the United States because they can’t afford treatment. But these death numbers are computed by factoring in the more nuanced ways a death can occur from not having health insurance.

Because health problems tend to progress over a long period of time, getting them addressed in their infancy is essential. But constant doctor checkups, visits to the clinic, and other forms of non-emergency care are a luxury that many can’t afford. The lack of preventative health care contributes to a majority of these deaths. Silent killers, like high blood pressure, are not identified in time to offer patients with the time needed to make the lifestyle changes necessary. Obviously, identifying the deaths directly attributable to lack of insurance or being under-insured is challenging. But conservative estimates place the yearly death total at 26,000, while a recent Harvard study estimated 45,000. Regardless of what the “true” total is, the single death of an innocent person because they don’t have healthcare is too many. Especially when, by any measurement, America is the wealthiest country in the world. How can we allow 20,000–60,000 deaths, when countries with much less capital than us shrink that number to virtually nothing?

The painful irony of our ineffective healthcare system is that it is remarkably expensive. Take a look at this chart from the Peter G. Peterson foundation.

Here, you’ll see that our proportional healthcare spending is higher than countries that provide a higher quality of care. Despite spending more of our collective wealth, our healthcare outcomes are worse. Which begs the question: how can figures within both the Republican and Democratic establishment ask “how we will pay” for Medicare for All?

This chart is a clearer indictment of our inefficiency. When healthcare per capita is broken down, the United States’ healthcare system again takes first place. For as much as the free market is touted as an effective, self-guided mechanism, the privatization of healthcare results in out-of-control spending for little benefit.

Our spending on healthcare is further proven to be inefficient when we look at the shortcomings of our healthcare system. If we are paying more than everyone else, we should at least be providing the best care, right? Unfortunately, the data paint another picture.

One way to examine healthcare outcomes is to look at life expectancy:

This chart is from 2014, but America’s life expectancy has not improved since then. Unfortunately, there is little reason to believe it will improve unless American healthcare fundamentally changes. One might assume that the United States’ current lag in life expectancy is an anomaly, but this 2017 study argues against that. This study forecasted the potential future developments of life expectancy in many countries and found that the US, among Japan and Sweden, will be the slowest growing in life expectancy. This hypothesis is particularly damaging to the United States because their starting point is much worse than the other two countries named in the hypothesis.

But life expectancy is only one metric, and admittedly, other variables contribute to it. Here is further data that more clearly point towards issues with America’s healthcare system.

As expressed by HealthSystemTracker, “mortality amenable to healthcare is a measure of the death considered preventable by timely and effective care.” In other words, this graph details the degree countries provide healthcare that stops preventable death. The trend continues to emerge: the United States, despite spending more than any other country on their healthcare system, lags behind in significant areas.

Another interesting piece of data here:

The US is finally in first place! This chart depicts the percent of adults who have experienced errors or delays within the healthcare system. This piece of data is particularly damning for the “wait lines” argument often pushed out against universal healthcare. Again, we see the “freedom” and privatization of the American health system not producing the results proponents would tell you are likely.

In fairness to the US healthcare system, there are specific areas in which their care is superior. Treatment of some forms of cancer and heart disease are better here than anywhere else, and that is inarguably a good thing. However, for the richest country in the world, and more importantly the country that spends the most on healthcare, to be so far behind on holistic healthcare measures is a tell-tale sign that the system is functionally problematic.

If the people (mostly) want Medicare for All, and the data bears that the policy would benefit the United States and its citizens, how come the transition has not happened yet?

The answer is simple.

The extent to which corporations control American politics is well-known and obvious. Unfortunately, the health care realm is no different. A look at California’s state-wide attempt to transition to single-payer healthcare in 2017 is a great example. This single-payer, Medicare for All bill in California came at a time where Obamacare appeared in jeopardy; there was desperation for some type of leftward move in healthcare. In theory, a California shift to single-payer would serve as a case-study that would elucidate benefits of single-payer.

The California bill had serious promise. Like the rest of the country, the concept of a tax-funded, single-payer healthcare system was popular — doubly so, in a state as liberal as California.

But the bill didn’t pass. This excerpt from IBTimes illustrates one (major) reason why:

“In the same time, the California Democratic Party has received more than $1.2 million from the specific groups opposing the bill, and more than $2.2 million from pharmaceutical and health insurance industry donors. That includes a $100,000 infusion of cash from Blue Shield of California in the waning days of the 2016 election — just before state records show the insurer began lobbying against the single-payer bill.”

The money insurance corporations poured into fighting California’s healthcare bill showcases their desperation to prevent reform. Insurance companies cause enough damage on their own, through advertisements and other forms of corporate propaganda. However, the eeriest part of the cash dump above is the recipient: the California Democratic Party. Like any other massive political donation, this lump of money functions as a bribe. It’s no coincidence that political figures who take these donations are suddenly “very concerned” about the implications of a Medicare for All system.

And this corporate prevention of Medicare for All extends to the national level as well. One particular individual sticks out as a good example: Pete Buttigieg. An article on Sludge depicts his steady regression from his initial 2018 stance that he supported Medicare for All. Essentially, Pete Buttigieg’s position mellowed the moment he entered the national spotlight and moneyed interests flowed in: “As of mid-2019, he was second only to Donald Trump in overall campaign cash from donors in the health sector.”

Let’s follow Occam’s Razor here. Did Pete Buttigieg randomly have a chance of heart, a sudden moment of mental clarity that allowed him to see the shortcomings of Medicare for All the moment he started receiving these checks?

His weasley rebranding of a public option into “Medicare for All Who Want It” was a devilish trick to maintain the name-popularity of M4A while twisting it into a policy that didn’t threaten the insurance companies. And let’s be clear: this extends far beyond Mayor Pete. Beto O’Rourke’s plan was called Medicare for America. Those further right, like Amy Klobuchar and Joe Biden, delivered a barrage of right-wing talking points about Medicare for All during every single debate, including the ghastly “How will we pay for it?” question. The only ones on the debate stage that ever defended the concept of a true single-payer system were Bernie Sanders, Elizabeth Warren, and Bill de Blasio. Almost the entire remainder of the field dedicated significant amounts of their time trying to flatten M4A’s appeal and fear-monger about American’s losing “choice” and “quality care.”

In fairness, some of the countries I cited as being superior to the United States in healthcare have a public option instead of a true single-payer system. One might ask, what is really wrong about Pete Buttigieg or whoever else advocating for such a policy if it will improve our healthcare system substantially? It’s a fair argument, as there’s no doubt a public option would improve our healthcare outcomes, especially the deaths attributed to lack of insurance.

Two points stick to mind.

1st

The basic principle of a negotiation. The first rule of negotiation is that the initial offer is sky high or dirt low. A skilled negotiator doesn’t enter the deal with a middling, milquetoast approach. Instead, they jump with something extreme, in the hopes that their opponent will have to compromise their initial proposal. There are legitimate logistical concerns about enacting a single-payer system or public option. An enormous percentage of Congress is bought out by insurance companies and would not normally act against their will.

Bernie Sanders has recently received flak for his reliance on “revolutionary” rhetoric, but there’s value in delivering political messages in easy-to-understand, basic slogans. His passionate stump speech of Medicare for All was an effective communication of his token proposal. If he were to be elected, then the American voters would be choosing “Medicare for All” as much as they had chosen Bernie Sanders. Suddenly, the public pressure for the Senate and House to capitulate to the will of the people is more significant, and the odds of radical healthcare reform become much higher. At this point, it becomes likely that at the very least, a public option emerges as policy.

If someone like Mayor Pete becomes president, his public option proposal would be so watered down by the time it passed that it would not significantly compromise the stranglehold of the insurance companies. And the insurance companies, by virtue of the extensive funds they give these candidates, are obviously aware of this fact. The candidates advocating for a public option know they won’t enact a public option, and they can’t even be blamed for it by the voters in the end: many policies are forcibly watered down before passing. Supporting a candidate campaigning on a public option allows them to reap the popularity and public desire of Medicare for All and then skate away free of blame when no serious healthcare reform actually happens.

2nd

Despite the fact that a public option is an enormous step forward in helping the uninsured, it also has serious flaws. How does a health insurance company fundamentally work?

For a health insurance company to be profitable, it (obviously) must take in more money in premiums, co-pays, and deductibles then it gives away in claims. If we have a strict dichotomy of private insurers and the public option, private insurers will certainly do everything they can to secure the healthiest members of society for their plan. This dynamic would inevitably leave the public option inundated with the poor and sickly (Public Citizen).

But outside of the weeds, and from a more zoomed-out perspective, the very notion of private health insurance companies existing contradicts the essence of what healthcare is — a right. The political commentator Kyle Kulinski often compares health insurance to the fire department, mocking the rhetoric used by establishment figures like Joe Biden when they emphasize the importance of “choice.” Who would choose a “private” fire department?

Health insurance is parasitic, and inarguably is a big part of the high costs of our medical system. Not only does the “choice” provided by the mega-corporations confuse citizens simply trying to get care, but it also slaps medical workers with immense stacks of paperwork to weave through. Without a doubt, the “unnecessary middleman” (another Kulinksi favorite) pumps up costs to an unnecessary level and burdens every side of the exchange — except for the health insurance companies, of course.

With Joe Biden now the presumed Democratic nominee, there is little hope for national healthcare reform in the near future. However, a few silver linings persist. Medicare for All is growing in popularity, as the exit polls show. We should assume this trend continues, as the demographics most opposing Medicare for All are the elderly, with the young overwhelmingly supporting it. Even Donald Trump has acknowledged its popularity through recent rhetoric. Public pressure will continue to mount, especially after the Coronavirus further demonstrates the desperate need for improvement. However, there is certainly a growing sense that traditional politics will not achieve this reform. Transitioning into a single-payer system may require the will of the people to be heard in a more profound way than at the ballot box. And depending on how bad things get in the future, that could be an inevitability. But the theory of change is not as important as the change actually happening, and I hope for anything that will push our lawmakers to give people the healthcare they deserve.