The Long Fight for Single-Payer

Why advocates should make the most of a Biden presidency

Movement Politics

In Rules for Radicals, Saul Alinsky wrote, “As an organizer I start from where the world is, as it is, not as I would like it to be. That we accept the world as it is does not in any sense weaken our desire to change it and what we believe it should be.”

Alinsky was a veteran low-income community organizer with strong ties to leftist movements, and was famously tied to Barack Obama in his 2008 presidential run due to his work as a community organizer in the South Side of Chicago. Alinsky’s work laid out a number of “rules” that self-described radicals must internalize in order to build power for the “have-nots” of society, working from a pragmatic standpoint of recognizing the disadvantages we hold at the present moment in time.

There’s another passage from Rules for Radicals, written with the memory of the violent 1968 Democratic Convention still fresh in mind, that holds especially salient at this moment: “Our youth are impatient with the preliminaries that are essential to purposeful action. Effective organization is thwarted by the desire for instant and dramatic change… To assume that a political revolution can survive without the supporting base of a popular reformation is to ask for the impossible in politics.”

It’s understandable that after two hard-fought attempts to change a party that seems so divorced from the struggles of poor and working people, some supporters of Bernie Sanders feel inclined to withdraw from the political process altogether — particularly when the prospects of his central policy proposal, single-payer health care, seems further away than ever. But pinning our hopes on one figure and despairing at his or her loss is the very antithesis to movement politics. No successful liberatory movement has ever been won single handedly, or in one fell swoop. If we’re to take our commitment to single payer seriously, now is not the time to give up and disengage. To throw away the political capital we’ve built would mean conceding the potential of the entire movement and misunderstanding its purpose entirely. There’s a need, as Representative Ocasio-Cortez recently said, to recognize that movement and electoral politics can be separate yet interdependent.

If there’s one thing the left should envy of our far-right counterparts, it’s their stubborn devotion to fight a long-term guerilla war in the public sphere. Grover Norquist, founder of Americans for Tax Reform, famously said, “I’m not in favor of abolishing the government. I just want to shrink it down to the size where we can drown it in the bathtub.” And over the last forty years, they’ve done tremendously well acclimating their ideas into mainstream public policy.

The aftermath of the 2008 financial crisis and subsequent campaigns by Senator Sanders have revealed the myriad of ways that our economy and health care system are irreparably broken. We have an opportunity to capitalize on shifting public thought for the first time since perhaps the advent of neoliberal economics during Reagan’s administration. For some of Sanders’ supporters, the prospect of a Joe Biden presidency is too much to stomach. But he’s made health care reform a central message too; what I hope to lay out is that this represents an opportunity for our cause’s advancement, not a retreat from it. By achieving three main policy goals, we can lay the foundational framework for an eventual single-payer system, making the transition smoother than it is even at the present.

A Single-Payer Blueprint

The most important element of this strategy is to significantly expand those who are on, and support, federally-provided health insurance. It’s become something of anathema among the left to support a public option when the alternative is single payer, but let’s not forget that for years it was an intermediary progressive ideal. And as long as the latter is immediately unattainable, it’s worth a revisit. If enacted as Joe Biden has proposed, every American would have the opportunity to enroll. Although the specifics on how much that plan would cost are sparse, there is one sticking point that does go farther than the public option proposed in the original draft of the Affordable Care Act. It enables the public option to utilize the negotiating power of Medicare, which would dramatically bring down the cost of services and procedures it would cover for those enrolled, and thus the cost of premiums. This could have a ripple effect of incentivizing businesses who currently provide their own insurance to push their employees onto the public plan if the savings are worth it, strengthening its bargaining power even further. The plan would also fill the Medicaid expansion gap by automatically enrolling those low-income Americans denied by their state governments, and doing so with an exemption on paying any premiums, mirroring Medicaid’s virtually free cost. As the most successful element of the ACA, the Medicaid expansion raised eligibility to 133% of the federal poverty line. A Medicaid Expansion 2.0 should raise that threshold both on traditional Medicaid and on the public option even further, to 150% or more, giving all working class and poor families guaranteed coverage at no cost. On the other side, the plan should adopt the idea of a Medicare “buy-in” by allowing people age 55 or older to enroll in Medicare before the current age of 65.

Collectively, these three policies — a broad, comprehensive public option, a second Medicaid expansion, and a Medicare buy-in — would put more bargaining power on the side of HHS while significantly increasing the number of people under its purview. And given the existing plans’ overwhelming popularity among those who are on it, fewer Americans would fall victim to fear mongering attack lines about the implications of abolishing private insurance. In fact, fewer would even have a stake in that debate. With 36% of Americans currently on government health care plans, we could see for the first time in American history, with these policies in place, a majority of the population on publicly-funded insurance, eroding private insurers’ monopoly on health policy. That goal — eroding the private market’s bargaining power against the public sector, must be central to any next step in health care reform if we’re to move closer to Medicare for All.

The second component of this plan is to lay the framework of health care cost containment. At the heart of every single-payer system is the state’s ability to directly negotiate the costs of goods and services provided by hospitals, pharmaceuticals, and medical device manufacturers. The US is a half-century long demonstration of why lacking such a mechanism is detrimental to health costs, and why even liberals who do not support single-payer have a buy-in for a solution. The ACA’s premise that introducing competition between insurers would reduce health care costs was a fundamentally neoliberal one that unsurprisingly failed. Health services aren’t an elastic commodity; there are no competitive alternatives, and people are willing to pay — or go as far into debt — as they have to because the alternative is pain or death. From the price gouging of insulin to HIV medication, we know the injustice this extracts on our most vulnerable. As long as there’s a profit motive involved in health care, there will always be an upward pull on prices, with the past forty years as living proof.

More obscene is the fact that this system works so well for both hospitals and insurers that the rates they agree on are negotiated behind closed doors for their own benefit. It’s the reason you’ll never be given a price quote for a simple hospital procedure before you actually get the bill in the mail, and why even a routine surgery, like a standard birth procedure, can vary wildly even among hospitals within the same city — from $4,701 to $15,973 in the Boston-Cambridge metro area, compared to a fraction of that in Canada, the UK, or France. The rates agreed upon are both arbitrary and inflated by both parties’ desire to bolster their finances, because the costs can and always are shifted onto the patient in the form of higher premiums or out-of-pocket medical bills. The end result is a nation that, unlike any other on the globe, finances its system with medical debt, bankruptcy, and absurd premiums and deductibles that cut deep into disposable household income.

So how do we move toward single-payer-like negotiation without single payer? It turns out there’s already a model that works incredibly well.
All-Payer Rate Setting, a criminally overlooked policy in health care reform, is a system used by Maryland with tremendous benefits since its adoption in 1977. And to no surprise, Maryland ranks lowest in the rate disparity issue mentioned above.

Essentially, all-payer rate setting works by establishing government-run commissions where health providers, insurers, and regulators meet to negotiate and set rates on all medical services and products. In order to expand this system nationally, and to avoid the ACA’s mess of an attempt to coerce each state into handling its own policies, this should be done at the federal level and coincide with the existing twelve regional boards of Medicare. Negotiations would take place annually to adjust for inflation or any other reasonable economic factors, but ultimately the price of any medical procedure would be both public and consistent across the entire region in which that board negotiates. The presence of government officials, whose mandate is to protect consumers alone, introduces for the first time a downward pull on health costs, putting an end to the runaway costs that have suffocated working families and reaped a windfall for insurance companies over the years.

But there’s an added benefit to this system in the long run. One of the biggest vulnerabilities for single payer advocates has been its up-front cost. There’s no doubt that once in place, single-payer produces annual savings that would far outpace the initial cost. Yet finding the appetite to cover that transitional capital is arduous. Most of that price tag is due to the very inflationary cost that’s been accumulated over the past half-century. Hospitals and facilities have budgeted in accordance, and it would be impossible to expect them to find sudden savings without hurting patients. But over time, as health care costs plateau or even decrease due to the new negotiated rates, that price tag both shrinks and becomes more accurate thanks to readily available pricing data that improves prediction models, making the jump to single payer more palatable for weary Democrats we’ll need to win over. And when the time comes, those negotiation boards will be in place and prepared to take over the budgetary infrastructure needed for a single-payer system, already having an intimate knowledge of the providers with whom they’ll be now exclusively negotiating with — by that time without any profit motive at all.

Finally, there’s the need for an entirely integrated, nationwide health care IT system. Part of the administrative waste of the current system is the balkanized array of patient tracking and billing systems that vary with each insurance company, creating entire divisions in hospitals and HR departments devoted to sorting out the differences. In 2009, as part of the American Recovery and Reinvestment Act, Congress passed the HITECH Act, which devoted $35 billion toward an influx of interoperable health IT systems across the sector. But progress has been highly uneven, with some providers still relying on paper records and others far behind the upgrades needed to meet industry standards. Still, the shift to the digitization of health records and “meaningful use” has been undeniable.

Using its strengthened clout, the HHS should build on this progress by setting basic, reciprocal IT standards that all providers must meet including patient-centric tracking metrics. In addition to improving efficiency in the health care system, it lays the groundwork for the digital health record network that Medicare for All would be responsible for adopting.

The Long Fight

The tragedy of Saul Alinsky’s work is that his efforts seemed to be in vain. By the end of the decade, Ronald Reagan’s presidency would be on the horizon, launching the far-right into power and beginning our disastrous ventures of eviscerating the social safety net and welfare system. In a warped sense of irony, his work has even been studied by those on the right, including Former House Majority Leader Dick Armey and Tea Party movement leaders.

Like the activists of the 1960s, we’re approaching a moment where we can either be demoralized by short-term defeat, or emboldened by the resilience of those we’ve fought to elect and the future that they might represent. If we want to see single-payer achieved within our lifetimes, now is the time to use the leverage we’ve built to bend policy in our direction, even and especially under a Joe Biden presidency. Abolishing private health insurance might not be possible immediately, but we do have the clout to shrink it down to a size where we can drown it in the bathtub.

Get the Medium app

A button that says 'Download on the App Store', and if clicked it will lead you to the iOS App store
A button that says 'Get it on, Google Play', and if clicked it will lead you to the Google Play store