No, overturning ACA would not smooth the way to single-payer care

This morning’s post by Matt Yglesias notes a fairly obvious but important issue that bears attention.

The comportment of conservative Supreme Court justices in oral argument leads many people to seriously consider what would happen if ACA is crippled or struck down. (Like Jonathan Cohn, Henry Aaron, David Cutler, Charles Fried, and Jonathan Chait, I was appalled by the oral argument. You can read my column at for more on that subject.)

Several commentators assert, or at least have mused, that overturning ACA might improve the prospects for a single-payer system. It’s easy to see why one might think so. Single-payer is less vulnerable to the commerce-clause challenge that bedevils the mandate. Outright failure of ACA would discredit bipartisan, market-based strategies within many core Democratic groups. The political and organizational simplicity of single-payer is appealing, too. Killing ACA heightens the contradictions of our fragmented and costly health care financing system, while taking off the political table some of the most workable strategies for incremental reform. Absent a serious and workable alternative, Medicare for all might look surprisingly attractive some years from now.

Still… I just don’t see it.

In the first place, I am confident that a smart and determined conservative judiciary would entertain new constitutional challenges to a single-payer system. Such a system would end or would damage much of the private insurance industry. It would reorder relations between the states and the federal government. It would upend self-insurance arrangements under ERISA, and more. If you believe ACA’s 2,700 pages was long and complicated, wait until you see the junk DNA that would accompany a politically and administratively viable single-payer bill. That’s fertile legal ground for opponents, even absent the current political polarization of the federal judiciary.

Single-payer also runs straight into precisely the political and institutional obstacles Democrats precariously navigated with ACA. I was reasonably closely involved in the public option debate. Many people believe the public option failed because Senator Lieberman hated liberals, or because insurers opposed it. These things mattered. Something else mattered, too. Pretty much everyone on the supply-side of the medical economy—including many constituencies who were otherwise strong health reform supporters—was very nervous  about the federal government acquiring so much bargaining power to dictate prices and other terms of medical care.

When wheelchair manufacturers, your community hospital, insurers, and many medical specialties line up against a single-payer bill, the path to sixty Senate votes seems narrow indeed. Whatever the American voters might tell pollsters right now, a concerted ad campaign supported by these same constituencies would be quite damaging.

Finally, there is the legislative Vietnam syndrome sure to ensue if the Affordable Care Act comes to naught. Health reform supporters acted with skill and determination, spent hundreds of millions of dollars, and took huge risks by devoting much of President Obama’s first term to enacting path-breaking legislation that was only made possible through the largest, most cohesive Democratic majority since 1964.

A core of furious activists might be energized if conservative justices snatch away the football. It might even help President Obama counterpunch to victory this November.  More fundamentally, though, people are energized by the possibility and the experience of actually winning.  Health reform supporters will be quite dispirited by the opposite experience. Across the ideological spectrum, political pros will be quite leery of undertaking such a massive effort again. Maybe in 2030, America would make another concerted effort to cover the uninsured. For thirty million people, that’s a long way away.


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