Why the Affordable Care Act is not the first step toward single payer

This is a companion post to my earlier one that listed ways in which the ACA could accommodate conservative reforms.

I assert that the ACA is not a stepping stone toward single payer. If the exchanges included a public option or if the Medicare eligibility age had been lowered, then I’d say it was a pathway toward single payer. But neither of those things happened. As it stands, the law’s structure does not offer a clear glide-path to single payer.

The closest thing to single payer-ness in the ACA is the Medicaid expansion. But, that’s not one risk pool, as true single payer is. It’s state based. Maybe we could call that “single payer lite™”. But even this isn’t anything like single payer as it’s normally conceived. First, it won’t be universal, at least not soon. The expansion is a state option, as decreed by the Supreme Court, and half the states aren’t expanding (yet?). But there’s more: A particular state’s Medicaid expansion need not be single payer-y at all. Arkansas’s private option will permit new Medicaid beneficiaries to select exchange plans, for example.

My conclusion is that the ACA is far more amenable to more conservative reforms than to more liberal ones. Of course, this could change. A public option could be added, for example. But, having had that political fight recently, I doubt it will. The most likely pathway leftward (in the sense of toward single payer) would be if the ACA failed in a sense that could be interpreted as market failure.

In fact, I do expect the ACA to fail in some states, but not in the ones that are most likely to adopt a state-level single payer program. Exchanges may fail where support for and enrollment into them is discouraged by political leaders and other institutions. Ironically, this is more likely to happen in states whose leaders are more ideologically supportive of market-based approaches. These are also states that are not expanding Medicaid. I don’t know if any ACA-based reform would be appealing in such states, but I do know that single payer would not be.


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