• 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.


    • Jonathan Bernstein recently suggested that conservative state governors and legislatures should have embraced ACA state waivers and made their states labs for the kinds of conservative reforms you’ve suggested the ACA is amenable to. bit.ly/I076zE Perhaps if exchanges fail in red states, and repeal is not an option, state govs their will belatedly seek to shape alternatives more to their liking. Recall, too, that Obama embraced idea of moving waiver start date to 2014 and GOP blew him off.

    • While you may be correct in the short to medium term, I think ACA very much is a long-term road to single payer. Once ACA is in place and has been up and running for a few years, and we’ve had experience with a well-regulated insurance industry, people will start to ask what it is that the insurance industry is getting for its 20% of the US healthcare spending it manages.

      At that point, it will be very easy to sell single-payer.

      Even worse for the insurance industry, if you look at the money actually spent on health care, the industry squeezes US citizens for a 25% surcharge. “Why do we have to pay another 25% for our medical care” is a very different story from “only 20% of what we take in goes to profit plus costs.” (Both of which are, of course, true.) I submit that it’s going to be time to sell those insurance company stocks you hold sooner than later.

    • Single payer, in my opinion, would not be a good step for this nation:

    • A functioning individual market will make it easier to remove tax exemptions for corporate insurance and the corporate mandate. Whether that move to a less skewed market for insurance will result in lower prices and better service or will make the public eager for universal health care really depends on your beliefs.

    • Let us pray that if single payer is widely promoted, it will be promoted with honesty over who has to pay what in new taxes in order for it to work.

      That has been a terrible weakness of the ACA. The fact that so many people are stunned by premium increases is an indication of the problem.

      A single payer system will require some combination of higher payroll taxes, higher income taxes, higher sales or financial transaction taxes, and firm controls on hospital budgets.

      These increases cannot just be on those making over $250K a year, or just imposed on the healthy insureds in the individual market.

      Vast numbers of corporations have self-funded plans and so pay nothing toward helping the uninsured. Vast numbers of seniors pay only a fraction of their Medicare costs. Many veterans get free care with no increase in their taxes.

      I actually want single payer, but it must be presented honestly in order to survive.

      • Have many people been stunned with increases or has it just been a few who have been given all the attention? My family, for instance, has been stunned by a big decrease despite ineligibility for a subsidy. We got a refund this year, too.

    • “I assert that the ACA is not a stepping stone toward single payer.”

      At present we have a mess (predicted earlier) and in the future my opinion is we will have a mess as well. The ACA was poorly constructed and I believe will have to quickly evolve into something else and that is happening right now. I believe your assertion and explanations are very reasonable.

      The question is will it really evolve? Already answered is if it does evolve will it become single payer which is more stable than the ACA (an opinion I believe held by most whether or not they agree with single payer). The alternative evolution would be towards a more market oriented system which you seem to believe more likely. I agree, but what are the chances the ACA will remain reasonably intact? …And if it remains reasonably intact, how?

      To those that are desirous of single payer”

      If single payer in this country could be proven to work then I might even support it, but I don’t believe it can. We have single payer today for most that are over 65 and that program is bankrupting the nation. Those that don’t read the Medicare updates every month don’t realize the problems this single payer system has. It changes policies all the time and yet the direction of costs continues upward far exceeding inflation.

      Those supporting single payer should be proving its efficacy in the Medicare program before attempting to place the entire nation under such a plan. However, to date, no single payer proponent has provided a cogent plan to solve Medicare’s problems. They have argued it works efficiently by inaccurate comparisons, but they haven’t met the burden of proof since Medicare costs continue to rise and look unsustainable.

    • Emily you are on the right track here.

      Medicare now spends more on Part A than it takes in from tax revenue.
      But there is no push to raise the payroll tax on all incomes, even though the 2.90% has not changed for about 20 years.

      Medicare Part B gets about 10% of its revenue from premiums paid by seniors, and the rest of its funding from income tax collections. Every year it eats into general revenue and leaves less for other worthwhile endeavors.

      I say this as someone who wants Medicare to expand — expand to lower ages, and to those with crippling illnesses at any age.

      But I also believe in pay as you go.

    • What about Vermont? It’s using ACA funds to set up single-payer in the whole state of Vermont. Will that make a difference for any of the other states?