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-------- Original Message --------
Subject: qotd: Ted Marmor and Ellen Shaffer respond on the political
feasibility of single payer
Date: Sat, 1 Feb 2014 16:41:20 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>
The Quote of the Day yesterday, by Kip Sullivan, asked the question,
"Was the ACA 'politically feasible'?"
http://www.pnhp.org/news/2014/january/was-the-aca-politically-feasible
Following are responses by Ted Marmor and Ellen Shaffer, with a reply by
Kip Sullivan:
Theodore R. Marmor, PhD, Professor Emeritus of of Public Policy and
Management and Professor Emeritus of Political Science, Yale University
The plea for a serious discussion about political feasibility by Kip
Sullivan takes us back to the really limited debate about that in
2009-10. The argument attributed to both Harold Pollack and Richard
Kirsch is just circular rather than convincing. The ACA was the best
that we could have in 2010. How do we know that? Because that is what
was produced in 2010. No, the test is what else could have been
proposed--or done--that was feasible politically and would have had a
better trajectory than the ACA, a reform package designed to win
Republican support that never emerged and consists of complex patches on
the patchwork of American medical care as of 2010. Kip raises the right
evaluative question, but the defensive circularity goes on and on. (by
the way, the 'yes but' attributed to me may have confused description
with my convictions).
I think a good case--not a perfect one--can be made that we would be
better off now if Obama had decided the economic stimulus was the key to
his first term and that expanding Medicare to those 55 and older was
within either the feasible set or would have left Obama in a strong
position to fight for that as Kennedy had pushed the original Medicare
bill every year of his Presidency. The ACA is not universal health
insurance in practice, whatever was said in theory. It is a source of
devil-like complexity, one that does not have a straight-forward picture
of how to expand financing coverage, let alone deal with the
second-order effects that provide the Republicans the basis for
criticism and lying about their own earlier inducements of private
health insurance expansion.
Any evaluation of a political outcome must consider the counter-factual
question of what else was doable then. One should not expect easy
agreement of course, but ruling out the question by repeating what
transpired is not defensible intellectually. And, worse, we are left
with an administratively costly and complex arrangement in which it is
hard to see what can be done to make it easy to work, let alone to
understand.
We have more to learn from German modes of administration of multiple
plans, but keep in mind that there the benefit package is for most
purposes common, not differentiated. And there are overall constraints
on the budget through limits on the contributions. We lack both.
Don--it really should be possible to treat the feasibility question
both historically and turn it to use for where we are now.
****
Ellen R. Shaffer, PhD, MPH, Co-Director, Center for Policy Analysis, San
Francisco
To the contrary, the single payer movement has failed to successfully
educate the public about what is wrong with the health care system, and
why we need a single authority with the power of the federal government
to set prices if we are to escape the disastrous cycle of bad access to
crummy health care that costs too much. It is not an easy set of
concepts to convey compellingly to people who don't work in the health
care system, or are so ill that they are regular patients, still a small
fraction of the US public. Nevertheless.
Having presented this argument consistently and assiduously for decades,
including to explain legislation I have helped to write, and including
in articles about the Affordable Care Act analyzing pro's and con's, I
can report a 99% - 100% rate of failure showing up at any public
gathering of single payer supporters and asking them to describe what
the system would do and why they support it.
Did we not advance the idea and substance of Medicare for All? Did we
not attempt to capture the essence of the price-fixing power of the
public sector, while hedging our predictions for its success, in
advocacy for the public option?
Insurance companies are bad. (We got that across.) Profit in medical
care is dodgy at best. Physician reimbursement is too high and
ineffectively distributed, but this can only be understood in the
context of a political economy that is way out of whack re: income
distribution and political engagement. It is well beyond wishful to
contend in this day and age e.g. that a single payer system would
magically reimburse health care professionals and institutions in a way
that would incentivize quality, respect and engage patients, and control
costs.
Single payer advocates did testify in Congress, and many including
myself wrote, spoke and organized. We did not succeed. Our opponents
were better financed and staffed, and history was not on our side. That
the ACA passed at all was in fact a testament to some very nimble and
extraordinary moves by Congressional leaders. It might have made a
difference if we'd had better arguments; better strategies (like
cross-issue alliances); better tactics; or lived somewhere else (with
more dense population and less geographic spread, a culture and practice
of social solidarity, a more vibrant intellectual community, different
socioeconomic demographics). Maybe not. Attributing our failure entirely
to the energy and/or bad faith of those who differed gives them entirely
too much credit. And dooms us to continuing to fail.
****
Kip Sullivan, JD
I agree with each of Ted's points: the feasibility question is an
important one, Kirsch's argument is circular, and Obama probably would
have been better off concentrating first on jobs and putting off health
care reform until later in his first term or until his second term.
I don't understand much of what Ellen is saying, and disagree with those
comments that I do understand.
Let me preface my reply to Ellen's comment by noting that her political
trajectory resembles Kirsch's. Like Kirsch she was deeply involved in
the campaign for single-payer in the early 1990s, then crossed over to
the multiple-payer camp and became a severe critic of the single-payer
movement while simultaneously claiming that she would support
single-payer if only it were politically feasible.
http://www.salon.com/2010/05/22/progressives_practical_healthcare_guide/
http://www.counterpunch.org/2010/06/29/scare-tactics-spin-and-health-care/
She opens her reply to me with the classic "yes but" double standard: A
strict standard for single-payer advocates and a loose or nonexistent
standard for multiple-payer advocates. She states that the single-payer
movement has "failed to convince the public" that we need a
single-payer. Note that she said nothing similar about what ACA
proponents did or failed to do. Did HCAN and Max Baucus "convince the
public" that we needed an individual mandate, accountable care
organizations, and a one-trillion-dollar-per-decade bailout of the
health insurance industry before shoving those provisions through
Congress? Of course not. But, in the worldview of "yes buts," that's
neither here nor there. Only single-payer advocates have to demonstrate
60 votes in the US Senate and majority support among the public before
they're allowed even to be at the table, much less write a bill and get
hearings on it.
In fact, large majorities of the public have agreed with the
single-payer movement since at least the 1980s
http://www.pnhp.org/sites/default/files/docs/2011/Kip-Sullivan-Two-thirds-support-medicare-for-all.pdf.
Her second paragraph makes no sense. She seems to be saying single-payer
advocates don't know how to make the case for single-payer. If that's a
correct interpretation, I have no idea what she's talking about.
Her third paragraph suggests she's lost touch with the single-payer
movement. She asks, Didn't we do a good job promoting the "public
option"? Wrong question. The "public option" that Democrats supported in
2009 (as opposed to the original version of the "option" proposed by
Jacob Hacker) was a sickly little thing that didn't remotely resemble a
single-payer.
http://pnhp.org/blog/2009/07/20/bait-and-switch-how-the-%E2%80%9Cpublic-option%E2%80%9D-was-sold/
But Ellen called the "option" absolutely essential.
In her fourth paragraph in her reply to me she states rather clearly why
she has lost interest in single-payer and has become a managed care
advocate. She repeats the standard managed care canard about the
fee-for-service payment method (it cannot "incentivize quality") and
then invents accusations I've never heard of (FFS causes doctors not to
"respect and engage patients"). In the interest of brevity, let me just
say these claims are nonsense.
Her last paragraph is hard to follow. She seems to say the single-payer
movement had as much access to Congress, and to the back-room planning
sessions, as, say, SEIU, AHIP, the drug industry, or the hospitals. I
really can't tell you what the rest of the paragraph says, other than it
promotes the usual "yes but" thesis: Our opponents were just too
powerful, what else could a good Democrat do but vote for an insurance
industry bailout?
It would have been helpful if Ellen had addressed the main point of my
comment: That discussing political feasibility would have been helpful
prior to 2009. I hope her disdain for the subject is not typical of all
ACA advocates.
****
Brief note about the PNHP Blog:
This is a provocative subject. If others wish to respond, rather than
loading up the email boxes of the list members, further comments should
be made at the PNHP Blog webpage. (Unfortunately, we have had to require
registration and moderation of the messages because of inappropriate
responses. We welcome all legitimate views. Because we have a very small
but overworked staff, messages may not be posted promptly.)
Blog, "Was the ACA 'politically feasible'?":
http://pnhp.org/blog/2014/01/31/was-the-aca-politically-feasible/
To register for the blog:
http://pnhp.org/blog/wp-login.php?action=register
Thanks,
Don McCanne
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