The single-payer specter haunting health care

June 13, 2017

Christopher Baum analyzes initiatives for single-payer health care in two major states and unravels the distortions of right-wingers trying to discredit this popular alternative.

ON JUNE 1, the California State Senate voted by a margin of 23-14 to pass the Healthy California Act, which would create a universal single-payer health care system for all residents of California, regardless of immigration status.

Two weeks before, in New York, the State Assembly passed a universal single-payer bill, the New York Health Act, for the third year in a row.

Both bills now face challenges in the other houses of their state legislatures--the California State Assembly and the New York State Senate, respectively. But the fact that they have come this far shows that support for single-payer health care is strong and surging.

The idea behind single-payer is to replace the current system--in which health care is administered under a complex and often predatory network of private insurance companies--with one where all people are enrolled in a single, government-administered health care program.

It is not difficult to see why this idea is popular. The Obama administration's Affordable Care Act (ACA) brought health care coverage to millions of previously uninsured Americans. But as of 2016, according to the National Center for Health Statistics, some 28.6 million Americans remained without health care coverage.

Nurses take to the streets for single-payer health care in California
Nurses take to the streets for single-payer health care in California (Healthy California | Facebook)

Even those who do have insurance are often unable to make use of it. According to the Commonwealth Fund's 2016 Biennial Health Insurance Survey, approximately 63 million people reported "not getting needed care because of cost."

And now, the Trump administration and the Republican-controlled Congress are doing everything they can to tear down even this flawed system.

The Republicans may or may not be able to agree on a version of the monstrously cruel and cynical American Health Care Act (AHCA), which threatens to leave an additional 23 million Americans without insurance by 2026.

But even if the GOP can't get it together to replace Obamacare, the Trump assault is adding to the pressures that were already undermining the ACA. Insurance companies are pulling out of the ACA-created marketplaces to sell policies to those without employer-provided insurance. Some 15,000 enrollees in 20 counties nationwide have no insurance plans at all to choose from in 2018, and those numbers are certain to grow, possibly into the many hundreds of thousands.

ALL THIS is why support for a "Medicare for all" single-payer system has gained momentum in the Trump era. Faced with the prospect of Trumpcare, more and more individuals and organizations are recognizing the need to fight for more than just preserving the ACA--to fight, in the words of Mark Dudzic, national coordinator of the Labor Campaign for Single Payer, "to expand an improved Medicare to everyone rather than to restore a failing status quo."

Although Democratic politicians at the national level continue to reject the idea of single-payer out of hand, several recent opinion polls suggest that a majority of Americans favor of a single-payer system.

But there are plenty of opponents, too--flogging myths and lies about what's supposedly wrong with a single-payer system.

When the California Senate Committee on Appropriations issued a report on May 22 suggesting that the California program might cost as much $400 billion a year--far above the state's entire annual general fund revenues--conservative pundits had their knives out at once. Here was "proof," they lectured, that a single-payer program is impossible--and they took the opportunity to shoot down the concept on philosophical grounds as well.

As Jake Novak sneered on

Let's stop here for a second and clarify something that's been lost in the eternally annoying debate about whether health care is a right or a privilege. The only human right connected to health care that isn't ruinous to all other rights and responsibilities is the right of an urgently injured or dying person to get emergency care, no questions initially asked.

Once that care is administered, the caregivers and/or those who paid for the care have a right to ask for some kind of payment. This is a basic ethical truth that, thanks to the bean counters in Sacramento, now has even more economic truth to back it up.

Set aside Novak's heartless views on the question of health care as a human right. Nobody has ever suggested that care should be provided without payment. The questions, rather, are who pays, and where the money comes from.

Nor does anyone deny that universal health care will be expensive. After all, when Vermont Gov. Peter Shumlin abandoned a proposed single-payer plan--one criticized by health care advocates as flawed--in 2014, he gave cost as the reason.

But this observation comes nowhere near "proof" that providing such care would be "ruinous to all other rights and responsibilities." It merely means that, like any other program administered by the government, from the Pentagon to rural road maintenance, this one will have to be funded in some way.

Beyond this, Novak ignores several important points in the California Appropriations Committee report. The first is that "existing state, federal, and local funding of about $200 billion could be available to offset a portion of the total program cost." The remaining $200 billion would likely need to be raised through a payroll tax--the report estimates a tax rate of about 15 percent.

But, the committee pointed out, "the overall cost of these new tax revenues would be offset to a large degree by reduced spending on health care coverage by employers and employees," which today accounts for an estimated $100 billion to $150 billion. "Therefore, total new spending required under the bill would be between $50 billion and $100 billion per year"--a long way from $400 billion.

On the other hand, as reported by the San Jose Mercury-News, a recent study of the California bill by economists at the University of Massachusetts at Amherst suggests the single-payer program might actually save the state some $37 billion. This assessment assumes, among other things, that the state follows the analysts' recommendations concerning implementation of a new sales tax and gross revenue tax to fund the program.

WHICHEVER ESTIMATE is nearest the truth, the question of funding is obviously extremely important. But first things first: what would we be paying for?

Although they differ in many details, the New York and California proposals for single-payer are broadly similar. Both are open to all residents, regardless of immigration status, and both cover a comprehensive range of treatments. Members would not pay any premiums, deductibles, co-payments or co-insurance for services covered under the program.

Members would have to enroll with a "care coordinator" of their choice--this could be, among other things, a primary care provider, gynecologist or specialist care practitioner of the member's choosing. The care coordinator is responsible, in the words of the New York bill, for "managing, referring to, location, coordinating and monitoring health care services for the member."

Although members must be enrolled with a care coordinator to be covered by the programs, they will be free to obtain health care from any authorized provider, without needing a referral.

Insurance companies would not be entirely eliminated, but under both bills, they would generally be barred from offering "benefits that cover any service for which coverage is offered to individuals under the [single-payer] program," to quote, again, from the New York bill.

This is important as a means of ensuring that the single-payer program is truly universal. As the sponsor of the New York bill, Assembly member Robert Gottfried of Manhattan explained to, "If wealthy and powerful New Yorkers can be in a separate boat and don't have a stake in the quality of the New York health program, then it could easily degrade the program."

Indeed, this would merely perpetuate the inequity that is so widespread today--one standard of care for the well off, another for the needy.

TO PAY for all this, both bills contemplate two main sources of income.

The first is federal funding, in the form of waivers allowing money that would have gone toward Medicare, Medicaid, Children's Health Insurance Program (CHIP) and other such programs, as administered by the respective states, to be applied instead to funding their single-payer programs.

In the event that these waivers are not granted, the bills provide that the states would continue to obtain funding through existing channels, but that the program would be administered in such a way that, to the extent possible, the specific arrangements under which funds are obtained will happen behind the scenes, allowing members to continue to deal directly (and solely) with the state's "single payer."

The second source of funds is, of course, taxation. The New York bill specifically calls for progressive taxes on payroll and other forms of income, and requires the governor to include the necessary provisions in the executive budget beginning with the fiscal year after the bill is enacted.

The California bill merely states that "it is the intention of the legislature to enact legislation that would develop a revenue plan." However, the San Jose Mercury-News reports that the California State Assembly will likely add the necessary tax provisions to its version of the bill.

In countering the right's propaganda about bloated taxes to pay for a single-payer program, it should be emphasized what people will no longer be paying under the proposed programs. There will be no premiums, no deductibles, no co-payments--no out-of-pocket expenses at all--and proponents of both bills argue that, for most residents, these savings will more than make up for what they pay in new taxes.

According to an analysis of the New York bill conducted in 2015 by Gerald Friedman, a professor at UMass-Amherst, "While the largest savings would go to working households earning less than $75,000, over 98 percent of New York households would spend less on health care than they do now."

The UMass-Amherst study of the California bill predicts a "reduction in health care spending for California's middle-income families of between 2.6-9.1 percent of income." Even for high-income households, the total increase in costs paid for health care would be only be about 0.6 percent of income.

In addition, as Dr. Paul Y. Song points out in the Huffington Post, moving to a single-payer system can lead to enormous savings by eliminating the price-gouging practiced by some health care providers today. Song gives several examples of massive price markups at the California Pacific Medical Center in San Francisco, ranging from $36.78 for a Tylenol with codeine pill (market value $0.50) to $14,110 for knee arthroscopy (market value $2,037).

Song argues that "powerful hospitals" justify this kind of markup with the claim that it is "needed to pay for uncompensated care." But this argument becomes meaningless if everyone has coverage. Song also notes that "Kaiser and United Healthcare use their massive market share to negotiate steep drug discounts"--and suggests a single-payer system could negotiate similar discounts for all.

THE FATES of both bills are uncertain, as of this writing, but any sober assessment must admit that they face an uphill battle.

Even if both proposals clear the remaining hurdles in their respective state legislatures, it isn't clear how the two states' Democratic governors, Jerry Brown in California and Andrew Cuomo in New York, would respond.

In California, Brown has made his skepticism about single-payer known. According to the Mercury-News, "Few expect he would sign the bill into law if it reaches his desk."

Meanwhile, in New York, points out that Cuomo is "widely believed to be eyeing a centrist-tinged presidential run in 2020"--and notes that his "last stab at an item on the progressive wish list, free college tuition, was a somewhat mixed affair"--which was the assessment of as well.

On the other hand, the fact that Cuomo brought Bernie Sanders onstage at the press conference in January where he announced the tuition program suggests at least some desire on his part to win support to his left.

Perhaps the looming catastrophe of the AHCA might drive these governors to take bolder, more progressive action than they otherwise would. But in any event, progress toward single-payer won't take place without a good deal of "encouragement" in the form of mass demonstrations in support of the legislation.

For those of us who believe that health care is a human right, the task is obvious: We must ensure that our voices are heard loud and clear, both in our own communities and in the halls of government, as we demand an end to the obscenity that passes for a health care system in this country today.

The stakes have never been higher--but as the growing support for these bills shows, the opportunity has never been greater.

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