One reason why President Bill Clinton was unsuccessful in his effort to reform health care is that although the opposition was unified, the advocates for universal coverage were split. One reform camp was willing to support a pluralistic model, as proposed by President Clinton, as long as it included guaranteed (mandated) coverage. The other insisted that a single payer plan - often described as Medicare for all - was the only acceptable outcome.
Jacob Hacker, professor of political science and resident fellow of the Institution for Social and Policy Studies, had this to say in the May-June issue of Health Affairs:
"Born in a policy hothouse, the Clinton plan wilted in the cold winds of politics."
He argues that a successful effort this time "will require updated strategies including a greater willingness to compromise on means, yet greater clarity on ends" and "serious efforts to bring on board ... reformers who support a universal Medicare plan, to provide them with the guarantees and arguments they need to embrace a less inspiring but more politically palatable approach."
President-elect Obama's health care reform proposal builds upon existing employer-based coverage provided principally by private insurers, instead of a "Medicare for All" approach. (Click on ACP's election tool for more information about the Obama plan and how it compares to ACP policies)
ACP understands why a single payer approach is appealing to some. Based on an evidence-based review of the experiences of other countries' health systems, ACP recommended that policymakers consider one or the other of two pathways to achieve universal coverage: a single payer financing model or a pluralistic model with coverage guaranteed by law. The paper notes that either have significant advantages and disadvantages that would need to be considered, but both are preferable to status quo of pluralism without universality.
The political reality, though, is that President Obama will not ask Congress to enact a single payer plan.
Today's questions: Will the "Medicare for all" camp be behind the Obama approach, even though it may be the "less inspiring but more politically palatable approach?" Or, will they hold out for a day when the political environment might allow for a single payer plan - at the risk of losing any chance for reform now?