Friday, July 11, 2014

Will American conservatives lead the U.S. to a single payer system?

The unrelenting opposition by American conservatives to Obamacare may have the unintended consequence of leading the United States to a single payer system like Canada’s.

How’s that, you say? Isn’t the whole point of conservative opposition to Obamacare to drive home the point that the government is incapable of managing people’s health care?  Yes.  And aren’t conservatives effective in driving home that point? Yes, polls show that confidence in government is at an all-time low, no doubt related in some degree to the attacks on the Affordable Care Act and its chaotic launch.  (The VA scandals undoubtedly will also undermine trust in government, as I noted   in a recent guest blog post for the Philadelphia inquirer).

Yet when future historians write the history of health care reform in the United States, they may very well report that Obamacare was a stepping stone to single payer—not because liberals persuaded voters that we’d be better off with the government fully in charge (they’ve been trying to make that case for decades, with little evidence of success), but because conservative opposition to Obamacare ended up destroying employer-based private insurance, leaving the government as the only remaining payer.

Consider the following:

The Supreme Court ruling in the Hobby Lobby case is widely viewed as a victory for conservatives, since it reins in the ability of government to impose mandates on for-profit companies that violate their owners’ religious beliefs.  But Don Munro, a contributor at Forbes, provocatively asks if Hobby Lobby will “signal the end of employer-sponsored health insurance.” Fred Rotondaro and Christopher Hale from Catholics in Alliance for the Public Good persuasively argue that the Hobby Lobby decision:

“…brings to the forefront something we’ve all known for sometime: that Obamacare—for all the good it’s done in increasing access to quality and affordable healthcare—is a messy law. It asks employees to be at the whim of its employers’ objectives and mission for what health care benefits they receive. It also asks employers to at times reject its deepest convictions in order to provide certain benefits to its employees.

This isn’t sustainable. A person’s access to quality healthcare shouldn’t depend on who their boss is. And an employer shouldn’t be heavily fined if they don’t compromise their religious convictions in providing healthcare for their staff. . . A single-payer public health care option eliminates such complications. No matter who your boss is or what business you work for, you get access to the healthcare you need. And employers will not be forced to compromise their religious beliefs while providing the public good of healthcare.

And let’s be clear, if you have something that is both supported by the United States Conference of Catholic Bishops and Planned Parenthood, you might be onto a plan that proves the angel Gabriel right: nothing is impossible with God.”

Renowned health economist Uwe Reinhardt also believes that the Hobby Lobby rule may lead Americans to re-examine employer-based health insurance:

“The ruling raises the question of why, uniquely in the industrialized world, Americans have for so long favored an arrangement in health insurance that endows their employers with the quasi-parental power to choose the options that employees may be granted in the market for health insurance. For many smaller firms, that choice is narrowed to one or two alternatives – not much more choice than that afforded citizens under a single-payer health insurance system. . .

. . . the Supreme Court’s ruling may prompt Americans to re-examine whether the traditional, employment-based health insurance that they have become accustomed to is really the ideal platform for health insurance coverage in the 21st century. The public health insurance exchanges established under the Affordable Care Act are likely to nibble away at this system for small and medium-size business firms, especially those with a mainly low-wage work force. In the meantime, the case should help puncture the illusion that employer-provided health insurance is an unearned gift bestowed on them by the owners and paid with the owners’ money, giving those owners the moral right to dictate the nature of that gift.”

But it isn’t just Hobby Lobby where conservative opposition to Obamacare may help bring about single payer.  CNBC reports that another pending court case against Obamacare’s insurance subsidies, instigated by conservative critics of the law, makes the claim that:

“those often-valuable subsidies are illegal because the Affordable Care Act only authorized such tax credits for people who bought insurance through one of the exchanges originally set up by an individual state or the District of Columbia—not the federal exchange. Nearly 90 percent of the people who enrolled in plans via the federal exchange qualified for those subsidies because they had low or moderate incomes. Take away those subsidies and many, if not most, of the enrollees on might not buy insurance next year because they will find it unaffordable at the full premium price. That, in turn, could create a much-feared ‘death spiral,’ where insurance pools have too many sick enrollees and not enough young healthy ones, and premium rates skyrocket. And if those subsidies are not available to individuals in the states served by, it would also mean that businesses in those states could not be mandated starting next year to offer affordable health insurance to their workers or pay a fine. That's because the so-called employer mandate is linked to the availability of those subsidies for workers who opt to buy individual insurance.”

A court ruling for the plaintiffs in this case (although considered unlikely) would be another huge blow to relying on private health insurance to make affordable coverage available to most Americans, because it would keep all Obamacare’s benefit mandates on the books, while making the private insurance offered through the exchanges unaffordable to the millions of people it was supposed to help.  But the “public option” part of Obamacare—Medicaid—would remain intact. 

And let’s not forget that conservatives are stoking public opposition to Obamacare’s mandate that people buy private insurance—even though they once championed an individual insurance requirement as an alternative to either single payer health insurance or requiring employers to provide coverage.

Now, I don’t see the United States rushing head-long into a single payer system (although just about all Americans regardless of their political leanings love Medicare), because the country is deeply polarized, and people have little trust in government, and even less in politicians. But it’s plausible that over time the unrelenting conservative attacks on Obamacare will end up showing Americans that it is just too difficult to provide affordable coverage through a system of regulated and subsidized private insurance and by counting on employers to continue to offer coverage, especially when employers can opt out if they have religious objections.   Conservatives then will not just have destroyed Obamacare—they will have opened the door to single payer as the only feasible way to provide affordable health insurance coverage to all.

Today’s question: Will conservative attacks on Obamacare lead the United States to a single payer system?


Unknown said...

Bob, the Government does not have the Constitutional power to pay for healthcare. Those of us working against it are organizing fast to create an article V convention of states for the purpose of limiting the scope, power, and jurisdiction of the federal government and to limit the terms of office for its officials. Among a suite of proposed amendments is one that would restate the commerce clause and return it back to its original intent. That would strip the power of this government back to a manageable size which would not include paying for healthcare.

Unknown said...

The other factor that may well drive this is that individual, non Obama care, health insurance companies are pulling out of the individual market except for 11 month, short term policies where it is still legal to discriminate against people with pre-existing conditions and have life time limits. In my state (MS) there is only one underwriter of individual plans left so they have a monopoly in that respect. As monopolies are not acceptable in this country (outside of public good items like water service, etc) my bet would be that instead of reentering the individual market, everyone will pull out.

Dan Munro said...

Thanks for the reference, but it's Dan not Don Munro. Also, there are several payment options for universal health coverage ~ not just single payer. Multi-payer could well be more palatable culturally ~ and get us off of selective health coverage sooner.

Caro said...

It can't happen soon enough.

Unknown said...

Interesting scenario. Just for fun, look even further into the future. It's not the righteous, conservative push-back that was the most ironic step. It was the complicity of certain groups back in 2008-2010 which served as the tipping point--one that is Shakespearian in its monumental irony and tragedy. Obama rocked the boat, but when the AMA, PRIVATE(!) insurers, the AARP and employee unions all leaned to the gunnels, this boat capsized!

Unknown said...

The supreme court decision is a good thing for religious liberty and contraception is not real health care or prevention of disease. It is a personal choice that people should pay for themselves. This ruling will not affect health care but obama care will adversely harm physicians and their patients because all that the government operates is problematic and can't be trusted.

PCP said...

So typical of liberals to try to find a way to blame conservatives for a mess that that have created.
Let me remind you bob that PPACA was passed without a single republican vote, far less tea party vote.
So bob, you, the democrats, Obama,the ACP, the AMA and the rest own this lock stock and smoking barrel, and you cannot despite your best efforts weasel yourself out of that.
You cannot and should not expect any cooperation from the right when you felt not so much as a single republican vote was needed, even after Sen. Ted Kennedy's by election sent shockwaves.

Harrison said...

The Republicans in committee were given virtually everything they asked for.
The concept was a Republican idea.
The Republicans insisted on the demise of the public option which probably would have circumvented any and all legal challenges.

But their negotiations resulted in the Republicans voting as a solid block.

In fact it is that solid block of voting that is the biggest and most unhealthy part of our current legislative process.

Our legislators are not listening to constituents.
They are voting as they are required to by their leaders, and the leaders are taking marching orders from big dollar donors and high profile organizations.

If they were voting responsibly then many Republicans would have voted for the PPACA, and they would have contributed constructively to the debate.
And they would have passed the very modest immigration bill that has emerged from the Senate.
And they would have passed the extremely modest gun control legislation that was proposed.
And they would not have wasted a ton of money with a meaningless government shutdown.
And they would have a agreed to find a way around the sequester cuts.

But the minority party in Congress only has power if it plays with the rules and if it votes as a block.
And they only keep their gerrymandered seats in Congress to support what little power they have by going along with the donors and the leaders.

Please open your eyes.

And if you have a criticism of the PPACA that is real, please express it.
All I hear is how awful it is for doctors and the patient physican relationship.
But we all know that market forces were already killing all of this.
The models of practice that are so nostalgically loved from the 70's are gone.
We live with insurance companies imposing capitation and global budgets and performance measures, and we have silo's created with office doctors, and hospitalists, and now SNF'ists.
And perhaps the worst thing out there is the monopolistic PBM's that make obscene profits without us even being aware of it.
And all we can find to complain about is the paperwork they impose on us. Look at how much middleman profit they are pocketing.
That is not Obamacare. That is the market.
It was evolving long before the PPACA.


ryanjo said...

Let's summarize the ACA fans talking points:
-- "all this bad stuff was already happening" (so let's throw in the towel and make it worse; enable the insurance profiteers and expand obscene paperwork. Let's just take the same sick system and expand it to 35 million more victims, subsidized with our tax dollars and cutbacks on sick senior citizens. Let's incentivize the big players to crush private practice with ACOs. Bigger is better, just look at our federal gubbermint!)
-- "if the opposition Republicans were consistent/thinking clearly/nice people, they would have voted for Obamacare" (explanation: must have been an unusual case of mass insanity, not hundreds of legislators trying to oppose an ideologue looking for his legacy, who celebrated the PPACA with his cronies and a champagne toast. No, that's not inappropriate! A very unifying moment...)
-- "if you have a criticism of PPCA that is real" (have you been reading this blog? The last few posts have been a logbook of Obamacare bloopers. Stay tuned, more to come!)
-- "they would not have wasted a ton of money with a meaningless government shutdown" (actually it saved a ton of money, and continues to do so. I guess the sky didn't fall. Sorry, libs)
Repeating the same tired rhetoric, left or right, doesn't make it true.
But there is one conclusion that you missed. The government isn't fit to reform healthcare. The sooner the system fails, the better. If our national medical organizations were leading instead of pontificating, they would be saying that now and loudly.

Harrison said...


I of course think it is fair to turn my own words back on me. I don't mind that.
But let me suggest a few things.

I'm not really a PPACA fan. I'm a fan of improving access to health care for all US citizens.
I would be fine with a single payer system.
I would have preferred the PPACA with a public option.
I agree with you that the PPACA as it is structured hurts small practices and individuality.
I'm not at all sure about ACO's.

But I stand by what I wrote about the politics of the U.S.

The Republicans have chosen to allow an extremist block control them. They are very ideological.

Democrats of course are not poster children for good government. They too are capable of banding together, and in fact did so with great tension to pass the PPACA.
I'm sure Sen Nelson of Nebraska hated voting for this.

But the political stunts of the right have been a problem.
The government shutdown and the sequester hurt people. Many lost their jobs and and suffered losses of benefits.
The economy has improved some and so that has helped but the cuts were real, and harmful and they continue.

The right's grandstanding on immigration also hurts people. Gov Perry sending Nat Guard troops to the border to do, well, what?. Nobody knows. It just looks tough. But it is meaningless grandstanding.
The real issue is what to do with children from non contiguous countries.
And the administration is acting within the law created by Congress.
Congress can change it.
But choose not to do so.

The cynical view that the government does no good and can't run anything flies in the face of reality.
The military is government run.
Social Security is government run.
Medicare is loved by millions and is government run.
The number of things the government does well, when it is supported by the political powers, is many.
But pointing out problems gets more political points.

And I really don't know what specific things about Obamacare are disliked?
Specific things in particular that we could not easily fix.

The exchanges were an easy fix and have been fixed. They mostly work.
The enrollment numbers are good.
The communication issues behind the scenes are being resolved.

At its heart it is a program aimed at improving access to health care, and the benefits are to follow from the improved access.

The problems stem from political opposition, with state leaders choosing to make political decisions that harm their own citizens.


PCP said...

The republicans were given everythig they wanted?? Really Harrison. Take tort reform for example. Republicans pushed, heck even ACP and AMA pushed, but in the end Democrats gave in to their trail lawyer lobby and tossed that. Everyone agrees that it will save SOME money, even if we disagree on the amounts involved, yet that was turned away.
Likewise SGR fix was sacrificed on the altar of cost containment, to ensure the bill would stay within the bounds of the accounting gimmicks. Yet like muppets our professional representatives went along. Not once hesitating to think what it means for the profession and its future. All on ideological grounds.

Republican solid block? Yeah you make my point eloquently. When you can't even win over a single moderate vote it shows the nature of that piece of legislation. Seldom have i seen 100% unanimity in the republican ranks, just look at them now, that it was so strongly opposed even by moderates is precisely my point.

Why is it that the opposition should vote for your agenda when it is so ideologically pure to you?
Immigration? Really you think taking about border security first is wrong? How many times before you democrats accept that we are a nation of laws? Lets just call a spade a spade, immigrants are a vote bank the democrats can count on and that is why they want this done. End of story.
Meaningless gov't shutdown. Really! Approaching 20 trillion in debt and spending like drunken sailors and all you see is obstructionism. Can't you see concern for our kids future perhaps?
That shutdown will be a damn joke compared to a credit meltdown and the loss of the US dollar as reserve currency and the resulting runaway inflation and loss of prosperity. That is hasn't happened is not a reason to feel snug and comfy that it won't. They said the same about house prices have never gone down once either, and I'm sure you remember how that ended.
Let me assure you it is purely democratic party principles that have much of the world mired in the poverty that is is stuck in. One look at South america vs North tells the sorry tale. If we move our system to be more like them then we've lost something that has driven us to the front of the pack. We surrender to the politics of envy that lead us into an economic quagmire. That sadly is precisely where this president and his policies are leading us. This is the most pathetic recovery in modern history after arguably the deepest recession in recent history. Have you ever wondered why? If you ask Obama he hasn't spent enough! Good grief man.
On our current political trajectory. America in 30 yrs = Argentina.

How can you argue something leading to the extinction of solo and small group practices is good for the doctor/ patient relationship. Since when have we become commodities? If the market forces were killing us already surely your solution is not to accelerate the process. There was a way to simplify and modify the market place. Those market reforms to open up physician entrepreneurship never took place. Sadly the cure here is worst than the disease. Or put another way the changes are accelerating what is bad in the system and you and the ACP have endorsed that on ideological grounds.
Obamacare addresses none of those inefficiencies you pointed out. The reason for that is it was a law meant to appease its opponents and crush its supporters. You very well know where we ended up as a profession.
I completely agree with ryanjo, the sooner this whole thing collapses the sooner real reform can ensue.

Harrison said...

PCP and ryanjo

What I read in your notes is fear. It seems you want to base policies on fears of what might be.

You fear a democratic voting block from immigration reform.
You fear a huge debt if we don't cut off government spending in any way we can.
You fear the US becoming Argentina.
You fear the erosion of the patient/physician relationship because of the intrusion of Obamacare and insurance companies and hospitals and ACO's.
You fear lawsuits from our patients and you are sure that that fear is driving up costs.

I'm not all that afraid.
You're afraid that I'm just a naive liberal because I'm not as afraid as you.

I know I'm provoking an onslaught.

But, well, I'm not hanging out by my window with an automatic weapon waiting for the agents from Obama to take my weapons and freedom.


ryanjo said...

Whoa. Is it a little hot in here? Whenever Latin American politics and assault weapons end up in the comments to a post ... well, points taken.

Let's get back to Bob's original question: Is there a secret conspiracy by conservatives to lead the US into a single payer system? (Did I get that right?)

PCP said...


You call me afraid. I think you are naive.
Presumably you are unaware of living conditions in other parts of the world. An open borders policy is pure idiocy.
Anyone who does not fear debt is arguably immoral. Either you do not believe in property rights or you do not understand math. Either way you are a danger to yourself and your society. And yes you would be Argentina! Need I elaborate with the news of the week.
Your lifetime has been consumed in an era of the US dollar's preeminence in global trade. What you take for granted daily from gas in your car to relatively inexpensive food to cheap household goods etc will all be a figment of your imagination should the debt bomb blow up. I doubt you will call any of those things unworthy of concern under the current fiscal trajectory.

Harrison, when I speak of the loss of the doctor patient relationship, when you inevitably become an employee of a corporation exerting its will on you, you might see to what I refer, and yes that is a legitimate concern and a definite leg down for my profession and its ability to offer unblemished independent advise to patients. I'm shocked you can't see or recognize that.
I fear that the psychological impact lawsuits have on th way we practice medicine driving up costs and I fear that healthcare is unnecessarily becoming unaffordable to my people. To this fear I admit.

I am not afraid of my people, I am afraid of the
Political power wielded by corporations that have come to dominate the health care landscape.
I worry that my professional autonomy and independence will be taken from me by undeserving politicians and corporations for their benefit and put patients and the system at risk. Obamacare is a giant leap in that direction and that is why I oppose it.
Your fear mongering notwithstanding.

Harrison said...

I agree.
Bob does seem to be siding with conspiracy theorists.

I think we read different source material.
I have read some of what you read, and don't completely disagree.

I will refrain from jab like posts.
It wasn't really aimed at you.
Really, how could it be?
I don't have any idea who you are or where you live or what you really think.


gleannfia said...

Agree totally with Harrison's points. With regard to the fear over debt: If we do not invest in the health of our citizens, everything else will be moot. Why is it that other countries get this and we do not?
I wonder if some of these same deficit hawks were protesting while W spent like a sailor on leave for two unfunded, immoral wars, not to mention Medicare D. Somehow, I doubt it.