The ACP Advocate Blog

by Bob Doherty

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?


Blogger Scott Williams 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.

July 14, 2014 at 10:51 AM  
Blogger Liz B 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.

July 14, 2014 at 1:05 PM  
Blogger 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.

July 14, 2014 at 9:04 PM  
Blogger Caro said...

It can't happen soon enough.

July 15, 2014 at 7:49 AM  
Blogger T Vannest 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!

July 18, 2014 at 1:18 PM  
Blogger 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.

July 19, 2014 at 7:33 PM  
Blogger 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.

July 20, 2014 at 11:22 PM  

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Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

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