Think of medical care without the worry your doctor won’t accept your insurance because she isn’t in the insurance company’s network of providers. Think of not having to worry about losing your health insurance if you ever lose your job. As an employer, think of the prospect of not having to pay ever-increasing and unpredictable premiums to maintain health insurance for your employees. And imagine the end of a confusing web of existing coverage options, which differ depending on the state where you live, your income, your age and your employment status.
It’s all theoretically possible. And if designed right, a single-payer health care system could drastically reduce the bureaucratic inefficiency of the current system and rein in health care costs through the government’s effective use of its buying power.
But is it realistic?
That’s at the heart of a debate right now, as former Secretary of State Hillary Clinton and Vermont Sen. Bernie Sanders compete for the Democratic presidential nomination. Should Democrats be content to fight to maintain the integrity of Affordable Care Act and improve upon the most significant health care legislation in a generation? Or should they keep their eye on what is the ultimate prize for many in their party: universal, single-payer health care?
As New York Times columnist Paul Krugman recently pointed out, the Affordable Care Act is a “kludge.” It’s “a somewhat awkward, clumsy device with lots of moving parts. This makes it more expensive than it should be, and will probably always cause a significant number of people to fall through the cracks,” he writes.
The Affordable Care Act is a kludge because American politics made it that way. In order to secure support from the incumbent players who could easily derail any reform — health insurance companies, health care providers, pharmaceutical companies and others — the law’s architects kept them at the heart of the American health care system. They did what they could to produce the most meaningful health care reform they could without rocking the boat too much.
The result is a health insurance mandate (a guaranteed base of customers for health insurers) and a confusing web of health insurance options — basically, a system that covers more people without changing the core of the American system. But the Affordable Care Act represents progress. Just 9.2 percent of Americans lacked health insurance last year, compared with 16 percent in 2010, according to U.S. Centers for Disease Control data released in Augusta.
Still, 29 million people remain uninsured.
The appeal of the single-payer system Sanders is proposing revolves around simplicity — no choosing a plan, no annual enrollment periods, no complicated formulas to determine the size of your health insurance marketplace subsidy, no health provider networks — and its universal nature.
But what’s to prevent Sanders’ “Medicare for all” proposal, which still has many details that need filling in, from becoming a kludge, writes health care expert Harold Pollack on Vox? Say a single-payer proposal becomes even remotely politically realistic. The incumbent players would undoubtedly wield their power in any political debate and extract a result that, undoubtedly, becomes more complicated and costly than the ideal.
Sanders says his single-payer system would be “federally administered,” though he has previously proposed a state-based model. What’s to prevent state officials from clamoring for some measure of influence over the system, either through the legislative process or through the courts? State-by-state variations of a national health care program — reminiscent of some states’ refusal to embrace portions of the Affordable Care Act, such as Medicaid expansion — would further resign it to a kludgy nature.
The result? A system with different benefits for Americans depending on where they live and the willingness of local politicians to carry out the idea of universal, single-payer health care.
Sanders is proposing ideas worth debating — both his health care proposal and the tax changes he has proposed to fund it. But Democrats are more likely to find success in maximizing the effectiveness of Obamacare than in, once again, entirely subjecting health care reform to a legislative process that could derail the progress of the past five years.