Taking Single-Payer Seriously

By Dave Kamper, Jacobin

29 May 17

Medicare for All is a moral imperative. But the urgency of passing it doesn’t mean we can forget about the details.

as the time for Medicare for All finally arrived? Many on the Left certainly think so.

“Various half-measures are not worth it,” physician and activist Adam Gaffney wrote a few weeks ago. “Single-payer is the alternative to the health care status quo.”

This is not just idle chitchat. A January Pew Research survey found that 60 percent of Americans think the government “has a responsibility to make sure all Americans have health care coverage.” And a recent Morning Consult poll showed 44 percent of Americans backed a single-payer plan, much more than those who opposed it.

Those are real numbers, and the Left has every reason to be excited that our arguments are gaining traction.

But if we want to make Medicare for All a reality, we have an obligation to think through the consequences of effectively euthanizing an industry that many have come to rely on for employment.

A Spending Machine

The private health insurance industry is, as many have observed, one of the primary drivers of health care costs. We spend far more on health care than any other advanced capitalist country and end up with inferior health outcomes.

The Affordable Care Act (ACA) kept that basic system in place. For all the talk of mandates and cost curves and exchanges, Obamacare massively increased spending in the health care system. When more people get health insurance, more people use health care.

The Medicaid expansion and the subsidies for coverage on the individual market funnel tens of billions of additional dollars into insurance companies and health care providers every year. In 2014, the first year that the ACA was more or less in full force, net expenditures on health care rose 4.6 percent. In 2015, they jumped 5.6 percent. The same year, the federal government estimated that outlays would expand “1.2 percentage points faster than Gross Domestic Product” over the next decade. By 2025, it projected, health care would no longer make up one-sixth of the American economy. It would make up one-fifth.

Much of this spending results in new jobs. From 2011 to 2016, overall job growth in the US sat at 8.3 percent, but the number of health care practitioners rose 15.8 percent. Nurse practitioner jobs increased 76 percent. Speech-language pathologist positions expanded by 29.6 percent. “Medical records and health information technicians” went up 58.6 percent. In the health insurance industry, “insurance claims and policy processing clerks” went up 11 percent.

As long as the ACA fire hose keeps spraying money at the health care industry, jobs will balloon accordingly. If the water pressure drops, the consequences will be real and drastic, even if the overall result is more equitable and more affordable health care.

Medicare for All wouldn’t just scrap Obamacare — it would uproot the entire industry. It would be a huge efficiency savings. But it would also be devastating in the short term for hundreds of thousands of working people whose only crime was getting a job at an insurance company, and the hundreds of thousands more who work as billing specialists for clinics and hospitals (the number of medical assistants shot up 44 percent between 2011 and 2016). Yes, the CEO of United Health Group made $101 million in 2011. But few of the 230,000 other people working for the company saw money like that.

Bernie Sanders’s recently announced Medicare for All plan asserts that we “need a health care system that significantly reduces overhead, administrative costs, and complexity,” and projects that his plan would save $6 trillion over ten years.

Those trillions — currently being sucked up by a bloated, profit-hungry industry — could do amazing things. Infrastructure. Education. Housing. Insurance for all, in and of itself, would be remarkable.

But you don’t save $6 trillion just by getting rid of the insurance industry. The US has 35.5 MRI machines per million people. The UK, with its National Health Service, has 6.1. Single-payer Canada has 8.5. We don’t need as many as we have. We can deliver complete patient care with many fewer machines. But fewer machines means fewer manufacturing jobs, fewer technician jobs, less need for new construction for new facilities, and so on.

And MRIs are just one facet of a huge health care system that will see efficiencies across the board in a single-payer system. The benefits of those efficiencies will be felt by all, the harms by few, but they will feel them hard.

The effects of these changes would be highly local. Some of the campuses of large health insurance companies employ thousands. Shuttering them would be like shuttering a steel mill or auto factory — the shockwaves would reverberate through the whole community. Like laid-off autoworkers, employees of insurance companies would be pushed onto the job market with a set of skills and experiences unsuited to most other occupations. The color of their collar wouldn’t change that.

And that disruption would have serious political effects.

The 2016 election hinged on the Rust Belt, states like Michigan, Ohio, and Pennsylvania that used to be home to huge numbers of unionized, high-wage blue-collar jobs. As those industrial jobs disappeared, cities across the Midwest sustained hits from which they still haven’t recovered.

The Democratic Party’s prescriptions — like trying to encourage fifty-year-old autoworkers to go back to community college to study IT — were both condescending and impractical. Many saw no reason to back a party that hadn’t done anything for them, and that left them exposed to the nativist economic nationalism of Trump.

We can’t risk the same thing happening because of single-payer.

Possible Prescriptions

Legislators in two of the states most seriously looking at Medicare for All, California and New York, don’t seem to have considered the job loss problem at anything more than a surface level.

The California bill simply requires that the state “provide funds … for a program for retraining and assisting job transition” for people who lose employment because of single-payer. The amount of money isn’t specified, isn’t guaranteed, and there’s no sense of what “retraining” means in any real sense. The New York legislation contains very similar language.

What’s more, any solution can’t just be about individual workers. It has to be about communities. Rochester, Minnesota has a population of 115,000; the Mayo Clinic employs 34,000. If Mayo shed five or ten thousand jobs because of single-payer’s efficiencies, all the retraining in the world wouldn’t avert a sizable blow to the local economy. And what good would it do for a Rochester resident to get a degree in something new, when the job market has basically dried up?

US representative John Conyers’s Medicare for All bill takes a more direct approach: it throws money at the problem. The legislation allows “clerical, administrative, and billing personnel” displaced by the law to receive their old salary (not to exceed $100,000) for two years, and to receive priority in job training. Even that bill, however, wouldn’t do anything to save communities — many of those displaced workers would take their money and move, only exacerbating the challenges of the Rochesters of America.

Any serious Medicare for All plan needs to include investments in affected communities on a scale this country hasn’t seen since New Deal projects like the Tennessee Valley Authority. In addition, any attendant growth in federal employment would need to be funneled back into the same communities that shed jobs. And that’s just for starters.

Medicare for All is a moral imperative. But the urgency of passing it doesn’t mean we can forget about the details. Otherwise we’ll send the message that our support for single-payer is more aspirational than practical, substituting hope for policy depth and leaving health care workers out in the cold.

Democrats Copied the GOP's Politics of 'Personal Responsibility,' and It Hurt America

By Yascha Mounk, The Washington Post

29 May 17

It shaped the way liberals see the poor – as victims of circumstance, rather than Americans who can rise up.

resident Trump’s proposed budget is a bait-and-switch. On the campaign trail, Trump styled himself as an advocate of working people who believed that the state has an obligation to help struggling Americans, irrespective of why they are in need. Whereas his main rivals for the Republican nomination insisted that Americans have a responsibility to procure their own health care, for example, Trump proclaimed that we “need health care for all people.” There was, he said in one interview, “a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”

Since taking office, Trump has reverted to a more traditional Republican playbook: His economic policy offers huge handouts to the richest Americans, and it justifies this redistribution from bottom to top with the classic rhetoric of “personal responsibility” — a trope that has dominated American politics for the better part of three decades. As Trump says in his official statement on the budget, he “will champion the hardworking taxpayers who have been ignored for too long” while reforming the welfare state so that it no longer “discourage[s] able-bodied adults from working.”

“Personal responsibility” is a peculiar phrase, at once anodyne and foreboding. It is both an expression of breezy common sense and a barely concealed threat to those unfortunate souls who might be so foolish as to act irresponsibly. With its popularity in campaign slogans, commencement speeches and self-help books, it would be tempting to dismiss personal responsibility as an empty incantation — a way to name-check virtues every decent citizen can rally around: love and lemonade, patriotism and pancakes, personal responsibility and apple pie. It’s such a routine part of American discourse that the literal meanings of the words barely register.

Don’t be fooled. This language has had a profound impact on American politics. Weaponized by conservatives such as Ronald Reagan, then slowly adopted by liberals such as Bill Clinton, “responsibility” has shaped public policies from health care to housing. It is no coincidence, for example, that the greatest overhaul of the U.S. welfare state, which Clinton signed into law with bipartisan support in 1996, was called the Personal Responsibility and Work Opportunity Reconciliation Act.

The peculiar power of “personal responsibility” (which I write about in my new book, “The Age of Responsibility”) stems from the fact that it seems to answer the question of what the state owes to whom. Conservatives often argue that some people lead irresponsible lives, characterized by laziness and bad choices. So, since a large share of the poor and the sick have but themselves to blame for their suffering, the state does not owe them anything. And to tax people who work hard and make good choices in order to look after people who are irresponsible is not just bad for economic growth; it is immoral. “Americans have choices,” as Rep. Jason Chaffetz (R-Utah) put it on CNN recently, taking this logic to its ugly extreme. “... Maybe, rather than getting that new iPhone that they just love and they want to go spend hundreds of dollars on, maybe they should invest in their own health care.”

This way of looking at the world was, as the conservative writer David Frum has pointed out, particularly seductive when economic opportunity for most Americans was plentiful. The rhetoric of personal responsibility seemed to be in keeping with the experiences of people who knew that a high school diploma and a good work ethic were enough to earn a middle-class salary. And it offered an explanation for why many members of minority communities, who suffered from the effects of discrimination, were not faring as well: By invoking personal responsibility, Americans could tell themselves that racial disparities did not stem from historical injustice but rather from factors for which the poor were themselves to blame.

But as economic opportunity began to dry up for many white Americans, the invocations of responsibility came to feel jarring. Whereas the Republican base once saw personal responsibility as a way to claim credit for its successes while casting blame for others’ failures, the same language now feels like a way of adding insult to injury. As Peter Beinart has argued, in the eyes of many traditional Republican voters, their party’s elites, not content with placing the agendas of big businesses and special interests over those of common people, insisted on also blaming them for their own struggles. Trump, in Beinart’s words, was so appealing in good part because “instead of demanding personal responsibility,” he pledged “state protection.”

That is one of the main reasons Trump paid such a small price for jettisoning GOP economic orthodoxy on the campaign trail: Long before his refusal to distinguish between the virtuous and the irresponsible, the old language of personal responsibility had started to lose its hold.

The vast gulf between candidate Trump’s promise not to judge ordinary Americans for their problems and President Trump’s policy of making life more difficult for Americans who fail to be self-sufficient creates a new opening for liberals. After decades when talk about personal responsibility gave conservatives ideological hegemony over most discussions of the welfare state, liberals could now go on the rhetorical offensive. Instead, they are stuck in defense mode, intent on refighting yesterday’s battles.

Stunned by the rhetorical power of “personal responsibility,” the left long ago came to accept the assumptions of its political adversaries. As G.A. Cohen put the point in a highly influential 1989 paper, egalitarian political philosophers began to incorporate “the most powerful idea in the arsenal of the anti-egalitarian right: the idea of choice and responsibility.” The same transformation soon became evident in everyday political rhetoric: Democratic Presidents Bill Clinton and Barack Obama spoke as though they wanted to help only those Americans who were in need for reasons beyond their control, incessantly emphasizing the plight of those who “work hard and play by the rules.” But since they sought to preserve key social provisions, they highlighted an empirical disagreement instead: Most people are not at fault for being in need. Rather, they are victims of larger social and economic structures. As Obama likes to point out, the poor are struggling because the economic “system is rigged against the middle class.”

He had a point, of course. Though Americans like to think of themselves as a classless society, economic mobility in the United States has fallen below the levels recorded in most European countries. And a big reason is the very racial injustice that constant talk of personal responsibility only serves to deepen. As study after study has demonstrated, the odds are still stacked against blacks and Latinos: They are likely to be born to less-educated parents, to attend worse schools and to have more trouble finding jobs than similarly qualified whites.

Yet, the left’s approach has not led to a more positive vision of the economy. All too often, the focus on obstacles has painted poor people as passive creatures who could never aspire to real agency. Instead of thinking of them as equals, just as capable of taking their fates into their own hands, the left has, as political philosophers Elizabeth Anderson and Jonathan Wolff have argued, adopted a stance of pity for those poor dolts who could never amount to anything because of all the structural forces aligned against them.

In attacking Trump’s proposed budget, and slowly building a forward-looking platform for 2020, liberals should break with the punitive politics of responsibility in a much more radical way. Over the past decades, they have allowed the welfare state to turn into a vast — and all too often discriminatory — machine for determining who is supposedly acting responsibly and who is supposedly failing to do so. (While workers who were laid off because their companies went bankrupt are eligible for welfare benefits in most states, for example, those who were fired because they came to work late are often ineligible.) Instead, liberals now need to envisage an economic policy that would empower citizens of all classes and races to lead meaningful, economically productive lives — whether or not they have used drugs or served time or failed to finish high school.

To build such a platform, liberals should, counterintuitively, recognize that personal responsibility can be a positive force. Stripped of its punitive connotations, responsibility is a virtue most people are eager to practice: It’s not just that they want to do more than live off government handouts. Most people also place huge importance on the responsibilities they have taken on for people beyond themselves — their children and parents, neighbors and fellow parishioners — as well as for their social and political causes.

Much of the economic policy of the past decades has been driven by the assumption that personal responsibility is a narrow, negative obligation and that the state has to incentivize people to live up to it. Instead, we should recognize that most people already aspire to a broader, community-minded notion of responsibility, and that the state should help ensure that people have access to the basic educational resources they need to realize this goal.

A positive vision of responsibility would not be a political cudgel against ordinary citizens, a way to punish people for their pasts or to deprive them of state assistance. Instead, it would start with the recognition that, with a little help, most people are perfectly able and willing to take control of their own lives.