Why Not Single Payer?

Like most progressives, I responded with disappointment to President Obama's decision not to pursue a form of single-payer health care. It seemed obvious to me then (and now) that single-payer is the most efficient way to provide health care access to the greatest number of people: Single payer would not only guarantee health care to everyone, it would reduce costs in the bargain. Barack Obama is not a stupid man; if I know this about single payer, there's little doubt that he does, too. But he never considered single payer because, I believe, support for it doesn't exist outside of a political minority of progressives.

Darlene commented here recently:

I will die cursing the day that this country failed to pass a single payer health care system. The power of the insurance/pharmaceutical complex matches that of the military industrial one. Pogo was right; the enemy is us.

She's right: The insurance/pharmaceutical complex is a massive and insuperable object in the absence of a movement powerful enough to overcome it. And that movement doesn't exist. So, why have liberals not been able to build a committed constituency for single-payer outside of themselves? It comes down to seven factors:

Right v. Privilege. That is, in this country is access to adequate health care a right or a privilege? Although he never pursued health care reform, Franklin Roosevelt provided a liberal rallying point when he included it in his Economic Bill of Rights. Progressives argued this question successfully, but only to a point.

Abstract. It's a curious reality that Americans can't envision a disaster until it actually happens, no matter how many experts foresee it. (See the broken levees in New Orleans and the financial meltdown.) Sure the health care system might collapse, but people might be crying wolf, too. It's difficult to organize a movement to ward off future possibility, even a likely one.

Difficulty. Health care reform is a long march; keeping an American political movement mobilized across generations is a rare thing, and a successful single-payer movement requires this. Moreover, the Congressional system of lobbying, filibusters, multiple committees to hear the same piece of legislation, competing proposals, and arcane rules render it incredibly difficult to pass major legislation. In the absence of contravening pressure, compromise based on the existing system is Pragmatism 101.

Priority.  Most people are insured so there's never been the general sense of urgency that single-payer requires. It's asking (in their minds) most Americans to risk something that meets their needs for the benefit of other people. On this issue, progressives seem unable to get others to connect the dots between rising health care costs and stagnant wages, increased co-payments, and rescission. Moreover, one administration after another has faced multiple issues competing for attention with health care reform and chosen to focus on more immediate problems. More than one observer believes that Barack Obama erred in addressing health care when he did for just this reason. (Personally, I find this to be a narrow tactical argument that fails to consider the history of health care reform, which suggests that to be successful, a president must move early in his administration.) A single-payer movement, if one existed, would always find its voice to be one among many, and would have the added burden of constantly having to justify single-payer as a priority in a political environment geared to the emotions of the moment.

People Don't Trust the Government. Despite the obvious examples of Medicare and Social Security, people don't trust the government to administer health care. I mean, look at how bad the systems in Canada and France are, right? Never mind that the Canadians and the French like their health care (or that France does not have single payer and that Canada technically doesn't either), it's easier to extrapolate a few horror stories to a general conclusion supporting the Reagan dictum that Government Is The Problem.

Free Market Ideology. Even a solid voter coalition of liberals and independents would require support from business groups (such as the Chamber of Commerce) and major employers to offset the political access of Big Insurance and Big Pharma. One might think that Boeing, General Motors, and Microsoft, to name a few big businesses, would be screaming for the federal government to provide relief from the burden of insurance benefits. But slavish fealty to the ideology of the free market prevents that.

It's easier to be against something. It's difficult to sustain a long-term movement in favor of an abstract change. Say what you will about the teabaggers, they showed up and protested. But, then, "no" is a simple word that requires no further explanation, especially in the context of a dishonest debate casting health care reform as a threat to individual freedom characterized by death panels and jail terms.

The impetus for single payer began to wane in the early 70s. Ronald Reagan established an anti-government gestalt that to this day pervades the thinking of most Americans even as they rely on government services and programs. Proponents of single-payer tout its rationality, but on Capitol Hill, that and $4 will get you a cappuccino...

Don't miss Jill Lepore's "Letter From Boston" in The New Yorker. Writing in the magazine's signature understated style, Lepore reports on the 1773 Boston Tea Party (which wasn't actually named that until 1834) and shows how today's teabaggers connect to competing efforts to coopt the original event during the Bicentennial celebration in 1976. Lepore introduces some of movers and shakers among today's Massachusetts teabaggers, including:

• the state head of a movement that detests government and elites, but who sees no contradiction between that and his federally funded job at MIT;
• a recent Ohio immigrant so appalled by Massachusetts politics that she leads an effort to ban same sex marriage. I doubt I could get a bookie in Vegas to take the bet that she thinks immigrants ought to learn English and adapt to local customs;
• a nurse who believes that government ought to spend money on defense, the post office, and roads ("maybe"). It either doesn't occur to her that half of her patients are likely on Medicare/Medicaid -- and therefore paying her salary -- or she simply detests them;
• A bitter policemen who thinks that because years ago he had to take second job to pay for his daughter's 10-day hospital stay, everyone else should have to, too. Again, the stunning refusal to connect the dots: In this economy, anyone looking for a second job competes with people who desperately need a first one. And, today, a 10-day hospital stay would bankrupt almost any middle-class family without health insurance. One might think that he'd hope that no one else has to share his experience, but one would be wrong.

The 'baggers earnestly discuss how to keep out the Obama=Hitler signs from the rallies without experiencing a shred of insight as to why they might appeal to that element in the first place. As one jovially introduces Lepore to his buddies, he patronizingly refers to her as "Jane Goodall." The reference escaped me until I figured out that it has something to do with Lepore's presumed acceptance of Charles Darwin's nutso theory of evolution by natural selection...

A close friend's nephew -- a fine young man in his 20's -- has been diagnosed with an aggressive form of cancer that resists chemo and radiation. There is, however, a pill that may help. He has no insurance, and the cost of the dosage -- if successful -- will run into tens of thousands of dollars, an amount that no doubt exceeds what his widowed mother makes at the job which, in this economy, she's happy to have. But the head Massachusetts 'bagger has a ready explanation for why this is just and right:

Can you imagine if the British said not only do you have to pay a tax on the tea but you have to buy the tea and you have to buy tea for you neighbors?

After all, we wouldn't want to be our brothers' keepers or anything as silly and naive as that...

Throw me something, mister...

Gas pump scenery...

A repentant Ken Starr defends Elena Kagen and says this right-wing bit done got out of hand...

The babies are coming, the babies are coming!...

Tomorrow is a long time...

Leaving Lesbos for the Isle of Man...