Thursday, May 13, 2010

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...


nursemyra said...

I like the photo links

Roy said...

Unfortunately, Americans seem to be addicted to that "free market" idea, and that's stymied more social service programs than any other reason in this country. We have a federal judge seat up for nomination here in RI, and a suitable candidate has been nominated to the President by our Congressional delegation. But the RI Chamber of Commerce has submitted an objection to him. Why? They say he has an anti-business bias. Their proof for that? That he was one of the lawyers on the legal team who successfully sued paint companies for foisting lead-based paint on the public after lead in paint had been identified as hazardous. Yup, it's dem ol' free market blues again!

Love the scene from Horse Feathers. The Tea Party needs to adopt that as their theme song!

Bill said...

Last night I had a bit of an epiphany regarding how truly ridiculous the public opposition to single-payer health care is. Interestingly enough this realization was inspired by, of all things, a humorous video game review.

The reviewers observation:

"If there's one thing that characterizes his [Tom Clancy's] games it's that they always seem to be about someone trying to take over the United States. Speaking as a foreigner, who the f*** would want to take over the United States? It would be like trying to keep a giant diseased ape in your apartment that eats money and suffers from life-threatening obesity and constant diarrhea but visciously savages you every time you try to give it free health care."

This pithy comment, while quite vulgar and humorous, actually sums up our problems nicely. Why is it that average Americans are not interested in accepting something free that they won't be footing the majority of the bill for, but rather the incredibly wealthy will be? It seems to stem from a delusional fantasy that maybe, just maybe, they might be the next Bill Gates or whoever and work their way into billions of dollars at which point they won't want to pay higher taxes.


re: Ken Starr:

Incredible, the man leads the right wing rally against Clinton for spurious reasons during the 1990s and now laments that things have gotten out of hand on the right. All of this while the man continues to fear monger in California while representing the state in the case brought against Proposition 8.

Anonymous said...

Yes, the enemy is us. And they have the deepest pockets and biggest mouths and no idea what truth is.

Greed, all is Greed.

K. said...

NM: Thanks! There are many talented photographers on the blogosphere. I'm lucky to have found some of them.

Roy: That's like saying someone is anti-food because they recommend refrigerating meat. What gets me is that whatever the liberal version of that is would be mocked as knee-jerk and unreasoning.

I'm reading a book called 13 Banks, which explains why the Wall St. meltdown happened. One thing the authors point out is the ideological triumph of the free market across party lines, another function of Reaganism.

Alan Greenspan led the charge. He actually believes that the financial market has such an absolute capacity for rational behavior that it will automatically deter fraud. I don't know if such an outlook on the part of the Fed Chair is naive or negligent, but it's laughable on the face of it. And yet the guy was such an august figure and the hypnotic vision of the FM held such sway that no one called him on such arrant nonsense.

You see this on Capitol Hill now with -- even given everything that has happened -- the objections to consumer protection being included in whatever reform bill is negotiated. And the ones in opposition are bald about it: Consumer protection is government interference in the free market. Well, yes: Isn't that what we're trying to accomplish here?

K. said...

Bill: I've puzzled over this myself. There is definitely a weird sympathy for the supposed tax plight of the wealthy that seems explicable only by the Lottery Mentality. Which is exactly what you say: I might hit it big some day and if that happens I wouldn't want to pay taxes fer Gawd's sake.

The other thing is the Camel's Nose Mentality. Sure, my portion of this is small or nonexistent now, but that won't last, and they'll point to the income tax and Social Security. But they never look at the opposite side of the coin, which is that people like Social Security and that the biggest tax expenditures are on national defense and block grants to states. Or that the reason their tax burden has gone increased is because of breaks for the wealthy.

Greg: I'm afraid you're right. Which doesn't mean that we stop speaking out!

Darlene said...

You have summed up the reason that we don't have a single payer health care system very succinctly. You have obviously given it a lot of thought. Thanks for a great post.

Common sense is sadly lacking in our adversarial political system. I wish I could live to see another Franklin Roosevelt shake it up again and accomplish meaningful legislation.

I posted the videos on clean energy and oil today, K.

Ima Wizer said...

Like Pogo quote ever.

K. said...

Darlene: Thanks, and thanks for getting me to think more about it!

I didn't realize what a long shot single payer was until I started reading up on the history of HCR. I'm convinced now that Obama delivered about as much as anyone could reasonably expect. I've heard progressives call it a bad bill, but to me that implies that the status quo is preferable and a willingness to let things slide for another 20 years.

The new law is half a bill, perhaps, in that it addresses coverage but doesn't do much about cost. Addressing cost is a massively tall order that requires bulletproof bipartisanship, something the Republicans are afraid to deliver even if they were so inclined.

Ima Too true, I'm afraid.

Foxessa said...

" ... keeping an American political movement mobilized across generations has never been done, and a successful single-payer movement requires this."

Abolition; the union movement; women's sufferage; civil and voting rights.

But yes, you're right as the U.S. attention was always short, but today it's even shorter and less focused. It can't connect the most obvious, bolded dots and numbers. Not all of us, but far too many. Fostered hatred has helped a lot with this.

We're teaching an course for seniors in the school's honors program. With very few exceptions not a damned one of them can write at level; they sure as hell can't reason or analyze. One then believes their reading skills aren't so good either.

But the kind of one-on-one, face-to-face, individual commitment at every grade level and by every teacher of whatever subject that is necessary to engage with the students' productions to teach effective reading and writing and thinking can't be done now.

The teachers to whom the schools and parents gave this as their primary responsibility are fewer and fewer as English classes and teachers are cut at every level; most teachers by by now can't read or write effectively either; the class loads and number of students is too high; at higher levels the last thing anyone judges a professor on is teaching -- and at every level teachers have to do too much else, including meetings to concentrate on teaching.

Love, C.

Love, c.

K. said...

The first time I read this, I thought you meant senior citizens! The American public education system has turned into one giant vocational school. There's no value assigned to critical thinking, writing, or the arts.

I don't know that I agree with you about Civil Rights and abolition -- I suppose it depends on how one defines when something became a movement -- but those examples have something in common that single-payer does not share: They all either tapped into a deep sense of injustice and/or signified a group that amassed enough influence to take something rightfully theirs but that had been denied them.

I don't know how single-payer advocates pull that off unless the system gets so broken that SP is the only alternative. And even if that happens, the ideologues and the insurance companies will fight it tooth and nail.

tnlib said...

K & OT: I wasn't talking to you in my last comment. Hope you know that.

mommapolitico said...

Man, you can bring it on home with single payer, and throw in Groucho, to boot! No wonder I love reading your blog, my friend! Once again, fabulous column!

K. said...

tnlib: I knew what you were getting at!

MP: Thanks! It helps having Foxessa keep me on my toes.

I'm definitely for single payer or some variant. But, at the risk of sounding like a Marxist, the conditions for it aren't there yet. And I've come around to the idea that one of the conditions is a crisis of such magnitude that Big Business has to make common cause with progressives. If BB benefit costs get high enough despite passing on as much as they can in higher employee co-pays, it might yet happen.

naomi dagen bloom said...

"It's easier to be against something."
That's so central to current American psyche though not new to our dilemna. Listening to NPR interview with Daniel Okrent on his new book, "Rise & Fall of Prohibition," was reminded of this.

Did we fool ourselves in our enthusiasm for getting Obama elected, not factor in that it would be followed by the release of all the negativity that seems to be always lying in wait? Also, think there are too many smart progressives who really, really do have problem with coalitions for something as complicated as health reform.

Distributorcap said...

as the most selfish society on earth - there is no way a single payer gets passed. congress, not only bought and paid for - but also as selfish as the average teabagger. for a country that goes out of its way to say how charitable it is - it is only charitable if it is profitable

K. said...

Naomi: Thanks for stopping by and commenting. I admit that I expected opposition, but not the ferocious hatred or the absolute degree to which obstructionism would take precedent over going about the country's business. Well, now we know what we're up against.

DC: As a society, we've bought into that thousand points of light nonsense as an adequate social response. Individually, of course, we take exception when it's us who has a problem. Then we expect the government to solve everything. But everyone else can take a hike.