For now, at least, the attempt to repeal the Affordable Care Act appears dead. Sabotage by a spiteful Trump administration is still a risk, but there is — gasp! — a bipartisan push to limit the damage, with Democrats who want to preserve recent gains allying with Republicans who fear that the public will blame them for declining coverage and rising premiums.
This represents a huge victory for progressives, who did a startlingly good job of marshaling facts, mobilizing public opinion, and pressuring politicians to stand their ground. But where do they go from here? If Democrats regain control of Congress and the White House, what will they do with the opportunity?
Well, some progressives — by and large people who supported Bernie Sanders in the primaries — are already trying to revive one of his signature proposals: expanding Medicare to cover everyone. Some even want to make support for single-payer a litmus test for Democratic candidates.
So it’s time for a little pushback. A commitment to universal health coverage — bringing in the people currently falling through Obamacare’s cracks — should definitely be a litmus test. But single-payer, while it has many virtues, isn’t the only way to get there; it would be much harder politically than its advocates acknowledge; and there are more important priorities.
The key point to understand about universal coverage is that we know a lot about what it takes, because every other wealthy country has it. How do they do it? Actually, lots of different ways.
Look at the latest report by the nonpartisan Commonwealth Fund, comparing health care performance among advanced nations. America is at the bottom; the top three performers are Britain, Australia, and the Netherlands. And the thing is, these three leaders have very different systems.
Britain has true socialized medicine: The government provides health care directly through the National Health Service. Australia has a single-payer system, basically Medicare for All — it’s even called Medicare. But the Dutch have what we might call Obamacare done right: individuals are required to buy coverage from regulated private insurers, with subsidies to help them afford the premiums.
And the Dutch system works, which suggests that a lot could be accomplished via incremental improvements in the A.C.A., rather than radical change. Further evidence for this view is how relatively well Obamacare, imperfect as it is, already works in states that try to make it work — did you know that only 5.4 percent of New Yorkers are now uninsured?
Meanwhile, the political logic that led to Obamacare rather than Medicare for all still applies.
It’s not just about paying off the insurance industry, although getting insurers to buy in to health reform wasn’t foolish, and arguably helped save the A.C.A.: At a crucial moment America’s Health Insurance Plans, the industry lobbying organization, and Blue Cross Blue Shield intervened to denounce Republican plans.
A far more important consideration is minimizing disruption to the 156 million people who currently get insurance through their employers, and are largely satisfied with their coverage. Moving to single-payer would mean taking away this coverage and imposing new taxes; to make it fly politically you’d have to convince most of these people both that they would save more in premiums than they pay in additional taxes, and that their new coverage would be just as good as the old.
This might in fact be true, but it would be one heck of a hard sell. Is this really where progressives want to spend their political capital?
What would I do instead? I’d enhance the A.C.A., not replace it, although I would strongly support reintroducing some form of public option — a way for people to buy into public insurance — that could eventually lead to single-payer.
Meanwhile, progressives should move beyond health care and focus on other holes in the U.S. safety net.
When you compare the U.S. social welfare system with those of other wealthy countries, what really stands out now is our neglect of children. Other countries provide new parents with extensive paid leave, provide high-quality, subsidized day care for children with working parents and make pre-K available to everyone or almost everyone; we do none of these things. Our spending on families is a third of the advanced-country average, putting us down there with Mexico and Turkey.
So if it were up to me, I’d talk about improving the A.C.A., not ripping it up and starting over, while opening up a new progressive front on child care.
I have nothing against single-payer; it’s what I’d support if we were starting fresh. But we aren’t: Getting there from here would be very hard, and might not accomplish much more than a more modest, incremental approach. Even idealists need to set priorities, and Medicare-for-all shouldn’t be at the top of the list.
Demonstrating in support of a paid parental leave bill in San Francisco last year. Beyond health care, the American safety net has major holes, especially when it comes to children. Credit Jim Wilson/The New York Times