mead cohen berger shevtsova garfinkle michta grygiel blankenhorn
ACA in the Midterms
Democrats Running Away from Obamacare…to Single Payer

In a wide-ranging interview with Vox wunderkind Ezra Klein, House Minority Leader Nancy Pelosi makes two big statements about Obamacare. First, she calls the Affordable Care Act a “wash” politically, and states that Democrats won’t be running “on or from it.” She then goes on to say that Democrats “stand ready to improve it as we see how it is implemented, not to let it be ‘repeal or retain’ but to have the Affordable Care Act and improve upon it.” When Klein asks her how she’d like to see it improved, she mentions she’s always favored a single payer system, as well as a public option.

This interview is very revealing. While individual Democrats may campaign on the ACA if they think their districts favor it, the party as a whole hopes to put the law aside and take up issues more likely to win them votes. Klein sums up the implications here:

If you had told most Democrats in 2010 that by the time the 2014 election rolled around Obamacare would have rolled out with lower premiums and higher enrollment than anyone projected they would have been thrilled. They knew when they passed the law that it was going to be a political loser in the 2010 election but they figured that if they could just get it up-and-running — and insuring millions of people — it would be a winner in future elections. And perhaps it will be. But the definition of “future” keeps getting pushed out. Obamacare is working, but not for Democrats.

Though Pelosi says they won’t run “on or from” the ACA, Democrats’ decision not to champion this signature piece of legislation is effectively a repudiation of it.

Either way, the GOP won’t let Democrats forget about Obamacare. Republicans intend to make the ACA the defining issue of the midterm. We’ve said from the beginning that the future of the Democratic Party is bound up with how this law performs politically. Vulnerable Democrats won’t just be able to put it to one side; they will need to have answers when the GOP challenges them over the issue. They could take a lesson from Pelosi’s interview, and talk about building on the law’s successes. In doing so, they could also endorse a pivot to a single payer system, as Pelosi seems to want. The idea has been floating around on the edges of liberal discourse for some time, but a major politician mentioning it is big news.

But if Democrats stop short of that, what will they propose? Will they advocate repealing the employer mandate, as Klein himself has suggested? Will they poach some conservative ideas like allowing insurance to be bought across state lines or mandating only catastrophic—not comprehensive—coverage? We don’t know, because Democrats have talked far less about how they would improve Obamacare than Republicans have talked about how they would replace it.

Features Icon
show comments
  • TheCynical1

    They could run to single payer — and straight into a discussion about the VA.

    • Thirdsyphon

      Ah, but the VA isn’t single payer. It’s single provider, and the difference is significant. Like the United Kingdom’s NHS, the VA model really is the kind of socialized medicine that conservatives think they’re complaining about when they criticize the ACA.

      • TheCynical1

        Point taken; my point was intended to be broader, about the limits of government in general.

        As Prof. Mead recently said in the context of the VA scandal, “The President probably doesn’t want to admit that there are downsides to government-run health care. If such abuses can take place under the
        direction of one government entity, why not under another?”

        • Thirdsyphon

          Without disputing your broader point that any government program carries at least some potential for abuse, I’d reiterate my response to you and expand it to Prof. Mead: the VA is different in kind from Medicare and Medicaid, in meaningful ways that make his implicit attempt to conflate these programs extremely dubious.

          I’d also point out that many private insurance companies and health care providers have been caught engaging in some rather sordid practices of their own.

      • circleglider

        There is no practical difference between single “payer” and single “provider.” Whether the means of production are owned and centrally-managed by a government bureaucracy or simply centrally-managed by the same bureaucracy makes little (if any) practical difference.

        US healthcare delivery was heavily managed the federal government prior to Obamacare. Now it is totally and entirely managed centrally —just like the VA.

  • Thirdsyphon

    The Democrats aren’t going to go straight for single payer. It’s too risky. My guess is that they’ll promote eliminating the mandates (individual and employer) and make up the difference by paying for coverage from general revenues. After that, the narrative can turn to whether the insurance companies are delivering adequate care, whether they’re gouging the taxpayer, and whether the taxpayers might not just prefer rolling the whole system over into Medicare.

    • Arkeygeezer

      The program will end up being rolled into Medicare sooner or later. That seems to me to be the only option for both parties. The American People will not allow the ACA to be repealed entirely without some substitute..

      • Corlyss

        Not Medicare, Medicaid. Vets are going to end up there too. It will become the default insurance program, in more senses than one. If the states had had any sense, they would have sued the feds over the unfunded mandate Medicaid represented when it first came out.

        • Arkeygeezer

          The ACA is under Medicaid now.

        • Thirdsyphon

          If the states had any sense, they’d have taken the money and expanded Medicaid. Public health problems impose costs that can’t be avoided. Even if people without insurance were simply turned away from emergency rooms and left to fend for themselves, their resulting disability and death would carry a huge social cost.

          • Corlyss

            “left to fend for themselves, their resulting disability and death would carry a huge social cost.”
            And what exactly do you think is going to happen day after tomorrow under Obamacare? With fewer hospitals, fewer doctors, fewer clinics, and the poor with “insurance” but no access, or access only if they can drive dozens to hundreds of miles away? I could be wrong, but I think those outcomes are going to persist regardless, unless the government is willing to set up conscription for doctors, impressed service for talented science students converting them to doctors regardless of their druthers, and truly nightmarish consequences for a supposedly “free” society. Nursing home with an Army. That’s where we’re headed if we aren’t already there. Seems to me the poor dying is unavoidable, and maybe we shouldn’t try to avoid it. The Government can’t stop all bad things from happening. At some point the cost-benefit trade-off has to kick in. We are not New Zealand, where they think they can repeal natural laws.

          • Thirdsyphon

            I don’t think it’s necessary to conscript a force of indentured physicians and chain them to their X-ray machines. The rest of the developed world seems to do just fine with a simple (and non-slavery based) single payer system.

          • Loader2000

            They don’t necessarily do just fine. In some places, like Germany, they do fairly well. In other places, like England, the system is horrible and the only reason they aren’t up in arms is because they don’t know anything else. Furthermore, many, of these countries are facing demographics that will make the current systems untenable over the next 30 years. Already, France, Italy, Spain, Japan, and many other countries are seeing deficits and expenses spiral (even faster than in the US) and revenues remain constant. Maybe we want to go in the direction of single payer, or maybe we don’t, but we shouldn’t simply assume that because things are working well (by our standards) in a few of these countries, that we will be happy the how the results turn out in our own country. Furthermore, there is a whole lot of innovation with regard to how health care is administered going on at the margins of society (the uninsured) in our country right now that isn’t happening in countries with single payer systems. When you increase security, weather military or economic, it always comes at the expense of freedom and often, of innovation.

          • Loader2000

            On the other hand, lots of countries (Austrialia, Norway, Canada, Denmark) seem to be doing pretty well with single payer systems. However, it is interesting to note that these are all countries with small populations and very, very large amounts/access to natural resources (land, petroleum, lumber, natural gas, fisheries). It may or may not be accurate to compare the US to these small population/resource rich nations with regard to national health plans.

          • Thirdsyphon

            The United States isn’t exactly poor, in natural resources or otherwise. Our GDP per capita is higher than every country in Europe, with the exception of tiny Lichtenstein and (on some rankings) Switzerland. I’m not persuaded that what’s affordable for Germany (GDP per capita 40K) is unaffordable for the United States (GDP per capita 53K).

          • Thirdsyphon

            The health care system in England isn’t just single payer; through the National Health Service, the government exercises a huge degree of control over how medicine is practiced, not merely how it is paid for. Unlike Medicare (but very much like the VA), it is fair to describe the English system as “socialized medicine.”

            Regarding single payer, I’m not simply making assumptions based on other countries; I’m making assumptions based on other generations in the United States. Americans over 65 have been insured through a single payer system for quite some time now, and all the polling suggests that the program is immensely popular with them. Nor has it stifled innovation. If the commercials on cable TV are any indication, innovative new health care products for the elderly are a booming industry. . . thanks in no small part to the steady revenue stream afforded by Medicare. Innovation for younger, less well-insured populations have been lagging by comparison because there’s no guarantee of their ability to pay.

            Finally, I would argue that enhanced security doesn’t always come at the expense of freedom and innovation. Sometimes they go hand in hand. Without the security of patent protections, for example, a lot of modern technology wouldn’t exist.

          • Corlyss

            You’re assuming a lot of facts not in evidence. E.g., that the Brits don’t routinely as a matter of policy lie about their health care system. And that many Americans over 65 get their health care only from Medicare – private employer plans accounts for a lot. And that Medicare pleases seniors because it’s good, as opposed to pleases seniors because, as pitiful as it is, it’s better than nothing.

            “. . . thanks in no small part to the steady revenue stream afforded by Medicare. Innovation for younger, less well-insured populations have been lagging by comparison because there’s no guarantee of their ability to pay.

            You’re making this up, aren’t you? Medicare doesn’t fund medical research. Most of the medical research that produces the products you see advertised on tv was the result of demographic canniness on the part of drug companies – they had only to look at the aging population and ask some actuaries about the next 50 years to realize there’s gold in that thar demo.

          • Thirdsyphon

            Medicare doesn’t fund medical research (at least not that I know of), but it does provide a guaranteed market for new medical products. This is (arguably) anecdotal, but every commercial that I see for diabetic testing supplies, mobility scooters, electric stairs, and sitting bathtubs is careful to point out that Medicare will reimburse the cost. There’s no similar guarantee open to the prospective manufacturers of products aimed at younger people.
            Also, there’s gold in the 65+ demo in large part because Medicare exists. Without that program, there’d be much less of an incentive for pharmaceutical companies to throw resources into developing compounds like Boniva.
            None of this, it bears mentioning, is a bad thing. We want this research to take place, as a society, and we want these drugs to exist. But there’s no ethical basis to justify a universal right to health care for one segment of the population while decrying it as creeping totalitarian evil for everyone else.
            Also, although my relatives have never complaind about the quality of care they’re getting from Medicare, sarcasm aside, “better than nothing” really is enough to make someone delirously happy if the alternative really is nothing.

          • Loader2000

            By innovation, I mean providing the same or better goods and services for less cost, or, in other words, efficiency. Not simply new, every more expensive procedures.

          • Corlyss

            That must be why we don’t have many foreign doctors working here! [engage irony systems now . . .]

      • Thirdsyphon

        I’ve long suspected that this was the endgame that Obama had in mind from the beginning.

  • Boritz

    “Will they poach some conservative ideas….?”

    Rare admission by The Feed that conservatives ever at any time had ideas about ACA, and it seems to be inadvertent at that.

    Question for Nancy Pelosi: If ACA morphs into single payer will the legislation call for congress to be covered by it according to the same rules as everybody else? They missed that opportunity when ACA was drafted but this would offer solidarity with the people a new chance..

  • Corlyss

    Republicans said back in 2009-10 that single payer was always the ultimate goal including the process of multiple failures along the way that would convince the furious public single payer was the only realistic option.

  • SisyphusRolls

    It’s worth noting that one (inadvertent) good thing ACA produced is a large, natural experiment in the efficacy of Medicaid, because Oregon couldn’t afford to cover all the newly eligible recipients and created a lottery. This effectively created a double-blind experiment.

    And the results weren’t good for Medicaid. Basically, Medicaid does not improve health outcomes vs. no insurance. And it increases emergency room use. The only long-lasting benefit was improved finances for recipients (which is to be expected from a big insurance program), though there are probably many more efficient ways to get similar financial improvement for working lower middle class people.

    In any event, when people claim Medicaid expansion improved public health in states that adopted it, the best evidence we have flatly contradicts that claim.

© The American Interest LLC 2005-2016 About Us Masthead Submissions Advertise Customer Service