by Kip Sullivan, JD

Conservatives never base their opposition to single-payer on the ground that it is “politically infeasible.” They oppose single-payer on policy grounds and they say so. The “political feasibility” argument is used exclusively by proponents of universal health insurance who profess to admire single-payer systems but who refuse to support single-payer legislation in any meaningful way (and often support legislation that impedes single-payer’s progress) on the ground that single-payer cannot be enacted, soon or at all. Merton Bernstein and Ted Marmor refer to these people as “political yes buts.”

“Political yes buts” have been lecturing single-payer advocates since the modern American single-payer movement began in the late 1980s. Several “yes buts” took issue with a comment I posted on July 20 on this blog entitled “Bait and switch: How the ‘public option’ was sold.” In that comment, I compared the original version of the “public option” promoted by Jacob Hacker, the intellectual godfather of the idea, and Health Care for America Now (HCAN) with the version incorporated in two bills introduced by congressional Democrats in July.

I reported that Hacker’s original proposal called for a public health insurance program that would enroll 130 million people whereas the “public option” contained in the Democrats’ House bill would enroll 10 million at most and the “public option” in the Democrats’ Senate HELP Committee bill would enroll approximately no one. (Now that Democrats in the House have compromised away to the Blue Dogs a requirement that the “public option” use Medicare’s rates plus 5 percent, I assume the Congressional Budget Office will attribute roughly zero enrollment to the House version too.)

I stated that a “public option” with zero to 10 million enrollees might not survive and, if it did, it would have little effect on health care costs and the number of uninsured and underinsured. I criticized the leaders of the “public option” movement for failing to notify the public that the mousey “options” in the Democrats’ bills bear no resemblance to the huge “public option” originally proposed by Hacker and celebrated by HCAN.

My July 20 comment moved rapidly over the Internet, starting with a few blogs maintained by some long-time single-payer advocates (including Black Agenda Report and Corrente), and triggered much discussion. From what I could see, most of it was appreciative. However, there was some criticism. The critics didn’t challenge my facts, nor my conclusion that the “public option” had undergone great shrinkage, nor that its advocates had failed to apprise the public of that fact.

The criticism fell into two categories. The first category boiled down to the argument single-payer advocates have heard for two decades: Single-payer legislation is not feasible, or is less feasible than some version of the “public option.” The second type of criticism amounted to: It doesn’t matter that the “public option” has been degraded to a tiny ghost of its former self because it will inevitably be strengthened after it becomes law.

Here is an example of the “political feasibility” argument:

Simple fact: Single-payer is not within the realm of possibility this term.

Here is an example of the argument that it’s ok to support the mouse version of the Democrats’ “public option” because fundamental reform is usually achieved by building on small incremental reforms:

The author doesn’t even seem to understand how legislation is made….The fact is, it will be a lot more politically difficult for members of Congress to vote against those future incremental improvements than to vote against the entire plan now. Once it’s in place, and constituents start calling their elected officials with complaints, they’re going to have to fix those problems – or at the very least, not get in the way of the solution….We won’t get there overnight, but this bill will at least be a decent start.

Here is an example by a critic who makes both arguments:

As Teddy Kennedy says, the most important thing is to get a public plan by hook or crook and then expand it. But I would love to know why this fellow and others like him believe that, all things being equal (the same presidential campaign, the same economic conditions) single payer could have been sold more effectively than a public plan.

I address both types of criticism in this paper.

The feasibility argument is old, and it’s backwards

I first heard the “political feasibility” argument from members of a Minnesota health care reform commission in the spring and summer of 1990 when the coalition for which I was working, the Health Care Campaign of Minnesota, started visiting commission members to drum up support for single-payer legislation. I remember very clearly hearing the political feasibility argument on a hot summer day in 1990 in the office of Senator Linda Berglin, a commission member who also chaired the Senate health committee. Berglin, who was and still is from the safest Democratic-Farmer-Labor district in Minnesota, said she wouldn’t support single-payer because “we can’t beat the insurance industry” (or words almost exactly like those). A year later she was claiming that legislation that relied on HMOs to contain cost would have a much greater chance of passing in Minnesota and that’s what she was going to focus on.

Over the years 1992 through 1994, Minnesota’s legislature did in fact pass a series of bills (collectively referred to as “MinnesotaCare”) that were supposed to achieve substantial cost containment by encouraging faster enrollment in HMOs, and thus establish universal health insurance by July 1, 1997. Of course, it all fell apart, beginning in 1995. Minnesota is no closer to universal health insurance today than it was in 1990 when I was first advised by my betters about how politically infeasible single-payer is and how politically feasible the HMO approach would be.

A half-dozen other states have suffered the same lesson. Legislative leaders, egged on by left-of-center groups that didn’t know much about health policy but which maintain close relations with Democrats, thought they could achieve universal coverage by funneling more tax dollars through “managed care” insurance companies. This occurred recently in the state of Massachusetts where “Romney-care,” a program that requires Massachusetts residents to buy health insurance from that state’s bloated insurance industry, was enacted in 2006. The program is having a very hard time staying afloat. All these multiple-payer state initiatives foundered because they did not contain cost.

It is now the summer of 2009. You can imagine my reaction to people who claim single-payer isn’t politically feasible but that other proposals that leave the insurance industry at the top of the health care food chain are. I want to get out my guitar and sing in a sad, tremulous voice, “Where have all the flowers gone …. When will they ever learn?”

How many times must universal coverage advocates rush onto the battle field to promote a multiple-payer solution and get slaughtered before they realize they can’t get to universal coverage that way? How many defeats will it take till they know that universal coverage without cost containment is not politically feasible? How many times can they be fooled into thinking that there are ways to cut costs other single-payer?

There are several reasons why the lessons of previous defeats don’t sink in with many universal coverage advocates. I’ll discuss two here: (1) insufficient knowledge of how social change happens; and (2) insufficient knowledge about the role that promoters of market-based solutions to the health care crisis played in marginalizing single-payer legislation in Congress.

Naivete about social change

As the remarks by critics of “Bait and switch” quoted above suggest, some “political yes buts” have a superficial understanding of how social change happens. They think it happens quickly or not at all, and they think it begins and ends in Congress.

This view of social change is often expressed in the mantra quoted above, “Single payer is not within the realm of possibility this term.” The implication is that if single-payer advocates cannot demonstrate that they have at least 51 percent of the votes lined up, they should retreat to the sidelines and watch the “political yes buts” do their thing. It implies that social change must occur within a single session of Congress rather than over the course of many sessions. It implies that movements for social change should, in the event that they do not have a majority vote locked up at the beginning of any given session of Congress, put their campaign in moth balls and forgo the opportunity to educate the public and build their movement through lobbying, testimony, rallies and all the other tools associated with campaigns to move bills in Congress.

In short, it implies an absurd Catch-22. To get the “political yes buts” to join them, single-payer advocates must show proof of having a majority of Congress on their side; but to get a majority of Congress on their side, the single-payer movement must build and wage a campaign relentlessly over many years in the face of active discouragement from the “yes buts” – and without pestering Congress with ideas unfairly characterized as utopian.

These demands, when they are spelled out, are obviously irrational. Universal coverage under a single-payer system is going to be difficult to achieve. The difficulty may be on the order of the difficulty of ensuring voting rights for women and civil rights for black people, to name just two examples of movements that took decades to accomplish their goals. If the leaders and supporters of these movements had accepted the Alice-in-Wonderland rules recommended by the “yes buts,” the women’s suffrage and civil rights movements would never have happened.

Naivete about the role of promoters of market-based alternatives to single-payer

The second reason some progressives don’t draw the right lessons from the failure of previous attempts to achieve universal coverage is that they fail to understand the role that advocates of bad policy have played in splitting the universal coverage movement and weakening support for single-payer within Congress. This is particularly true of the failure of Bill Clinton’s Health Security Act in 1994. The conventional wisdom within the “yes but” wing of the universal coverage movement is that Clinton’s bill died because advocates of universal coverage did not rally around his bill quickly enough in the face of “Harry and Louise” ads, and because Clinton didn’t engage in skillful “messaging.” The fact that the Health Security Act was a horrendous bill is not part of the “yes buts’” folklore.

There have been three cycles of health care reform in the last half century – 1970-73, 1992-1994, and 2007 to date. At the dawn of each cycle, single-payer legislation had already been introduced. But early in the cycle, single-payer legislation was “taken off the table” (to quote a statement Sen. Max Baucus now wishes he had never made). Each time the Democratic leadership chose instead market-based proposals that had no track record and no evidence to support them. Each time they favored reform deemed more “politically feasible” than single-payer because it left the insurance industry in place. In all three cycles, the alternative, market-based proposal was promoted by one or two policy entrepreneurs (that is to say, it wasn’t an idea that bubbled up from the grassroots).

Single-payer legislation was the first out of the chute during the 1970-1973 cycle. In January 1970, Sen. Ted Kennedy introduced what we would today call a single-payer bill. But Kennedy and other leading Democrats quickly abandoned single-payer in favor of a theory about cost containment called the “health maintenance strategy.” This strategy revolved around a new-fangled type of insurance company proposed by a Minnesota physician named Paul Ellwood that Ellwood called the “health maintenance organization.”

Ellwood would become rich and famous selling his HMO idea. He single-handedly convinced President Richard Nixon to endorse legislation to subsidize the formation of HMOs all over the country. While Ellwood worked the Republicans, the AFL-CIO worked the Democrats. Within a year, Kennedy and many other Democrats had been persuaded to abandon the single-payer approach in favor of legislation that would subsidize HMOs. The 1970-1973 cycle ended with the enactment of the HMO Act of 1973. Thus was the world’s first HMO industry born. As we all know now, the HMO experiment failed.

Two decades later, when the 1992-1994 cycle opened, single-payer legislation was not only in place in Congress it had also been introduced in many states (the first state single-payer bill to be introduced was introduced in Ohio’s legislature in 1990). The first modern-day single-payer bill was introduced in the US House by Rep. Marty Russo (D-IL) in 1991 and in the Senate by Senator Paul Wellstone in 1992. But as was the case during the previous cycle, the Democratic leadership was seduced by an alternative to single-payer. Once again, Paul Ellwood played an important role in luring Democrats away from single-payer.

Late in 1992, candidate Bill Clinton was persuaded by representatives of a group Ellwood helped form, the Jackson Hole Group, to support something called “managed competition.” The Jackson Hole Group was a coalition of insurance company executives and conservatives who met regularly at Ellwood’s mansion in Jackson Hole, WY. The theory of “managed competition” held that if the insurance “market” were tweaked (with report cards on insurance companies, for example), competition between insurers would intensify, Ellwood’s beloved HMOs would gradually seize more market share, and this would drive industry-wide premiums down. Clinton’s endorsement of “managed competition within a budget” catapulted what might have remained an obscure idea into the political lime light. When Clinton was elected, single-payer legislation once again languished while the Clintons, with help from groups like Families USA, AFSCME, and Citizen Action (now called USAction), flogged their managed competition bill. The 1994 cycle ended with the death of Clinton’s bill in September 1994, and the unraveling of similar managed competition legislation enacted in Minnesota and Washington.

Déjà vu

The cycle we’re in now bears many similarities with the last two cycles. When this cycle began (2007 is as good a year to pick as the first year of this cycle, although that is somewhat arbitrary), single-payer legislation was better positioned than ever before to be taken seriously by Democrats. Single-payer bills had been introduced in several states as well as the US House (Sen. Bernie Sanders would introduce a single-payer bill in the Senate in 2008). Polls were showing that two-thirds of Americans and 60 percent of doctors support single-payer (or “Medicare for all”) legislation.

But once again an articulate policy entrepreneur appeared on the scene to sell a market-based alternative to single-payer that would leave the insurance industry at the top of the health care food chain, and once again the Democratic leadership fell for it. This time the entrepreneur was not Paul Ellwood. This time the policy entrepreneur was Jacob Hacker, a professor of political science at Berkeley. Just as Ellwood and the Jackson Hole Group had before him, Hacker said enhanced “competition” among insurance companies was the solution to the health care crisis. (The name of Hacker’s latest paper is “Healthy competition.”) This time enhanced competition would not come from “managing” competition, but from the creation of a “public option.” This time the coalition that promoted the alternative to single-payer was not the Jackson Hole Group, but HCAN, assisted by a sister coalition called the Herndon Alliance.

The Herndon Alliance was founded in 2005 by many of the same groups that would create HCAN in 2008. The Herndon Alliance paved the way for HCAN’s promotion of the “public option” with some laughable “research” claiming to find that Americans want a “public-private-plan choice” approach and don’t want a single-payer system. I have written elsewhere about the bogus “research” conducted by the Herndon Alliance. Suffice it to say here the Herndon Alliance cooked up a new and more insidious version of the “political feasibility” argument.

Until about 2007, when the Herndon Alliance first began publishing its “research,” there was only one variant of the “political feasibility” argument, the one that said the insurance industry is too powerful to beat. The Herndon Alliance variant claimed single-payer is not feasible because Americans don’t want it. According to this variant, American “values,” not the insurance industry, are actually the greatest impediment to single-payer. According to the Herndon Alliance, Americans “value choice of insurance company” and “they like the insurance they have and want to keep it.” HCAN and Hacker picked up these refrains and promoted them vigorously to the public and to members of Congress. This inexcusable attack on single-payer no doubt helped key committee chairs in Congress (Kennedy, Baucus, Waxman, Rangel and Miller) feel more comfortable taking single-payer off the table and concentrating on the “public option.”

By early 2009, it was clear the Hacker-HCAN-Herndon Alliance propaganda for the “public option” and against single-payer had worked with the Democratic leadership, and that the Democratic leadership would fall once again for a market-based alternative and remove single-payer from the table. The removal of single-payer legislation took place without the firing of a single shot in public by the insurance industry and the right wing. It took place at the request of the “yes but” wing.

In the House, single-payer legislation, HR 676, has been rammed back onto the table, thanks to hell-raising by the single-payer movement, including the arrests of some brave doctors and nurses who disrupted hearings in the Senate Finance Committee last May. Last Friday night, Speaker Nancy Pelosi agreed to allow a floor vote on whether to substitute HR 676 for HR 3200, the Democratic leadership’s “public option” bill. This is a significant victory for the single-payer movement, but it should not have come so late in the 2009 session. If Pelosi and the three committee chairmen who wrote HR 3200 had permitted HR 676 to go through the normal committee hearing process, single-payer advocates would have had more time to educate Congress and the public about why a single-payer system is superior to all other alternatives.

It appears almost certain that the reform cycle we’re in now will end the way the last two did – with the Democrats’ competition-based alternative to single-payer going down in flames. It is extremely important that progressives, especially progressives in the “yes but” camp, understand why this happened. Yes, the ultimate villain in these dramas was the insurance industry and their conservative allies. But universal coverage advocates must understand the role of the “yes buts,” and the policy entrepreneurs they listened to, in splitting the universal coverage movement and in seducing Democrats to support legislation that was no more likely to pass than single-payer legislation and wouldn’t have cut costs if it had passed. If they don’t see this – if they persist in believing the insurance industry is the only force single-payer advocates have to contend with – they will, wittingly or unwittingly, help perpetuate the pattern we have seen in the last three reform cycles. They will, in short, perpetuate the insanity of doing the same thing over and over, seeing it fail, and not learning from failure.

It is not inevitable that a scrawny “public option” will be strengthened

The argument that any “public option” is better than none has rarely been articulated, but I suspect we will hear it more often as the reality sinks in that the “public option” in the Democrats’ bill is a joke. “Public option” advocates who learn for the first time that the “option” in the Democrats’ bill will insure few or zero people have only two choices: to abandon the “public option” movement, which is no doubt emotionally difficult to do for those who have invested heavily in the movement, or to continue to work for the Democrats’ version of the “public option” and rationalize that choice with the argument that a tiny “public option” can always be improved once it is established.

The problem with this argument is that the “public option” is not your typical government program. The “public option” is not like the space program or the various college loan programs, to take a few examples, all of which can be expanded or contracted as the years go by without seriously threatening the very existence of the program. The “public option” will be a business. And this particular government-run business may never get very big; it may not even survive. If it doesn’t get big, or doesn’t survive, it won’t develop the huge public fan base that protects popular programs like Social Security and Medicare. In fact, the reverse could happen. A miserable early performance may cause Americans to turn against the idea of a Medicare-like program for the non-elderly. Unlike public programs, businesses don’t have an indefinite time period to develop a supportive public. Businesses don’t automatically take root and go on living forever. The “public option” must prove its ability to survive and undersell the insurance industry quickly. Moreover, the “public option” will be attempting to break into a business that has been consolidating over the last few years. The insurance industry is extraordinarily difficult to crack.

“Public option” proponents who urge us to support even a token “public option” must remember how much is at stake here. At stake is not only the willingness of the public to believe that government health insurance programs can outperform the insurance industry. At stake as well is whether Congress will give the insurance industry a trillion dollars per decade of taxpayer money.

The Democrats’ legislation calls for subsidies to people under a certain income level (probably 300 or 400 percent of the poverty level) so all Americans can afford to obey the proposed law requiring them to buy insurance from either the insurance industry or the “public option.” These subsidies will probably amount to a trillion dollars per decade. If the “public option” doesn’t survive, or survives but never insures more than a tiny percent of the population, that will mean that all or nearly all of that trillion dollars will go to the insurance industry.

It is not written in stone that creation of the “public option” must go hand in hand with a huge bailout for the insurance industry. After all, one could imagine a scenario in which enrollees in the “public option” are the only ones who get subsidies. That was Hacker’s original plan. But Democrats decided early in their bill-writing process that subsidies had to go to both the “public option” and the insurance industry, and Hacker and company did not complain. That decision, plus the Democrats’ desire to achieve near-universal coverage, plus the Democrats’ decision to create only a tiny “public option,” means that if a “public option” is enacted it will be enacted only in conjunction with an enormous insurance industry bailout.

A well-fed insurance industry is bad news for both single-payer and “public option” advocates. An insurance industry strengthened by a trillion dollars per decade of new tax dollars will not only be in a better position to oppose single-payer legislation, it will also be in a stronger position to lobby Congress and the regulators to ensure the “public option” remains stunted.

“Public option” advocates should start talking about the “public option” as if it were inextricably tied to an insurance industry bailout. They should write the phrase “public-option-insurance-industry-bailout” on a Post-it note and paste it to their bathroom mirror to remind them to be honest with themselves and the public about this fact.

To sum up: “Public option” proponents who claim that any “public option” is better than no “public option” because even a skinny little program can be beefed up later are sadly mistaken. A weak “public option” may not survive to be beefed up later, and whether it survives or not, it will serve as fig leaf that will let Congress justify an insurance industry bailout. A strengthened insurance industry is the last thing either the “public option” or the single-payer wing of the universal coverage movement needs. Please say after me: A weak public option is far worse than none at all.

Single-payer will still require a political struggle

As I said in “Bait and switch,” I have no illusions about how difficult a single-payer bill will be to enact. I am under no illusion that a single-payer bill would have passed Congress in 2009 given the world as it was in December 2008. I do believe, though, that if the “yes but” wing of the universal coverage movement had thrown their considerable weight behind single-payer prior to 2009, say, in 1992 when the last reform cycle began, we would either have a Medicare-for-all style system by now, or we’d be on the verge of enacting one now.

Will HCAN and Hacker put out a call to their followers to do all they can to win the floor vote on HR 676 this fall? Or will they give lip service to HR 676 and sit on their hands? When the 2009 session of Congress ends, will HCAN et al. offer their usual misinterpretations of why reform failed?

How quickly America enacts a single-payer system will depend in part on whether progressives learn the real lessons of the failure of the “public option” movement in 2009. If the “yes but” wing draws the same lessons it drew from the failure of the Clinton bill – that the “base” was not well enough organized, or that the Clintons didn’t “sell” their plan skillfully – unity within the universal coverage movement seems unlikely, and the day we get to a single-payer system will be postponed.

I believe the “yes buts” must confront some inconvenient truths immediately. The “political feasibility” rationale for doing nothing to assist the single-payer movement was never a good one or, at minimum, after two decades of constant use, has become an embarrassment and must be discarded. It is foolish to argue that even the tiniest “public option” will constitute a victory that can be built on later. If the “yes buts” see these truths, then unity within the universal coverage movement should be possible. And if unity comes to the universal coverage movement for the first time in 40 years, single-payer can’t be far behind.

Kip Sullivan belongs to the steering committee of the Minnesota chapter of Physicians for a National Health Program.