Point-Counterpoint

Journal of Health Politics, Policy and Law, August 2015

The Affordable Care Act versus Medicare for All

By Laurence Seidman

Abstract

Many problems facing the Affordable Care Act would disappear if the nation were instead implementing Medicare for All — the extension of Medicare to every age-group. Every American would be automatically covered for life. Premiums would be replaced with a set of Medicare taxes. There would be no patient cost sharing. Individuals would have free choice of doctors. Medicare’s single-payer bargaining power would slow price increases and reduce medical cost as a percentage of gross domestic product (GDP). Taxes as a percentage of GDP would rise from below average to average for economically advanced nations. Medicare for All would be phased in by age.

http://jhppl.dukejournals.org/content/early/2015/06/09/03616878-3150160….

Medicare for All — If It Were Politically Possible — Would Necessarily Replicate the Defects of Our Current System

By Harold Pollack

Abstract

Medicare for All, ideally implemented, could offer powerful advantages over our current health care financial system. Unfortunately, the political obstacles to such a system are formidable and are likely to remain so for decades. More to the point, a politically viable single-payer system would not replace our currently dysfunctional health care politics. It would be a product of that same legislative process and political economy and thus be disfigured by the same interest group politics, path dependence, and fragmentation that Laurence Seidman rightly laments.

From the text

Laurence Seidman’s brief for single payer will be congenial to many JHPPL readers, and for good reasons. As someone who has spent the past seven years advocating for the Affordable Care Act (ACA), I must concede that a well-conceived, well-implemented Medicare for All system would offer powerful advantages over our current health care financing system.

Medicare for All would be fundamentally more disruptive for tens of millions of people. As a matter of basic accounting, a huge reform that creates millions of winners creates millions of losers, too: affluent workers receiving generous tax expenditures, too many constituencies to count across the supply side of the medical economy who are likely to be squeezed in a new system, individuals subject to small or large tax increases, to name a few. This list includes some of the most powerful and organized constituencies in American politics. They would have to be accommodated in complex, sometimes unappetizing, ways.

Medicare for All cannot offer itself as the replacement of our depressing health politics. It would have to arise as another product of that very same process, passing through the very same legislative choke points, constrained by the very same path dependencies that bedevil the ACA.

For the foreseeable future, the main health policy challenge is to make the ACA work.

I hope that the public option returns in some form as a viable choice within the new marketplaces. One possibility would be to allow individuals over the age of sixty the option of purchasing public insurance coverage. Many Americans would welcome this option, which would also provide needed competition and market discipline of providers.

Policies like this may someday pave the way to a Medicare for All system. More likely, these would allow the possibility of public insurance carving out a complicated coexistence with private coverage. This may be the best outcome. If we keep our shoulder to the wheel in pursuing the messy, frustratingly incremental process of health reform, we can create a more humane and disciplined health system. That’s no small accomplishment. I’m not sure what else we can do either.

http://jhppl.dukejournals.org/content/early/2015/06/09/03616878-3150172….

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Will Doctors Be An Impediment To Reform?

By Harold Pollack
The New Republic, August 2009

On the left, there are Physicians for a National Health Care Program. (I happen to dislike PNHP leaders’ unhelpful stance in the current debate, but that is another story.)

http://www.drsforamerica.org/blog/-will-doctors-be-an-impediment-to-refo…

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How not to argue about health policy

By Harold Pollack
The Incidental Economist, December 3, 2011

One can make a principled decision to withdraw from the incremental politics of American health policy. I understand why single-payer advocates are tempted to take this course. Most do so with greater awareness of the attendant tensions and costs. PNHP was a sideline, not always very civil participant in the political fight to enact and preserve health care reform. Indeed its leaders denigrate important provisions of ACA that expand access for 32 million people and protect millions against catastrophic financial risks. I wish the group would talk and act rather differently in this debate.

http://theincidentaleconomist.com/wordpress/weekend-edition-how-not-to-a…

This pair of Point-Counterpoint articles from the Journal of Health Politics, Policy and Law renew the debate over the Affordable Care Act versus Medicare for All. Laurence Seidman presents the solid case for the policy superiority of the single payer Medicare for All model while Harold Pollack also acknowledges the superior policies of single payer, yet rejects it based on our dysfunctional health care politics.

Policy is not the issue in this particular debate; it is the politics. You do not compromise clearly superior policy to conform with the dysfunctional politics, but rather you change the politics in order to support optimal policy.

PNHP’s mission is to educate the public on the single payer model – an essential step in changing the politics. Harold Pollack instead supports incremental changes, such as those of ACA, as a means of negotiating the politics. Both approaches are reasonable and neither should be completely rejected in deference to the other one. The ultimate goal should always be the utopian version of single payer, and every effort must be made to achieve that goal. In the interim, incremental measures that improve health care should be supported. But it is important to continue to inform the public on the inadequacies of these interim measures that perpetuate hardship and suffering, lest inertia set in.

Harold Pollack writes about “pursuing the messy, frustratingly incremental process of health reform,” and says, “I’m not sure what else we can do.” Yet he concedes that “a well-conceived, well-implemented Medicare for All system would offer powerful advantages over our current health care financing system.” He says that he wishes PNHP “would talk and act rather differently in this debate.” This defies any interpretation other than that PNHP should abandon their mission of single payer and join him in supporting his incremental pathway to reform. Yet he suggests that “the best outcome” may be “the possibility of public insurance carving out a complicated coexistence with private coverage.” PNHP emphatically disagrees that this would be the best outcome.

Recognizing that policy goals must not be compromised and that the politics must change, we wish the incrementalists “would talk and act rather differently in this debate.” After all, we do share the ultimate goal of health care justice for all.