With the demise of Trumpcare, there’s no better time to fight for single-payer.
By Adam Gaffney, M.D.
Jacobin, March 27, 2017
We should take great pleasure in the fall of the American Health Care Act (AHCA). The AHCA was essentially what you would get if you convinced Ebenezer Scrooge to heavily edit the Affordable Care Act (ACA), which made it at the same time unoriginal, nasty to the poor, and generous to the rich.
In its original form, the AHCA would have, in Dickensian fashion, cut some $880 billion in Medicaid spending over a decade, thereby reducing enrollment by 14 million by 2026 and fulfilling Paul Ryan’s sick collegial dreams. It would have largely turned the ACA’s premium- and income-based tax credits into flat vouchers, leaving millions unable to buy a health plan. It likely would have blocked some women’s access to abortion. And it would have diverted some $883 billion in tax breaks to, for the most part, the very wealthy and the medical-industrial complex.
But now it is as good as dead. Good riddance.
At the same time, its demise does not mean we are moving forward, only that we are treading water. Here are five reflections on the death of the AHCA, and on the path ahead.
1. This was the right-wing plan.
Many described AHCA as hastily conceived and slapdash, which is to some extent true. However, in partial defense of Paul Ryan (words very reluctantly uttered), the AHCA was heavily based on a detailed blueprint, “A Better Way,” that he and the House GOP published nine months ago. The surprise over the bill’s content was itself surprising.
The truth is that in the context of strong popular support for Medicare — and given that the Right has no actual desire to undermine the private health insurance industry — the AHCA was about the most they could (or for that matter, wanted to) achieve: namely, a weird version of the ACA with more regressive funding and paltrier benefits, along with the partial strangulation of Medicaid and a middle finger to Planned Parenthood.
They really don’t have anything else up their sleeve. If they try to repeal Obamacare again, it will likely be with some variety of the same nonsense.
2. The AHCA’s collapse is not an endorsement of the health care status quo.
The AHCA was extremely unpopular, but its failure does not mean all is well with the US health care system. While the AHCA would have increased the ranks of the uninsured to an inhumane 52 million, an estimated 28 million will still remain uninsured by 2026.
Today, families are squeezed by rising drug prices and high copayments and deductibles, too often facing bankruptcy and financial strain. By slashing the health care safety net, the AHCA would have sharply exacerbated these problems. But Paul Ryan’s callousness doesn’t make the present state of affairs any less deplorable.
Indeed, a large part of the popular discontent with the ACA is less about what the law did than what it failed to do. Now fully implemented, the ACA modified — but did not remake — the US health care system. People remain justly angry that they’re still being squeezed.
Wrangling over the ACA’s positives and negatives is going to be less relevant with each passing year: it will remain, as Ryan admitted during a glum press conference last Friday, “the law of the land.” Moving forward, criticism should be aimed less at Barack Obama’s law (which, we should acknowledge, did some real good), and more at the persistent injustices and inequalities intrinsic to the American health care status quo: uninsurance, underinsurance, racial health inequalities, tiers of access based on insurance, extortionist drug prices, medical bankruptcies, inferior health outcomes, needless deaths, and so forth.
3. The Left is winning the discursive battle.
When the Congressional Budget Office reported that the AHCA would result in an additional 24 million uninsured, it was widely seen as a damning indictment. The notion that all should be covered — that there is a right to health care — is increasingly becoming common wisdom, such that even the Right has taken to cribbing the Left’s language: Republicans chattered nonsensically about “universal access,” while Trump vowed that he would cover everybody.
However, on the Left, it is critical that we not allow the language of universal health care to be adulterated. Many already speak of the ACA as a universal health care program, a puzzling assertion given the 28 million or so that remain uninsured.
In addition, we should envision health care universalism along much broader and more egalitarian lines: the elimination of uninsurance, the end of cost-sharing, and the creation of a single tier of coverage that provides equitable access to health care for all.
For instance, as critically important as Medicaid is to the more than 70 million Americans who rely on it, we shouldn’t forget that its participants sometimes receive segregated care, or are relegated to the back of the line. Clearly, health care equity necessitates equitable health care coverage.
And equitable systems save lives: as a widely reported study recently described, individuals with cystic fibrosis (CF) in Canada live on average an entire decade longer than their counterparts in the US. Canadians with CF also received more lung transplants, even though the US is allegedly king when it comes to high-tech care.
4. National single-payer is the next step.
In fact, this is already happening. “In the wake of the Republican failure to repeal the Affordable Care Act on Friday, leading figures in the progressive wing of the Democratic Party are rallying behind a single-payer health insurance,” a Huffington Post article over the weekend began. “Sanders to offer single-payer health care plan,” a headline in Politico yesterday read. Democratic congressman John Conyers reintroduced his single-payer bill in the House earlier this year.
And most importantly, activist groups are organizing with muscle and creativity throughout the country.
The iron is clearly quite hot. With the death of the right-wing challenge, single-payer is the alternative to the health care status quo. Various half-measures are not worth it at this point. For instance, a “public option” is sometimes described as a way to shore up private health insurance exchanges, but that’s precisely what we’re not trying to do. We’re trying to replace them.
5. This is a winnable battle.
A majority of the country wants single-payer. Both physicians and nurses voice strong support. And now the conservative alternative has been disgraced. Politicians have yet to follow the populace, but, with enough grassroots activism, they can be pressured and flipped, or — if recalcitrant — confronted with primary challenges or defeated at the polls.
The insurance industry will no doubt fight to the death, but it’s enormously unpopular, and surmountable.
A single-payer universal health care system would not, by itself, secure the much larger goal of health justice. To accomplish that, all types of oppressions — along racial, gender, economic, and environmental lines — would need to be undone.
But it would be an enormous first step.
Adam Gaffney is an instructor in medicine at Harvard Medical School and a pulmonary and critical care doctor at the Cambridge Health Alliance. He blogs at theprogressivephysician.org.
