By Claire M. Cohen, M.D.
Common Dreams, October 18, 2021
It is a mistake for activists to once again allow Democratic politicians corrupted by big money to determine the nature of the struggle for single-payer Healthcare. We must have a strong fight on the national level in order to win this. Otherwise, we are abandoning a struggle that has strong public support and giving Congress a free pass to do nothing.
The United States is not Canada. Due, in large part, to the racist culture of the United States, successful struggles for progressive policies on state levels do not automatically translate into national victories. In his article in Jacobin, Gerald Friedman’s main example, Medicaid, proves the point. The Medicaid Program, unlike Medicare, was set up so that states have great discretion and authority on how to implement their own programs. More “progressive” states in the Northeast and on the West Coast have had more coverage, fewer restrictions, and less means testing in their Medicaid programs for decades. States with more reactionary and racist governments, especially in the South, have had more means-testing and restrictions leading to less coverage. The better health outcomes of the more progressive states have not led the more reactionary states to see the error of their ways. If anything, these reactionary states have dug in their heals. In fact, as of this year, there are 12 states that are still refusing to expand Medicaid despite being offered large “carrots” by the Biden Administration. Also, my state Pennsylvania, which currently has a reactionary legislative majority, is taking its lead from those reactionary states, and going in a more regressive direction! Given the racial demographics of the states, it could well be that having some states successfully obtain single-payer would mean an increase in racial disparities nationwide.
The Southern states did not get rid of slavery or segregation because of the example of the Northern states. History shows that, if anything, they retrenched and fought steadfastly for their “peculiar” institutions. It was only when these struggles became national fights (the Civil War, the Civil Rights, and the Black Liberation struggle) that they were successful.
Furthermore, it was Medicare’s implementation as a national program that enabled it to have a powerful effect in ending segregation in medicine throughout the country. Yes, there were local struggles, but they were expected to meet the national mandates. It is a mistake to conflate local struggles for national goals with local struggles limited to local or state attainments.
Advocates for de-emphasizing the national struggle for single-payer (or even laying it down) in order to put the emphasis on achieving state single-payer programs seem to think that working for state single-payer programs will be a much easier battle. But peculiarities about the American governance system and HHS policy, in particular, are likely to make things more complicated and difficult. Secretary of Health and Human Services Becerra, with his reversals in order to be in line with Biden Administration health policy, has already shown that he can not be counted on to give favorable interpretations of section 1332 of the ACA, making it easier for states to implement their own single-payer programs. And even if Secretary Becerra decides to allow flexible interpretation of 1332, what is to stop states from being regressive (like Pennsylvania) instead of progressive?
Finally, there are two suggestions in the Friedman paper that appear confusing. In their paper, Friedman et al discuss states using Medicare Part C to establish a state single-payer system. But isn’t that in essence establishing a state Medicare Advantage? Is this what we want: the privatization of single-payer right off the gate? Also, they talk about not prohibiting employers from offering separate health insurance. Unless I’m missing something, I can see a multi-state company offering its employees United Healthcare, or CVS offering its employers Aetna, or even better yet, Walgreen offering its employees a DCE. My experience working as an employee in a big hospital chain is that it would not hurt them one bit to do this. So would that state really have a single-payer system?
The Democratic Party has been famous for watering down and derailing progressive struggles for at least fifty years. And activists have too often been complicit in their own failure by ceding to Democrats. Just because Biden lays down Medicare For All does not mean we have to or should. We need to do just like the Freedom Riders did during the Civil Rights movement, they forced the hands of the reluctant Kennedy brothers. We need to put our efforts together and force reluctant Democrats in Congress to pass what 80% of Democratic voters, and 60% of the entire electorate already support: expansion of national, single-payer, improved Medicare for all, not just for some. As Frederick Douglas said,” If there is no struggle, there is no progress. Power concedes nothing without a demand.” Let us not be so ready to concede in the face of President Biden’s obstinateness. Keep the struggle for national single-payer going until we win.
Dr. Claire M. Cohen is a black child psychiatrist in Pittsburgh who is a member of National Single Payer, PNHP and the Western PA Coalition for Single Payer Healthcare. You can contact her at firstname.lastname@example.org.