One school of thought in progressive circles, if the Supreme Court strikes down the Affordable Care Act, is that this will afford an opportunity to return to the public with a full-throated call for “Medicare for All,” a single-payer system that would use taxes to fund health coverage for all of the country’s citizens, as is done throughout the world. This would reduce administrative costs and create added bargaining power to lower costs throughout the system.
That has been the sine qua non of health policy on the left for some time, not least because it has proven effective in virtually every other country in the industrialized world. It fits best with the moral argument for universal care, contrasted with the cruelty of denying care in the name of “cost-cutting.”
Leading this effort at the national level would be National Nurses United, the union for registered nurses that grew out of the old California Nurses Association.
“The right fought [the Affordable Care Act] just as bitterly as they would have fought if it was single payer,” said Chuck Idelson, spokesman for National Nurses United — a union and trade association of registered nurses that has consistently supported Medicare for all.
“Medicare continues to be an extremely popular reform — it’s one of the most popular reforms in U.S. history,” said Idelson.
NNU will host medical screenings and town halls and other events in the run up to the Court’s decision to push single payer as a preferable alternative to the health care law.
In fact, on Saturday night, NNU will reunite Michael Moore and the stars of SiCKO, the 2007 film on our broken health care system, for an event in Philadelphia. It will be one of the first major events in the wake of the ruling on health care, and those assembled will almost certainly respond with a single-payer message. NNU also has put together town hall meetings across California to discuss deeper the health care crisis and the single-payer solution.
This may be most acute in a state like California. Medicare for All at the national level will be an excruciatingly heavy lift, and in the wake of the searing health care fight in 2009-2010, politicians in Washington are likely to be extremely wary of touching anything related to health care in the near future. But at the state level, things might come together more easily. Vermont has already passed the framework for a single-payer plan. And California has approved a single-payer framework, without the funding mechanism, in the state legislature on two occasions, in 2006 and 2008. Both times, Governor Arnold Schwarzenegger vetoed the bill. And there’s no real reason to believe that the current Governor, Jerry Brown, won’t do the same.
However, if the ACA gets thrown out – even if just the mandate is stricken – the forces continuing to push for single-payer in California plan to make a big splash. Progressive organizations like the Courage Campaign, as well as NNU’s state Chapter, the California Nurses Association, plan to reintroduce an effort to pass single-payer at the state level, as the best option to providing quality, affordable health care for all citizens. Rick Jacobs, the head of the Courage Campaign, said he would like to see a broad-based coalition, including community groups dealing with a broken health care system on the ground, come in on this effort.
There’s an active bill for the single-payer framework, SB810, in the hands of state Senator Mark Leno. California’s legislature has grown a bit more moderate on the Democratic side over the years, and single-payer actually failed to garner a majority by two votes in this legislative session, unlike in 2006 and 2008. But the single-payer campaign would presumably make that a litmus test in future elections.
This would be a long road, however. Because of the 2/3 requirement for any tax increases in California, you could not pass any revenue-raising measures inside the single-payer bill without Republican support, which isn’t coming. So the idea has always been to pass the bill, and then put on the ballot a funding mechanism for single-payer in the next election. The ability to use federal funds for a single-payer system, by pooling funds from Medicaid and SCHIP and other sources, would be limited until the waiver to provide ACA-compliant coverage hits in 2017. So you’re talking about five years at a minimum before single-payer could approach reality in California.
In the meantime, health advocates have outlined steps for California to provide increased coverage if the Supreme Court struck down the individual mandate and insurance regulations (the entire law is another matter). “I’ve never seen these efforts as competing but complementary,” said Anthony Wright of Health Access California. “I would argue that it builds infrastructure, for lack of a better term, policy and political infrastructure.”
Wright did not agree with the argument that the Court striking down the ACA would provide an opportunity for more far-reaching proposals. “I think it takes away tools or abilities,” he said. Jacobs disagreed, likening the prospect to coalitions that have been built in California recently for other measures, including a homeowner’s bill of rights that could pass in the next week. “The stages wouldn’t happen overnight,” Jacobs said. “What can happen is that, if this gets struck down, we have a political opportunity that’s similar to what we had” with the homeowner’s bill of rights, which brought progressive groups, unions, community organizations and ultimately politicians like Attorney General Kamala Harris together in support. “We’ve seen examples in the last year of how the political winds can be used to advance some progressive stuff,” Jacobs concluded.
Another argument made by single-payer supporters is that Medicare for All would stand on solid Constitutional footing, as it has been the dominant delivery system for senior health care for almost 50 years. However, Wright of Health Access California argued that the current battle on the Court is largely an invented issue, and who’s to say that conservatives won’t come up with some other novel legal interpretation to challenge a Medicare for All framework. “With the issue of the mandate, we’re already going back to pre-New Deal jurisprudence,” Wright said. “The Court took the breathtaking step of even hearing the challenge to the Medicaid expansion. This put on the table the ability to regulate commerce and ability to spend to reach national goals. Those are the two central tools of progressive governance. And all the skirmishes we’ve had on everything from birth control on would be magnified tenfold.”
But, Jacobs argued, this gets sidestepped a bit if it applies solely to a state, although the use of federal Medicaid money in that process could provide a lever. “You can’t attack it in the same way, and there’s nothing in the state Constitution that would prohibit this,” Jacobs said.
Jacobs saw the value in increasing coverage through the existing remains of the law, even if the mandate got struck down. But his group would continue to push for the optimal solution. He put it this way: “OK, there’s something in there, not very much, we’ll take something, but it’s not the answer we seek.”