Some notes on healthcare and state single-payer

Good morning and hello,

 

In this email I'm going to tell you how to make money from home as a YouTube influencer. Just kidding, it's an email about state single-payer movements. I'm up very late and I'm tired so if something doesn't make sense, just email me. 

 

Since we last spoke, I wrote for Jacobin -- it's a five-step plan to realizing universal healthcare in America. It's not the only plan, of course, but I hadn't seen something like it written down in the lefty mags I like and I thought it might be helpful to have some concrete steps about what policy changes might look like.

 

It seems that 2020 can (must) be a referendum on the question of universal healthcare. To get there, we need to force Democrats to champion it. Right now, their offerings are grotesque; less than pathetic. The Center for American Progress released an AHCA "alternative" that is neither inspiring nor progressive. It focuses on market stabilization--basically, paying the risk corridors (basically, government money paid to insurers if the sick people they're covering are sicker than expected--which, as a result, prevents them from increasing their premiums for the next year too severely. It's an essential component of the ACA for which the GOP House chose not to appropriate funds, illegally, and is the instigator of the 'death spiral' phenomenon). That's fine, but pathetic for a think tank which is treated like the vanguard of American progressivism. If anything, the CAP plan is a tacit acknowledgement that private-market insurance is dependent upon government subsidization to keep from restricting access to poor or sick people. Pathetic.

 

So, as always the work is, then, on ourselves to champion the causes we need. One place we've seen some real movement is in state single-payer movements. 

 

I'm on the record as being skeptical of the feasibility of single-payer. I'd like to explain my objections to the operations and strategy of state SP movements, briefly, and then clarify some feelings I have had after watching the California movement and talking/listening to some folks there.

 

 

1) Healthcare spending is counter-cyclical. Healthcare is most needed when the fewest people have jobs. If a state funds single-payer with an income tax, it's setting itself up to fail--it has the least income available when more people need to have healthcare paid for. States can't print currency and, thanks to dumb balanced-budget amendments passed in the 80s, 48 of them can't deficit-spend. States also don't have, say, F-35 programs they could cut to pay for their single-payer program--in a down economy, states would have to cut funding from, say, schools or infrastructure. Unacceptable.

 

2) Waivers. All the single-payer bills we've seen have a dependence on receiving Medicaid or Medicare waivers (permission to deviate from national standards, but still receive federal money) from the federal government--either from HHS secretary Tom Price or CMS head Seema Verma. They're both miserable people who murder poor people in the name of 'efficiency,' and it's reasonable to fear they would reject the wavier application. I have some things to say about the AHCA's approach to federal waivers--it's absolutely buckwild and extremely dangerous--but I'll save that for another time.

 

 

1) Implementation. NY's bill took for granted that it would get all 20 million citizens in New York State of Health. I am skeptical, and I am skeptical of how effectively it could bring costs down as it focuses on scaling membership. I know this is a little pedantic, but this shit is tough. The ACA taught us that the worst ghouls in the world will come running to fuck up any semblance of a threat to corporate domination of our bodies, and that doesn't stop once a bill is passed. Implementing the ACA was a brutal, agonizing process--it's still not even done yet!--and I want to see at least the seedlings of a plan in the state bills. This doesn't need to be very detailed; just some acknowledgement of "here is how we will keep some of the goons off our backs while we grow." One idea I like a lot--I'm sure it's not mine but I don't know where I read it. Maybe my friend Ankit?--is to get corporations on board by trading the employer mandate for a corporate tax high enough to fund the plan but lower than the current amount of money spent on insuring employees. Corporations will be incentived to get their employees off corporate insurance and on the public plan. Nobody feels screwed for paying taxes on something they don't get. Everyone wins, and it takes a big ally away from the pharma, provider, and insurance lobbies.

 

2) Partial federalization of healthcare. A lot of my thoughts on state movements ape the structure of Abby Moncrieff's work on malpractice https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1269422. In short, partial federalization of healthcare costs have made states inadequate to perform it on their own. In her words:

 

3) I guess I'm just afraid that the nabobs in charge of the Democratic Party (read that Jeff Stein piece again) will seize any failure in state programs as justification for not pursuing it at the federal level. My girlfriend likes to point out that Brandeis's philosophy that states are the laboratories of democracy is absolutely inappropriate for a public utility like healthcare (and I would lovingly add that localized care delivery systems are an essential component of health justice--healthcare needs are different in different places). Several states have been unable to pass or implement state single-payer programs, and I would spit out my own teeth if the liches who run the Democrats use failure in California or New York to shirk their responsibilities in 2018 and 2020.

4) There's this piece in the Intercept that I misread as being an attack on the California single-payer movement. I gave it a more generous read and saw that it's really a condemnation of malignant leadership. I think that's fair. A lot of politicians are going to pay lip service to healthcare revolution and then, as Rendon showed us in California, miss the football when their donors object. Fuck 'em.

State Single-Payer Movements Are So Good

So with all those objections to state single-payer programs let's talk about why state single-payer movements are great and I love them. Like any argument I like, it's really not that complex!
 

- Healthcare is a big-tent issue. Everyone is affected by it. Everyone is upset by it. Offering any kind of aspirational eschatology about liberating folks like you and me from rich people profiting off our aging parents' illnesses is a great way to get butts in seats or on doors. What else could be so compelling? (I think the answer is "police violence," and i think a movement which addresses both is the surefire mass-mobilizer of the next decade. DSA, take note!)

- If you can convince someone to fight for single-payer in their state today, you can convince them to fight for federal single-payer later. It is not difficult to explain the risks in the program to them and insist that federal single-payer is both the real goal and a separate machine, freed from the restrictions of state infrastructure. People aren't dumb if you take them seriously. 

- State movements have leverage over state politicians. We need to primary every Democrat in 2018 and 2020. A powerful, angry movement of voters for state single-payer will either create candidates from within who will champion the cause or force opportunistic politicians to hop aboard the bandwagon. This seems essential for electoral change in the upcoming elections. Hell yeah.
 

 

- You know a movement is meaningful when "normies" come out to the rallies. Normies love the single-payer movements. We must venerate, celebrate, cherish, and protect them. 

Criticizing single-payer movements for being misguided (as I did a few months ago, incorrectly) is pedantic and unimaginative. So long as state movements are transferrable to federal movements--and I believe they are and will be--we should continue to organize in the states. I hope state organizers keep this in mind as they begin putting together their plans, and it's going to be a central argument in my speeches this month. Hell right.

~~~~~~

OK some quick  Curiouscat  questions:

- What is the counter to the argument that America's healthcare is the best in the world, even if that healthcare is only for a select few? Obviously we should be a society that takes care of its citizens and fuck the rich, but would the standard of care for the tippy-top drop under UHC?
America's healthcare is the 'best in the world' if you're already wealthy. Comparisons to other nations never include the millions of Americans who are precluded from accessing care (their wait times are "infinite"). And American wait times aren't that great--wait time for a knee replacement in Boston, if i recall correctly, is about the same as in Australia (one of the weaker single-payer countries). 

About care dropping--I don't think so. There's nothing prohibiting the ultrarich from continuing to spend a ton of money on private surgeons. Those private surgeons are often the same people who push the AMA to further increase specialist salaries at the expense of primary care providers. I hope they all go to an island together and perform surgery on each other forever, away from me.

There's also a fear that universal healthcare will lead to healthcar rationing in the US. I think that's bunk. There's a ton of money that can be better allocated. Spend less on outrageous administration costs and more on preventative care and primary care clinics. Reduce hospitalization costs and increase the salaries of home health aides (of whom there will be 1.2 million by 2020, making 11 bucks an hour but being billed at $130 a visit). 

There's a study I'm too lazy to google about how of all kinds of government spending, healthcare generates the most economic activity--something like $6 for every dollar spent. So let's spend more! And let's spend it by giving people who provide care fair wages, not lining the pockets of their middle-managers.

- Could u respond to matt stoller's point that medicare-for-all is insufficient bc it doesnt address monopolization of providers
Of course. Not familiar with Stoller's argument, but it seems like he's being a pedant here. Medicare-for-All protects Americans from being forced into poverty by illness, creates a machine that can punch costs down, and introduces a lot of incentives for the government to keep its citizens from being sick, hungry, or mentally ill. It is not the final universal healthcare solution, and it doesn't need to be -- it is just the structure by which we can start to realize health justice.

- im gona eat your balls
Thank you

Happy Fourth of July, the nice day to enjoy a hotdog and the Hard Times promo. 

Also if you live in Houston, I'm speaking at a cool thing in town this Saturday. It's a big healthcare town hall and I'm repping the Houston DSA. If you live in Philadelphia, I'm doing the same thing there on the 27th. If you live somewhere else and are the kind of person who organizes these things and want to invite me, let me know! I get nervous but I really enjoy it.

Your friend,
Tim