If Obamacare is overturned, will that lead to single payer? And would that be a good thing?

at 10:10 AM ET, 03/29/2012


Buttons reading 'Repeal Obamacare' are displayed at the American Conservative Union's annual Conservative Political Action Conference (CPAC) in Washington, Feb. 9, 2012. (Jonathan Ernst - Reuters)
Last week, I wrote a column envisioning a world in which the Affordable Care Act is repealed and the Ryan budget is implemented. Here’s how I saw it going:

It’s unlikely that the model in the Republican budget will prove sustainable. That legislation would repeal the Affordable Care Act, cut Medicaid by a third and adopt competitive bidding for Medicare. The likely result? The nation’s uninsured population would soar. In the long run — and quite possibly in the short run — that will increase the pressure for a universal system. Because Republicans don’t really have an idea for creating one, Democrats will step into the void.

In reply, Will Wilkinson snarked:

Even if the Republicans win, they lose, and Democrats get everything they always really wanted! This sort of thinking is so wishful it’s almost touching.

This is, I think, part of the unfortunate tendency for disputes over health-care reform to be framed in terms of which political party they benefit. As the thinking goes, if the Supreme Court overturns the Affordable Care Act and then Medicaid gets cut by a third, that’s bad for President Obama and the Democrats and good for Republicans.

That’s true, so far as it goes. But if health-care reform gets overturned, that’s primarily bad for the uninsured. Obama and the Democrats might be disappointed, but odds are they and their families will continue to enjoy health-insurance coverage. They’ll likely even continue to enjoy political success. It’s very easy to imagine health-care reform getting overturned in June and Obama and most incumbent Democrats getting reelected in November. It’s very hard to imagine health-care reform getting overturned and the 30 million people it’s expected to cover getting insured.

There’s a flip side of this that you see on the left, and that many people thought they saw in my column: If the individual mandate is overturned, it will essentially wipe out the only plausible path to a sustainable private health-care system and single payer will be the eventual result. So: Yippee?

Not in my view. I think that path would look something like this: With health-care reform either repealed or overturned, both Democrats and Republicans shy away from proposing any big changes to the health-care system for the next decade or so. But with continued increases in the cost of health insurance and a steady erosion in employer-based coverage, Democrats begin dipping their toes in the water with a strategy based around incremental expansions of Medicare, Medicaid, and the Children’s Health Insurance Program. They move these policies through budget reconciliation, where they can be passed with 51 votes in the Senate, and, over time, this leads to more and more Americans being covered through public insurance. Eventually, we end up with something close to a single-payer system, as a majority of Americans — and particularly a majority of Americans who have significant health risks — are covered by the government.

The key word there is “eventually.” This is a long, ugly process that ensures a very large uninsured population for decades. It’s also a process that ensures there won’t be a coordinated effort to control costs for sometime. Yes, it might end up with a system that’s tilted further towards public insurance than what’s envisioned in the Affordable Care Act. But it’s not at all obvious it would be a good system, and, in the decades between here and there, there will be a lot of unnecessary suffering and deaths among the uninsured. That’s the real cost of losing this opportunity to insure 30 million people. And it’s a cost that too often gets swept under the rug in Washington’s handicapping of the political fallout.

 
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