Steve Burns: Mapping a path to single-payer

For those of us who want to see the U.S. enact a single-payer health care system, the past year has been a frustrating and even humiliating experience. Denied a seat at the table as health care "reform" was discussed and completely ignored by the media, we then had to endure the painful sight of one of our strongest champions, Ohio Congressman Dennis Kucinich, reduced to a broken man, as he abandoned his demand for even a public option, single-payer's weak-tea substitute. Joining Kucinich were 77 House Democrats who had all pledged to withhold their vote for any bill lacking a public option; all folded in the end.

So this probably isn't the best time for a single-payer advocate to look for the bright side, and it seems even more of a delusional exercise to try to lay out a path from the Rube Goldberg contraption cooked up by House and Senate Democrats towards a sensible system of health care delivery.

But let's try, nonetheless. How do we get to single payer from here?

First, let's start by recognizing one of our strongest allies in the push for single payer, the insurance industry itself. If we can count on anything, we can count on the greed and short-sightedness of the health insurance industry to do a large part of our work for us.

Imagine you're an insurance company CEO, and you've just been handed tens of millions of new compulsory customers, all forced to buy your defective products. And, thanks to the small army of lobbyists you enlisted, you've completely escaped any meaningful cost controls. How would you respond to this situation? "Wait a minute..." you say, "People have to buy my product, no matter how much I raise the price, and there's no limit on how far I can raise the price?" The 40% premium hikes we saw earlier this year are just a small taste of things to come.

Of course, the price of health insurance has been increasing at far beyond the rate of inflation for decades now (more than doubling in the past ten years), but the difference now is that the government is on the hook for those price increases in a way it was not before. Under the new legislation, costs to individuals forced to buy private insurance are capped at a percentage of income, and real incomes aren't going to increase any time soon, so that leaves the feds picking up a larger and larger share of premium costs.

So we can expect the federal costs of this "reform" to skyrocket, as insurance CEO's do what they do best - raise their prices and profits through the roof. This will inevitably set up a tension in the House and Senate between fiscal conservatives, opposed to these rapidly escalating costs, and corporatists, both liberal and conservative, who want to keep shoveling taxpayer money into the for-profit insurance industry.

Whenever you're facing the overwhelming power of a corrupt government-corporate "partnership" (as we increasingly are these days), it's important to look for a wedge issue that can split the partnership apart, and get the cronies fighting among themselves. Escalating federal costs - tied to escalating insurance-industry profits - are that wedge.

But squabbles among corporate elites and government elites aren't enough. We need a strong, broadly-based popular movement to hammer the wedge in further. Where will that movement come from?

Here, I'm sorry to say, some patience is required. Over the past year, there has been enormous opposition to the Obama bill, both from people like me on the left, and from the entire Republican party on the right. But, as we all know, this opposition alone wasn't enough to prevail. One key reason was that the opposition was ideologically based, and therefore easily divided along ideological lines. A "movement" that requires me to work with Glenn Beck is obviously never going to get anywhere.

How do we build a stronger and broader movement against mandatory for-profit insurance? Here, it's important to recognize two points:

1) Whenever we're talking about a bill that has not yet become law, opposition will inevitably form along ideological lines, because arguments pro and con will be based on predictions about what may happen in the future, which are in turn dependent on our assumptions about how the world works, which are naturally dependent on one's ideology.

2) The number of people involved in an ideologically-based movement will always be much smaller than the number of people who join in a self-interest-based movement, especially in a depoliticized nation like the United States. The vast majority of Americans -- who listen to neither Glenn Beck nor Amy Goodman -- tend to take a "wait and see" approach to legislation, a position they're encouraged to take by our media, which provides virtually no useful information about a bill until the bill is passed. Our government and media elites treat us as spectators rather than participants in the process of governing, and most Americans accept the spectator role, whether reluctantly or willingly, until their own personal interests are directly threatened.

In short, no strong popular movement until self-interest begins to bite. And the bite won't come until 2016 (remember, I said some patience is required). Around 2016, millions of Americans will be receiving letters from their favorite government agency, the IRS, notifying them that they must either spend thousands of dollars out-of-pocket to buy insurance from insanely profitable - and insanely unpopular - for-profit insurers, or pay a fine to the IRS and get nothing in return (the bill actually sets the start date for the individual mandate at 2014, but serious fines for non-participation don't really kick in until 2016.)

How will those millions of Americans respond? Some will respond ideologically, of course, and we will surely see a populist movement on the right based on civil disobedience and non-participation in the hated Obama plan.

The right-wing populists will win the bulk of the media attention (as they always do) but the response of most Americans to the insurance mandate will be based on rational calculations of self-interest rather than ideology. Most of those facing the mandate will compare the costs and benefits, and if their need for insurance is great enough, and their ability to pay is great enough, they will enroll. Many will even be grateful for the opportunity to buy insurance that they could not afford previously.

The opportunity to build a broad popular movement against mandatory for-profit insurance comes not from the ideologues, but from the millions of Americans who will not be able to pay the cost demanded for private insurance. Think about any working-class family you know. Do they have $1500 to $8600 socked away in a savings account, waiting to be handed over to Humana or WellPoint? Of course not. Rather, millions of American families are just one major car repair bill away from insolvency. These people will disobey the mandate, not because they're being told to do so by Glenn Beck, but because they simply cannot pay.

The key question will be whether those who cannot pay view their actions through a lens of individual failure -- the failure to earn enough to participate in the for-profit insurance market -- or as a political act and a collective act. Will they join with others who also cannot pay, and organize into a political force? Clearly, single-payer advocates have a role to play here.

The challenge for single-payer advocates like me will be that an opposition movement built of those who cannot pay will not, at first, be based on a desire to completely remake the system. Rather, it will form around a demand to make federal subsidies more generous, so that everyone can participate in the system. This is a demand we should heartily endorse, knowing that any changes that increase the federal share of premium costs will further drive in the wedge between Congressional corporatists and Congressional fiscal conservatives. Our short term goal should be to make the system more expensive, so that pressure in Congress to reduce costs by cutting private insurers out will increase.

But what is the chance that, even facing rapidly escalating costs, Congress would ever choose to cut their insurance-industry cronies off from the public feeding trough? Ironically, the health "reform" bill itself contains two small seeds of hope.

The first is in cuts to the Medicare Advantage system, first established under President Clinton and later expanded by President Bush, which provided government subsidies to for-profit insurers to offer supplemental coverage to those on Medicare. The entirely predictable outcome of this plan was that private insurers profited at public expense, until the Obama administration saw a ripe opportunity for cost savings with which to fund the President's larger health care plan. In fact, the bulk of cuts in Medicare in the Obama plan come from cuts to for-profit Medicare Advantage providers, which could lead to a shifting of these services out of the for-profit sector and back into the public sector.

The second seed of hope buried within the bill's 2000 pages has nothing to do with health care. It's in changes to the federal student loan program that would have the federal government lend directly to students, cutting for-profit bankers out of the very profitable (for them) student loan market. This common-sense change was helped along by several high-profile scandals in which bankers "partnered" with colleges and universities to steer students into high-cost, high-profit loan packages. As with Medicare advantage, and as I expect to be the case with mandatory insurance, the CEO's proved to be their own worst enemies - and our best allies.

Clearly, none of this is going to happen quickly. It will be six years before the individual mandate begins to take hold in a serious way, and a falling-out between corporate-government "partners" over escalating costs won't happen soon, either (It was nearly seven years between the Bush administration's massive expansion of Medicare Advantage in 2003 and the Obama administration's cuts to the program in 2010.) But, for those of us who demand single-payer, long-term struggle is nothing new. Our parents and grandparents joined in this struggle in 1948, and our children may be part of the struggle in 2020. Now is not the time to give up hope.

Steve Burns is Program Director of Wisconsin Network for Peace and Justice.