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A Revolutionary Reform Called Single-Payer

A rally to support health care reform and a single-payer system. (Michael Fleshman / CC BY-SA 2.0)

Being a socialist (which I’ve been since age 19) committed to the democratic transformation of society doesn’t mean rejecting all reforms that fall short of thorough societal reorganization. Serious and substantively progressive reforms are critical to left movement-building and to the meeting of human needs in the here and now. This is particularly true when the reforms have deep, far-reaching, positive implications for masses of people and the cause of democracy.

Look, for example, at the long-standing, progressive “reformist” call for universal, government-provided health insurance in the United States. Legislation put forward by Michigan Rep. John Conyers every year since 2003—HR 676: The Expanded and Improved Medicare for All Act—would expand the nation’s existing single-payer, government-funded system of health insurance for citizens 65 and up—also known as Medicare—to Americans of all ages. Conyers’ “Improved Medicare for All” bill would align the United States with rich peer states by covering the medical expense of all its citizens from birth. Health insurance would become a basic human right in the U.S., removed from the realms of profit making and commodity exchange, as it is in Canada, Japan and most of Western Europe.

Direct and Obvious Benefits

The direct benefits that would flow to everyday Americans from this single-payer system would be profound. Health care costs would fall dramatically with the big private insurance rackets/corporations and their giant marketing operations, parasitic premiums and exorbitant profits removed from the equation. Health care providers would be released from the burden of juggling the paperwork of numerous separate payers. A single, central and publicly accountable government payer would set reasonable, democratically mandated price ceilings.

Coverage no longer would be denied to those unable to pay out of their own savings. Quality care would be made equally affordable for all, regardless of class, race and other invidious social distinctions and inequities. People born and kept in the lower and working classes would enjoy access to the same quality care as those born into the capitalist and professional class elites. Millions of Americans would be released from financial anxiety over unforeseen illnesses or accidents.

In 1993, David Himmelstein explained these basic and remarkable social-democratic benefits to Hillary Clinton, then head of the White House’s health reform initiative. Himmelstein was head of Physicians for a National Health Program. He told the first lady and future Democratic Party presidential nominee how single-payer would provide comprehensive coverage to the nation’s 40 million uninsured while retaining free choice in doctor selection. It was certified by the Congressional Budget Office as “the most cost-effective plan on offer.” And, Himmelstein added, it was backed by the great majority of U.S. citizens. This is what Clinton, a leading corporate Democrat, said in response, before wearily dispatching Himmelstein: “Tell me something interesting, David.”

Sixteen years later, the newly elected, neoliberal Barack Obama doubled down on corporate Democrats’ cold-hearted dismissal of single-payer. Right after he entered the White House, Obama set up a health care reform task force chock full of big insurance company representatives. Not one of the more than 80 House members who had endorsed single-payer—not even the veteran Conyers—was invited to participate. The outcome was the so-called Affordable Care Act (later dubbed “Obamacare”), a complicated, corporatist and “market-friendly” bill based on a Republican plan drawn up by the right-wing Heritage Foundation. Because it left the price-gouging and profit-taking power of the big insurance and drug syndicates intact, the ACA condemned a vast swath of the nation to continuing inadequate and unaffordable coverage—while the right-wing noise machine railed against “socialized health care.”

This history is no small part of the secret of how and why vicious right-wing Republicans took over the White House in 2001 and 2017.

The Safety Net, Democracy and Workers’ Power

Other more indirect but significant benefits would accrue to the nation if it shifted away from its largely employment-based system of health insurance to “Medicare for All.” For instance, untold millions of Americans stay stuck in jobs they hate and/or for which they are ill-suited because they fear losing health insurance if they leave their current positions.

And there’s the significant and rarely noted democracy dividend that would ensue from single-payer. Millions of U.S. workers are frightened, for good reason, to say or do anything their bosses might disapprove of on or off the job. The national working-class majority’s dependence on the employer class for health insurance has chilling authoritarian implications. This is a country in which you put not just your job but also your health care coverage and often your family’s health coverage at risk by saying, writing or doing anything your workplace superiors find objectionable.

The kinds of transgressions that can jeopardize you and your loved ones’ medical coverage are endless. They include trying to form a union, participating in a work stoppage, putting up a Facebook post against racism, backing a political candidate your employer dislikes, attending an environmentalist protest or even just dressing in a way that irritates a boss or letting it be known that you have a better way to perform some work task. First Amendment rights of free speech and public assembly don’t mean all that much when exercising them can cost you your job, or your health care and that of your family.

It isn’t just about health care. There’s an intimate relationship between the strength of a nation’s social welfare state and working people’s capacity and readiness to fight for their own interests and the common good on and off the job. It’s not for nothing that you can’t receive food stamps while engaged in a labor strike in the U.S. The American business class used its influence to prohibit state food assistance to striking workers long ago. Capitalists know that working people’s marketplace and workplace bargaining power are enhanced by the existence of a strong government safety net, which reduces the hazard workers face when they challenge boss-class authority. Big business has pushed through the dismantlement and delegitimization of social welfare programs for decades, in no small part because capitalists-as-employers want, in political science professor Frances Fox Piven’s words, “to make long hours of low-wage work the only available option for many.”

Rolling back and pre-empting the social safety net carries a triple boon for the U.S. capitalist class. The first dividend-boosting attraction is that slashing social expenditures and programs save the rich tax payments to support the common good. The second lure is that reducing social spending reduces inflationary pressures, which helps protect the real value of interest payments from debtors (most of us) to wealthy creditors. The third draw is that we-the-working-class majority have less power to resist and challenge their profit-seeking authority within and beyond the workplace when there’s no strong welfare state backing us up. Along with the related collapse of unions and collective bargaining, the comparative weakness of the U.S. welfare state is a key factor behind the long stagnation of wages and the nation’s extreme economic inequality.

Curbing Overwork, a Great Scourge of Democracy

Speaking of long hours, there’s another and related collateral benefit that would flow to American workers and citizens from the introduction of Medicare for All: curing the scourge of overwork. According to the Organization for Economic Development and Cooperation, American workers put in the longest hours per year among their counterparts in other wealthy nations. U.S. employees, for instance, put in 423 more hours than German workers. In many U.S. professional sectors, workweeks of 70 hours and more are not uncommon. Add in brutal commutes and extensive car travel related to the nation’s sprawled-out residential and shopping patterns, and it’s no surprise that hundreds of millions of U.S. citizens face a critical shortage of free time.

This is outrageous and problematic on numerous levels. It is an indication of the nation’s savage economic unfairness: More and more wealth and income has been getting distributed upward out of ordinary people’s households and into the hands of the wealthy few at a time when U.S. labor productivity continues to rise (albeit slowly) and workers spend more time on the job than their counterparts in Europe and Japan.

Beyond the fairness issue, overwork takes a terrible toll on working people’s physical, emotional and mental health. It’s a critical factor—along with the high cost and restricted availability of health care—behind the low life spans Americans face (26th of 35 Organization for Economic Development and Cooperation countries) compared with people in other wealthy nations.

At the same time, overwork and the loss of free time has a significant negative impact on the U.S. citizenry’s capacity for self-rule. Free time is, among other things, a major democracy issue. In my experience, social and political movements in the U.S. founder again and again because of (among other things) time-shortage and exhaustion: People lack the leisure time and vigor required for meaningful activism and public engagement. Without a reasonable abundance of time off the capitalist treadmill and out from employers’ watch, people cannot form and sustain grass-roots organizations for social justice, peace, environmental sustainability, economic fairness and democracy. (For what it’s worth, the 19th century pioneers of the U.S. labor movement talked and wrote about the demand for shorter hours—early American unions’ top issue by far—largely in terms of how overwork stole from citizen workers the time and energy essential for meaningful participation in the great experiment in popular governance that supposedly had been launched by the American Revolution.)

Ask any savvy progressive what measures, actions and other changes we need to create more free time for working people—essential for democracy and basic human, personal and social health. He or she will mention some good ones: a significant upgrade in the U.S. minimum wage (which would help more working-class households forgo second and third jobs); the relegalization of union organizing to bring back unions (“the people that brought you the weekend,” to quote a clever bumper sticker); collective bargaining over wages, hours, benefits and more; the enforcement of rules on overtime pay; mandatory work-sharing to balance out the workweek and provide jobs for the unemployed; and a retreat from mass consumerism, which leads many working people into a disastrous cycle of work, spending and debt.

Also useful in curbing overwork would be single-payer health insurance. Single-payer would give workers more courage and more time to organize and fight for shorter hours with no reduction in pay. With improved Medicare for All in place, lower-paid workers no longer would be compelled to take second and third jobs to pay for health insurance and to save up for possible future medical emergencies. At the same time, single-payer would remove a major structural incentive pushing employers to extract as much work as possible out of each of their full-time, benefit-receiving, salaried workers: the high costs of employee health care, equivalent to 40 percent of total compensation of salaried employees. Because costly health care benefits are paid per employee, not per hour worked, economist Juliet Schor noted in her classic study, “The Overworked American: The Unexpected Decline of Leisure,” employers are driven by employment-based health insurance to try to get as many hours as they can from as few employees as they can. This ironically pushes millions of employees into physical and mental illness.

‘What’s the Something Much Better?’

Beyond its more obvious direct benefits, then, the Medicare for All legislation long championed by Conyers would be a great boon for democracy, labor rights, workers power and citizen engagement in the U.S. on numerous levels. It is the embarrassingly obvious and elementary answer to a deeply insulting question asked by longtime senior Obama adviser and intimate Obama family confidante Valarie Jarret during the following dialogue with “PBS NewsHour” host Judy Woodruff in January:

Judy Woodruff: Just last night, the United States Senate took another step toward repeal of Obamacare, the Affordable Care Act. They say that’s what they’re going to do. They’re going to get rid of what’s there now and replace it with something much better.

Valarie Jarrett: Well, what’s the something much better? That’s my question. That’s the question the president has been asking for eight years right now. So, if there is a something better, let’s hear it. What’s the secret?

“What’s the something much better?” Beneath her corporate-serving pretense of cluelessness, of course, Jarrett knew very well the real and progressive answer to that question, as did Obama: single-payer. Much better, that is, for the nation’s poor and working-class majority, not for the big insurance companies and their Wall Street sponsors, key backers of the Democratic Party.

‘Designed to Fail’

This essay might seem like an endorsement of Sen. Bernie Sanders’ recently released Medicare for All bill—SB 1804. It is not. I agree with single-payer activists Margaret Flowers and Kevin Zeese. In a recent analysis of SB 1804, they note that the proposed measure is plagued by core flaws that will “prevent it from fully transforming our health care system to a public service”:

● Investor-owned, for-profit provider facilities are permitted to continue to operate within the system, with no budgetary controls to restrain them.
● The bill excludes long-term care, keeping it in Medicaid, which forces people and their families to live in poverty to receive benefits.
● SB 1804 includes an absurdly long transition period that seems like a setup for failure. As Flowers and Zeese write: “Most universal systems are started at once—on a certain date everyone is in the system. This is how we did Medicare as a totally new system in 1965 before we had computers. The delayed implementation period over four years is such a complex transition that there are concerns it will proceed poorly, and support for a universal health care system will disappear before it is complete. With complexity comes greater costs. HR 676 would start all at once, which would not only allow the savings needed to cover everyone but would also put us all in the same boat so that we all have an interest to fix any problems that arise.”

Flowers and Zeese have created a chart comparing HR 676 and SB 1804 and a chart outlining the prolonged transition for SB 1804.

“Basically,” Flowers told me Saturday in an email interview, “Sanders’ bill allows for-profit providers to continue to operate without any budget restrictions. That, in itself, is a huge gift to Wall Street. And the four-year transition seems designed to fail.”

Flowers and Zeese rightly share the left blogger Jim Kavanaugh’s suspicion that “S 1804 may actually be a ‘Trojan Horse’ for the Democrats’ favored proposal, a public insurance they refer to as a ‘public option’ being added to the current mix.” Flowers and Zeese called the public option a “Profiteer’s Option” because, they explain, “it will serve as a relief valve for private insurers to jettison people who need care.”

“As a leader in the Democratic Party in the Senate,” Flowers noted in August, “Sanders is trying to walk the line between listening to the concerns of his constituency, which overwhelmingly favors single-payer health care, and protecting his fellow Democrats, whose campaigns are financed by the medical-industrial complex. Sanders needs to side with the movement, not those who profit from overly expensive U.S. health care.”

(Flowers is right to describe Sanders as a leading Democrat and not, contrary to the senator’s formal designation, an Independent. See my July 2015 essay, “Bernie Out of the Closet: Sanders’ Longstanding Deal with the Democrats.)

Guns Versus Butter

Another reason to not get too terribly excited about Sanders’ bill—which, of course, is dead on arrival in a Republican-controlled Congress (making it a low risk for 15 other Democratic senators to sign on with it)—is that Bernie “F-35” Sanders remains wedded to the giant U.S. military empire, which sucks up more than half the nation’s federal discretionary spending. As the leading radical writer, speaker and activist Glen Ford noted on Black Agenda Report in June:

The United States does not have a national health care system worthy of the name, because it is in the war business, not the health business or the social equality business. … In the U.S., progress is defined by global dominance of the U.S. State—chiefly in military terms—rather than domestic social development. … War is not a side issue in the United States; it is the central political issue, on which all the others turn. War mania is the enemy of all social progress—especially so, when it unites disparate social forces, in opposition to their own interests, in the service of an imperialist state that is the tool of a rapacious white capitalist elite.”

U.S. war spending steals vast resources that are required to build a real and lasting social-democratic safety net and people’s economy. We can’t have imperial guns and social-democratic (much less democratic-socialist) butter at the same time. We must choose between them. As Martin Luther King Jr. explained in his famous Riverside Church speech on April 4, 1967, America will “never invest the necessary funds or energies” to end poverty and domestic economic insecurity so long as its military machine “continue[s] to draw men and skills and money like some demonic destructive suction tube.”

Like the mid-1960s “democratic socialists” Michael Harrington, Max Shachtman, and Bayard Rustin (see this excellent study), “Bernie the Bomber” Sanders (as Burlington, Vt., peace activists dubbed him when he lined up forcefully behind Bill Clinton’s criminal air war on Serbia) is still stuck trying to straddle the fence between opposition to poverty and support for the American war machine. He is far from alone in being plagued by this dilemma. It is a common affliction among “progressive Democrats,” the left-most major party force in a militantly imperial nation where honest discussion of what its giant and destructive military system really does at home and abroad is taboo.

Paul Street
Contributor
Paul Street holds a doctorate in U.S. history from Binghamton University. He is former vice president for research and planning of the Chicago Urban League. Street is also the author of numerous books,…
Paul Street

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