Democrats from Joe Manchin to Bernie Sanders are doing a great job uniting in defense of the Affordable Care Act. Moving forward, there is a risk we will form a circular firing squad around support or opposition to single-payer health care. A better approach is to unite around universal coverage, and around various forms of the public option, so that consumers can buy into Medicare or Medicaid if they so choose.
More from me here, in a tome at Democracy Journal.
Author: Harold Pollack
Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect, tnr.com, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.
View all posts by Harold Pollack
Harold's article starts with the goal of universal coverage but ends up with a menu of incremental reforms that postpones the goal to a more remote future. That is after all how most advanced countries reached universality. Even the UK, with its apparent NHS revolution in 1948, was building on an extensive patchwork healthcare system that had evolved between the wars, much of it under Neville Chamberlain, a fine policymaker and administrator in domestic matters, capax imperii nisi imperasset.
I still wonder. The fragmented nature of incomplete American public healthcare fragments the body of citizens into competing groups of beneficiaries of different programmes (Medicare, Medicaid, Obamacare exchanges, subsidised employer-based insurance, veterans.. ). The fragmentation undermines their solidarity, and offers hostages to wedge attacks. To overcome this, Democrats need to offer not just the dream of universal coverage, but a real path to reaching it. This could be phased, but it needs to be a three- or five-step plan.The public option and Medicare/Medicaid buyins are fine as initial measures, but they should clearly be seen as such.
One way of signalling and making concrete this intention would be to require the states to set up Health Care Commissions with a mandate to manage and plan all the existing forms of public health care, and plan for coordinating and extending them. That provides a political and managerial focus for the move towards universality. The commissions should be encouraged to cooperate across state borders: some of the Western states like Wyoming are far too small to manage a comprehensive healthcare system. Contrariwise, the largest states – California, Texas, Florida,, New York, Illinois – should bee encouraged to federalise themselves into smaller operational units. NHS decentralisation has empowered Wales, it seems to be working OK. The Welsh population of 3m looks a reasonable minimum size for a health care authority. Norway has 5.2m, Denmark 5.7m, with even better healthcare.
Harold:
In thinking about healthcare in terms of principles, I arrive at some different ones:
1)Insurance is not a principle, healthcare is. Do we need armies of accountants deciding how to ration?
2)Profiting from healthcare should not be a principle. Those who provide care should be well compensated but does it need to be the path to riches?
3)Dealing with root causes is a principle, e.g Nutrition and therapies.
As to the legislative processes, I don't have much optimism that our campaign financing system can produce politicians who can rise above the inherent compromise resulting from contributions. Citizens pay the legislators, but the donors own them.