That image is the final result of Colorado’s Amendment 69, a 2016 ballot measure that would have established a statewide program to provide universal healthcare coverage and finance healthcare services for Colorado residents. As you can see, it was defeated in a landslide. Even with Presidential year turnout in a blue state carried by Hillary Clinton, scarcely one-fifth of voters supported the measure. Even a strong primary campaign (including a commanding victory in the Colorado Democratic caucuses) by Bernie Sanders, probably the most high-profile single-payer advocate among national politicians, didn’t appear to move the needle. To illustrate, this was the result of another state ballot single-payer (SP) measure in a state with a similar political orientation:
Official results here. Different state, different year, different proposal and different political environment, but an almost exact carbon-copy result. I included this result not as evidence to suggest any grand theory or slag anyone in particular, but instead to show that SP as an issue has pretty tepid support at the ballot box, and that mere positive exposure to the idea doesn’t seem to matter much. I’ve read many excuses for the failure of Colorado Amendment 69, ranging from poor ballot language to health insurance industry spending to non-support from establishment Democrats, but when you lose by almost 60 points in a blue state , you have a problem that better campaign strategy or more resources isn’t going to come close to solving. A defeat that total suggests a deeper structural issue that resists easy explanations or standard solutions.
I take no pleasure in the lagging support for these measures, as I consider health care to be one of my core concerns. It is a disgrace that we have the health care system of a developing country given our levels of wealth, education, and technical expertise. The Affordable Care Act was a big step in the right direction and will be remembered as a major milestone on the road towards universal heath care, but it has substantial limitations. The time is long past for the United States to join the rest of the world in implementing a comprehensive universal health care system, and while I’m somewhat skeptical that single-payer is truly the end-game in health care reform, I’d take it over our current system in a heartbeat.
That all said, I feel quite strongly there is a disconnect between what some people would like to see happen in the next round(s) of health care reform and what is actually achievable given the current political climate (and probably in the near future, too). That reality is problematic for progressives, particularly for those who put a strong emphasis on SP or are perhaps inclined to use it as a litmus test for politicians asking for support. To be clear, there is nothing wrong with having an optimum outcome or end goal in mind, but when people insist on fealty to a specific policy proposal (instead of measurable results) that’s probably non-viable, that is a stance likely to result in both personal frustration and political defeat.
SP supporters object to the notion that the policy is non-starter. They will note, correctly, that polling shows that a majority of Americans favor universal health care, often by wide margins. They will sometimes cite polling that suggests that Americans are open to, or perhaps even prefer, a SP system or something very similar. Here is a good example of a poll that shows strong support for reform that
I, too, am encouraged to see that Americans are receptive to reform, but I feel that many people arguing for SP are overstating the strength of their position. A poll is really only a snapshot in time of public opinion; it really doesn’t tell you much about the depth or durability of support or opposition. A prime example of this phenomenon is gun control, where poll after poll shows wide public support for stiffer background checks, but the institutional clout of the NRA and other similar groups has stifled many attempts at reform.
Here are a couple problems with the idea that generic support for something like SP signals :
First, Health care reform is popular in the abstract but grows more unpopular when attempted:
Link
That’s the polling aggregate on what would become the ACA from Obama’s inauguration through a few weeks post passage. The trend lines are clear. Remember “death panels” and the chaos of the health care town halls? That was all over a bill that largely kept the existing health care system intact and had the support of large influential organizations like the AMA, AARP, AFL-CIO and others (more on that in a bit) Sure, some of that opposition came from the left for not going far enough, but I think it’s would be overly optimistic to think that a SP plan would convert all of that into support without losing some from the center as well. To add a second data point , please note that something very similar happened during Bill Clinton’s ultimately unsuccessful attempt at health care reform during his first two years.
Second, Many voters who may otherwise support health care reform will balk at the large tax increases required for SP health care
First, I’d like to reference some fairly recent polling, conducted for Kaiser Family Foundation in February 2016. First, some good news:
Half (50 percent) of Americans say they favor the idea of having guaranteed health insurance coverage in which all Americans would get their insurance through a single government plan while 43 percent say they oppose it.
That’s a fairly solid result, but when informed that they would have to pay up for such a plan:
20 percent overall shift their opinion from favor to oppose after hearing that guaranteed coverage through a single government plan would “require many Americans to pay more in taxes,”
A 20 percent drop in support puts would put that plan (or one polling similarly) into net unfavorable territory. And that is a weakness, that soft support, that Republicans, health Insurance companies, and anyone else with something to lose from reform will exploit. Guaranteed. Yes, you can attempt to explain to voters that they will realize a net savings, but when you have to explain in politics you are generally losing.
Unfortunately, in addition to some polling weaknesses, we have a real world example of a Single-Payer reform effort falling apart largely due to an inability to agree on a funding mechanism. In Bernie Sanders’ home state of Vermont, which Hillary Clinton won in November by a 26 point margin, a reform effort originating in the legislature that many had hoped would serve as a model for the country died in 2015:
Governor Peter Shumlin released a financial report that showed the cost of the program would nearly double the size of the state’s budget in the first year alone and require large tax increases for residents and businesses. Shumlin, a Democrat and long-time single-payer advocate, said he would not seek funding for the law, effectively tabling the program called Green Mountain Care.
“In my judgment, now is not the time to ask our Legislature to take the step of passing a financing plan for Green Mountain Care,’’ Shumlin said.
I’d like to add three more additional concerns I have that I feel many SP advocates don’t have a good grasp on, but that I can’t cover in detail without turning this diary into a novella. First, I think any attempt to institute SP will fail miserably without a buy-in from most of the health care industry, in particular the providers themselves. The provincial health care plan adopted in Saskatchewan that inspired the Canadian Medicare program actually triggered a strike by doctors, and anything even remotely close to that level of opposition here would be very difficult to overcome. Groups like PNHP and National Nurses are fine but they represent a fraction of a fraction of that industry, and while the appeal of practicing medicine without the interference of insurance companies certainly has appeal, those professionals are going to have other concerns that need to be addressed.
Second, I’m very concerned little groundwork has been laid with traditional Democratic base groups such as organized labor, women’s health, African-Americans, GLBT, etc. I think there is far too strong an assumption that these groups would be aboard the SP train when it leaves the station but, while those groups are certainly inclined to support universal health care, I have never received the impression that they are willing to go all-in without significant input into the process. Any plan for major reform, SP or otherwise, is unlikely to get traction without their support.
Finally, I think there’s a responsibility to ensure as smooth a transition as possible to whatever the next delivery and/or financing system would be. That’s not just a policy issue, it is a political concern as well. “If you like your health care plan, you can keep it” was one of Obama’s bigger political slip-ups and we all saw what happened when the healthcare.gov roll-out hit major snags. The potential disruption caused by major reforms shouldn’t be waved away, as I have seen some do, as the cost of sticking it to the health insurance companies. Same basic principal also applies to any of the number of state-level proposals currently floating around, as a disastrous transition in a blue state would give ammunition to opponents of reform and scare off potential allies.
To be clear, my intention here was not to dissuade anyone from working on health care or attempting to build support for single payer. Additional health care reform beyond the ACA will be a heavy political lift that will require significant strategic foresight and the creation of broad, active coalitions. Focusing on incremental improvements is sometimes going to be part of the process. If this becomes another just tribal skirmish where people seek to win short-term advantage for their particular group, there’s going to be little substantive change. Currently, the state and local levels likely provide the best opportunity for positive change, but as we have seen recently, it will be challenging and success is not guaranteed.