Reaching a Tipping Point

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Ever since the election of Donald Trump and the Republican takeover of both chambers of Congress, the Affordable Care Act–which expanded healthcare coverage to more than 20 million people in the nation–has been their number one target. Yet, repeated attempts by Congress to pass a bill that would directly repeal the ACA, otherwise known as Obamacare, have to date all failed. These attacks on the ACA have also had an unintended result: they have helped revitalize the movement pushing for a single-payer system in the U.S.

“The Campaign for Guaranteed Healthcare, a group of progressive organizations committed to single-payer healthcare, convened right after Trump was elected to lead fightback efforts against the GOP repeal agenda,” says Stephanie Nakajima, Director of Communications of the nonprofit advocacy group Healthcare-NOW. “Operating from the idea that the best defense is a strong offense, the Campaign has been resisting the repeal efforts by holding rallies, call-in days, district visits and other actions demanding not only a stop to these proposed cuts but also an expansion of healthcare through the passage of a national single-payer plan.”

It seems their efforts enjoy widespread public support–a recent poll conducted by the Pew Research Center found that 60% of those surveyed believe the government has a “responsibility” to ensure healthcare access, which resonated with the findings of an earlier 2015 Kaiser Health poll that revealed that 58% of voters supported some version of “Medicare for All.”  

Currently, America’s market-driven health system ranks an abysmal 50 out of 55 assessed countries in efficiency, according to a Bloomberg report, while the World Bank found we spend more of our GDP per capita on healthcare than any nation on Earth with the exception of the Marshall Islands. Building on the momentum of growing public disillusionment with America’s broken healthcare system and fresh from a popular campaign in the Democratic presidential primary, U.S. Senator Bernie Sanders of Vermont introduced his “Medicare for All” bill in the Senate last spring, with an impressive 16 co-sponsors (a House version, HR.676, had over 100 co-sponsors as of May 2017).

The Sanders bill would overhaul Medicare by cutting out private insurers and eliminating premiums, copays and deductibles, while expanding coverage to include services such as vision and dental care. The plan would be gradually phased in, first by dropping the age of eligibility of Medicare from 65 to 55, and then the following year to age 45, then to 35, and then finally to all residents regardless of age. The costs to the plan–which is estimated to be $16 trillion over a decade–would be offset by a  a 7.5% payroll tax on employers and significant increases on taxes for corporations and high income households. Sanders recently held an online town hall this year on his bill that drew a record-breaking 1.1 million viewers.

The Sanders bill also benefits from broad support by many healthcare groups looking to adopt a national single-payer plan, including Healthcare-NOW and the Physicians for a National Health Plan (PNHP).

For those still confused about the definition of single-payer, the term refers to a not-for-profit system that offers universal coverage either under a single public or quasi-public plan that pays for healthcare–usually run by the national government. In some cases, such as in Canada (and as proposed in a number of bills in the U.S.) the delivery of care remains under the control of the private sector, while in other nations, both the cost and distribution of care is handled by federal agencies. PNHP advocates for a single-payer system that ensures every resident of the U.S. would be covered for all medically necessary services, without tying health insurance to employment or a restricted network of care, thereby enabling patients to have a choice among many different doctors and hospitals. Like with the Sanders’ bill, PNHP also encourages a plan that eliminates premiums, copays and deductibles, while asserting that the savings on the administrative waste that results from our current healthcare system–which adds up to approximately $500 billion annually–could instead be directly applied to patient care.

But not everyone thinks that the Sanders bill is the best route to achieving universal healthcare  in the U.S., especially given our current political atmosphere.

“A plan like Sanders not only radically changes how we pay providers but how we finance the system and all state budgets as well,” says healthcare policy analyst, Jon Walker. “I believe that is not a fight that needs to happen at the same time complicating an already difficult change.”

Instead, Jon Walker has authored an alternative plan called the “Medical Insurance and Care for All program,” or MICA. Based heavily on former U.S. Democratic Representative Pete Stark’s Americare Health Insurance Act, MICA diverges from the Sanders bill in that it would require some cost-sharing from patients, namely through copays for doctor visits and prescription drugs. These costs would be strictly controlled and range from $15 (for primary care and specialist provider visits) to $45 (for an emergency room visit) and between $1-$50 for medications; coverage would not be available for dental and vision, though states can choose their own wraparound healthcare options offering these services. Additionally, low income individuals would qualify for reduced copays ranging from a 20% reduction for those making between 250% and 300% of the Federal Poverty Level to 80% reduction for those making under 100% of the FPL. Very low income households would also qualify for supplemental Medicaid coverage in their states. Employers would be mandated to either offer MICA to their workers or a competitive private plan.

“[The] Sanders bill wants to make massive gains but would start multiple huge fights to get there, many which aren't necessary,” says Walker. “MICA is designed to maximize the amount of gain relative to the amount of fight it will take, and any change will take a huge fight so that is important.”

However, Nakajima is concerned that MICA doesn’t have the legislative or grassroots support or recognition that would really allow it traction to eventually get it passed were it introduced to Congress, while also relying too much on a mixed public-private insurance system that is too similar to what we already have and therefore more prone to the pitfalls of the marketplace.

Then, there are those who believe we need a more incremental approach to single-payer.

Dr. Harold Pollack, a public policy expert at the University of Chicago, has endorsed focusing on maintaining the ACA’s Medicaid expansion and pushing for its adoption in holdout states, as well as demanding a public option on the ACA exchanges. Many others have also pushed for a public option, which was originally supposed to be part of the ACA and would have theoretically controlled costs of the healthcare plans offered in the individual market. Writing for Vox, Jacob Hacker–who helped initially devise the public option component of the ACA before it was scrapped–likened it as “Medicare for more” rather than “Medicaid for All.” Hacker has touted that simply offering a lower-cost public option would offer bargaining power to “push back against drugmakers, medical device manufacturers, hospital systems, and other healthcare providers,” while offering subsidies to help lower and middle-income people better afford premiums. One benefit of the public option is that the Congressional Budget Office has repeatedly scored it favorably in terms of producing significant savings relative to private insurance.

However, while single-payer advocates are usually at least somewhat supportive of these more moderate reforms, they are wary of it distracting from the larger changes our nation needs to make for healthcare to truly be equitable and accessible to all.

“We take a somewhat nuanced approach to incremental reforms,” says Nakajima. “But there is simply no way to afford universal healthcare without something close to a single-payer system and the sort of cost controls it brings, so incremental reforms are limited and usually involve spending a lot more for greater access.”

Instead, Healthcare-NOW tends to focus more on state level single-payer legislation as a way to build momentum for a national system.

“[That] is how Canada implemented its single-payer program, province by province originally, then eventually a national bill,” says Nakajima.

Currently, single-payer bills are pending in 16 states. In 2011, Vermont became the first state to pass single-payer legislation, but abandoned plans to enact the law in 2014, citing costs as the deterrent. But bigger states with larger economies are considering their own single-payer bills and seem better situated to put them into effect if they pass. For instance, the New York’s single-payer bill passed its State Assembly last May, though it would still have to make it through a Republican-controlled State Senate to become law. And Massachusetts, the state that passed a sweeping universal healthcare law in 2006 (known informally as “Romneycare”) that the ACA was ultimately based on–overwhelmingly passed an amendment in their Senate last November to a broader healthcare reform bill that would instruct the state to estimate costs of coverage under a single-payer plan in the Commonwealth. If the state finds that single-payer could cover all residents at lower costs than its current system, the administration would then be instructed to develop a single-payer proposal for consideration by the legislature. Considering that Massachusetts has acted as a healthcare trendsetter in the U.S., this move could eventually have national implications.

In the meantime, even though Trump and the GOP have failed to directly repeal the ACA, they have had better luck using a series of back door measure to erode it. The most successful of these attempts so far has been the passage of a tax bill which, in addition to massive giveaways for the wealthy, included language that would repeal Obamacare’s individual mandate. This mandate required that all U.S. citizen have healthcare or pay a tax penalty, ensuring participation in the health exchanges and funding Medicaid expansion. Twenty GOP-controlled states have responded to the passage of the tax bill by suing the federal government to overturn the ACA altogether, claiming that without the mandate Obamacare is now unconstitutional. While it’s unclear how this will play out, a partial if not total repeal of the ACA is looking more likely at some point in the near future. In which case, single-payer is seeming more and more like the necessary antidote to a poisoned healthcare system.


Laura Kiesel is a freelance journalist whose articles and essays have appeared in The Atlantic, Politico, The Guardian, Vice, Harvard Health blog and many other publications. Originally from Brooklyn, New York, she currently lives in the Boston area.