As single payer transitions from left-wing dream to viable public policy many pundits are sounding alarms that the reality of the government program will not meet the rosy expectations its advocates paint of it.
This is true. But only because single payer will be much better than they ever imagined.
Americans, once they get over the hassle of changing the card they keep in their wallet, are going to absolutely love single payer.
When you say single payer is free, people will reply that it’s not really free because you already paid for it with taxes. But while that’s the “technical” definition of free, it’s not the “consumer” definition of free.
Single payer, like a cup of coffee on your red-eye, is free at the point of consumption.
And though you may have already paid into the system, like property taxes pay into local elementary schools, the system is free when you actually use it. No one is checking your credit as you drop your kids off in the morning.
Psychologically, therefore, you experience it as free, like taking a book out of your local library. A service is provided to you and then you don’t use your own money to pay for it.
I actually learned this insight from my father, a life-long Republican, who recently turned 65 and switched to Medicare. Thinking I would catch him in a fit of cognitive dissonance, I asked him how he liked relying on a government program and he said, “It’s great,” before adding: “It’s free!”
That is when I, the educated adult, the man of letters with a master’s degree in public policy, the informed voter with political opinions about the moral uses of state resources, replied that, in fact, Medicare is not really free because he has spent a lifetime paying taxes and the funds for Medicare come out of the pool of revenue the government has collected from tax payers just like him, and he looked at me like I had three eyes and was visiting him from a planet that didn’t understand math, but somehow built spaceships.
“It’s free, now, Michael,” he reiterated. “For me.”
It’s free now. For me. Your Republican voting base in action.
It’s for everyone!
That being said, even if people like free stuff, they might not like the transition to free stuff, the theory goes. You know, the whole switching the card in your wallet and finding a new doctor to upsell you fat freezing sessions.
This wisdom that change can be unpopular was gleaned from the passage of the Affordable Care Act. Obama actually tried to address this in advance by promising that “if you like your health care plan, you can keep it”, which turned out in practice to not be perfectly true.
But sometimes an army is built to win the last war instead of the one it should be fighting.
To that end, maybe we should be focusing instead on another lesson from the ACA, the insight Sarah Kliff learned from her reporting on Obamacare enrollees in Kentucky who had voted for Trump.
What rankled these working class people wasn’t the change in the system, which they were actually reasonably excited about, so much as the perception that ultimately it was poor people who got better health insurance than them because they were on “the government program,” which they perceived as, ahem, “free.”
So it’s a choice on what to focus on. How people can be inconvenienced by change versus how they can be incensed by unfairness.
Specifically, the lesson is that giving different things (Medicaid vs exchange plans) to different people (the poor vs the working class) breeds resentment. And that resentment between political groups is an intrinsic hazard to any public policy.
Single-payer nicely solves that political friction in healthcare policy by putting everyone on the same plan.
Actually, this isn’t even a new lesson, we just forgot about it.
Franklin Delano Roosevelt himself advocated for the universality of a state-run pension system when he was setting up Social Security. Sure, you could means test Social Security and only give it to people who “needed” it, but he knew that any program that gave to some without giving to others would suffer from political frailty as the haves would fight the have-nots.
Social Security then is structured to eliminate resentment. Obviously, there can be no resentment over who receives this government program if everyone is receiving this government program.
And single payer will work in the same way.
Now, one caveat is that there is actually a class of people who are bothered with getting the same thing everyone else gets: the rich.
Which is actually another reason Americans are going to love single payer.
You’re going to have the same insurance as rich people!
Have you ever noticed how people only use two words to describe their insurance? Not public or private. Government or private. High-actuarial value or low-actuarial value. Whatever that means.
No, all insurance to everyday Americans is either “good” insurance or “bad” insurance. Two very general value-laden words that don’t transmit details like Anthem-Blue Cross Silver Tier PPO.
(Disclaimer: I literally had to check my insurance card to remind me what I personally have and I’ve used this insurance for multiple hospital stays. It’s good, actually.)
If you’re applying for a new job, for instance, you ask, does it offer “good” insurance? You get sick and have to use it, you complain to your friends that it’s “bad” insurance.
But once single payer is implemented, the sameness of the program coupled with the fact that rich and famous people use it will confirm its value for us psychologically in a way that Obamacare, with all its different options makes it hard for us to choose just gives us decision anxiety
Single payer guarantees to people that they’re getting the same insurance as their congressman, their senator, their president—and Tom Hanks. You think Tom Hanks would have “bad” insurance?
Or maybe a better celebrity is Jimmy Kimmel. We now have the Jimmy Kimmel Test, coined to say that “no family should be denied medical care, emergency or otherwise, because they can’t afford it.”
In his monologue detailing his newborn son’s medical challenges, Kimmel made a point say that his son got the surgery he needed because they had good insurance to cover the procedures his son required and otherwise the means to pay for them if they didn’t.
He lamented that some Americans didn’t have the same access to health insurance, even after the passage of the ACA.
Well, every family in America is guaranteed to pass The Jimmy Kimmel test when every family is on the same insurance plan as Jimmy Kimmel.
Actually, it’s better than free because it’ll put more money in your pocket!
Right now, you pay for your premiums and then the deductible and then the co-pays up to the plan’s out-of-pocket maximums.
You get bills from a doctor who took your temperature, then another doctor who looked at your foot, and then another doctor you met for ninety seconds in the ER, who’s not in your network even though the ER was in your network, explain that if you can.
It’s frustrating. It’s exhausting. And to quote Josh Barro, “nobody wants to deal with that crap.”
Well, you won’t have to anymore.
All those various ticky-tacky fees and expenses are going to go away and be replaced with a simple tax that comes out of your paycheck.
Just like your healthcare premiums do now.
Yes, that will be a “change.” Instead of some your pre-tax money going to an insurance company, some of your pre-tax money will go the single-payer insurance system.
See the difference?
You will once that cut gets smaller over time. As single-payer saves America money by negotiating a discount on drug prices, giving a haircut to exorbitant provider reimbursement, and reducing administrative costs, the overall fiscal burden of healthcare in America will go down.
So it will, like your premiums, take money out of your paycheck, just less of it than you’re already used to.
Single payer, in other words, will someday soon result in your take home pay getting bigger. We have a word for that in America.
It’s called a raise.
And that money will stay in your pocket!
The biggest fear from our current system is that even with insurance, it’s not enough to cover the costs of the healthcare we may need.
That we’ll have a major emergency, like being shot at an outdoor concert, and we’ll worry how we’ll pay our medical bills.
Is the treatment covered? Is the follow up visit covered? I thought I paid for the co-pay. What’s this other bill I’m getting in the mail? What’s a facility fee? Why does a band-aid cost $629?!
Not anymore. By protecting us from all these extra fees, single-payer keeps money in our own pockets.
We already see this in action with Obamacare, which led to a decrease in people who declared bankruptcy as out-of-pocket yearly maximums protected people from losing their houses to pay off hospital bills.
And in states, like California, where Medicaid has been expanded, it’s even reduced the use of exorbitantly expensive payday loans.
Single payer insurance will go even further and protect people from shelling out large chunks of their savings on unforeseen medical emergencies.
What will people do with their money instead?
Maybe they’ll renovate their kitchen, or buy a new car.
And there’s nothing your boss can do about it!
I am willing to take Jonathan Chait’s word for it that Americans generally like the insurance they get through the employer.
I am not ready to believe that Americans generally like their employer.
And I am really not ready to believe that Americans like, in any way, the fact that their employer, who they may or may not like, can take their insurance away from them.
With single-payer that won’t be possible anymore.
You can tell your boss to shove it, go do a dozen shots of Fireball, and not have to worry about the medical fees when you face-planted off a bar stool.
You think Americans are attached to their employer-sponsored insurance?
Wait until Americans learn that single payer means they can drunkenly dance on bars again without worrying about going bankrupt from emergency room bills.
They’ll dare you to pry single-payer out of their cold dead fingers.
Alternatively, you could also quit your job and start your own company. Single payer will help you do that, too.
That sounds amazing. But how long will I have to wait for single-payer?
It depends. In some ways single-payer can be written as law in one fell swoop, or there are various glide path options that will bring it about in several smooth steps.
No matter how it’s implemented though, I think we’ll look back in five years and wonder how we ever lived without it.
So don’t worry about any short-term headaches that’ll arise, because this will be as popular a public policy as they come once it’s actually implemented. Just ask Canada.
Not every public policy is going to offer such a win-win situation, so single-payer provides us with a rather unique opportunity to enact a program that will be not only positive, not only popular, but actually work really well for what it’s designed to do.
Like a local library, but with x-rays.
It will be good for Americans, and Americans are going to love it. We should embrace this fact like our lives depend on it.