Should universal care advocates bite their tongues on single-payer?

June 8, 2011 — It was not so long ago that a universal, single-payer health insurance program administered and financed by the federal government looked like a viable policy option. Barack Obama supported a single-payer system on the campaign trail in 2008, and, in the early stages of the subsequent battle over health care reform, both a single-payer framework and a “public option” that would compete with private health insurance were solidly backed by many Democrats and a significant portion of the general population.

But by the final stages of the debate, amidst united Republican opposition, single-payer had largely been excluded as an option by the Administration. What became known as the Patient Protection and Affordable Care Act (ACA) did not include even a public option. And for the last year, as Republicans attempt to repeal the ACA and hobble it by underfunding, Democrats and health care advocates have rallied behind it. For many, the fact that the ACA represents far less than they had originally wanted has been put aside, with the legislation recast as a victory to be defended.

There is still a vocal group of advocates, however, who believe that the ACA does not go far enough in providing guaranteed access to quality, affordable health care. And indeed, at both the state and national level, there has been a resurgence of interest in moving the United States past the Affordable Care Act and into a single-payer system. Single-payer bills have been introduced at the federal level and in several states; this year, Vermont became the first state to pass a framework bill that could introduce a single-payer system in the next several years.

But these single-payer proponents are finding it hard to recruit those organizations who favor increased access and affordability, but who feel that support for single-payer could make the ACA more vulnerable, and  that support for the ACA is obligatory because the legislation constitutes the only “realistic” policy choice. According to advocates who continue to press for a single-payer system, however, the acquiescence of those sympathetic to pro-access arguments has had a significant impact on narrowing the debate over how the health care system in the U.S. should work — and on moving the center of gravity of that debate further to the right.

AARP: a case study

AARP (formerly the American Association for Retired Persons), which describes itself as “the nation’s largest membership organization for people 50+” is perhaps the most visible example of this phenomenon. Claiming more than 40 million members, AARP is a powerhouse on Capitol Hill. In 2009 and 2010, the organization threw its full weight behind the ACA, and according to some, was instrumental in getting the final bill through Congress.

But AARP did not fight for a single-payer model during the debate over health care reform, and it has not endorsed any of the bills that are currently in play at the federal or state level. Single-payer advocates in Vermont as well as California, where a new single-payer bill was recently introduced, said that AARP has been largely absent from the debate. AARP representatives in both states acknowledged that the organization has not declared support for either of the bills.

“They are missing in action,” said Andrew McGuire, who founded the group California OneCare, which advocates for single-payer health care on the state level. “It’s a bit odd when you consider who they represent.”

Don Bechler, who chairs another California-based single-payer advocacy group called Single Payer Now, elaborated: “Private insurance is bad for seniors. Seniors use the health care system the most, so the problems with the private insurance market affect them the most.”

“We’re advocating for a health care system that spends its money on health care, not on insurance companies,” Bechler continued. “We don’t want people to go without health care. If those aren’t AARP’s priorities, it makes you question whether they have the best interests of seniors at heart.”

What’s the justification?

The most prominent bill that was introduced at the federal level during debate over health care reform was H.R. 676, which was proposed by Rep. John Conyers (D-MI) in early 2009. Single-payer advocates quickly rallied around the bill, which provided a framework for moving the United States into an insurance system modeled on Canada’s. Later that year, AARP released a statement explaining to its members why the organization was not supporting H.R. 676:

Starting over with a new, “single-payer” program will not eliminate the problems Medicare, Medicaid, and SCHIP currently face, such as the spiraling costs of procedures and prescription medications, as well as technological advances that are often not comprehensively tested to be proven safe or effective before marketing. H.R. 676 does not address the problem of increasing health-care costs. Rather, it allows costs to continue to grow, which will result in unaffordable coverage.

That statement did not add up for some advocates, like Dr. David Himmelstein, associate professor of medicine at Harvard University and a member of Physicians for a National Health Program.