Like Water Dripping on a Stone: Rethinking the Politics of Single-Payer

In Health Care Reform, History and Politics, Politics of Policy on May 24, 2009 at 1:39 am



In the run-up to the universal health-care bill being debated in Congress, one of the more contentious issues on the political left has been the question of single-payer and its’ inclusion or exclusion from the debate. Recently, we’ve seen single-payer advocates getting themselves arrested to draw media attention, a huge amount of back-and-forth within the progressive blogosphere (of which the links here are just a small sampling), and a good deal of fear about the public option getting watered down or eliminated.

I feel somewhat ambivalent in this debate, in part because I agree with the policy of single-payer advocates, but I find myself turned off by their political style. And I think a lot of it has to do with a particular theory of activism and an ahistorical understanding of how social policy happens that I really disagree with.

Especially as we draw closer to the crucial mark-up and voting phases, and ever closer to passage of the Baucus/Kennedy/Dingell/Obama health care legislation, it’s imperative that the progressive movement think very carefully about what we want to accomplish.


One of the ironies about the debate over the current health care reform versus single-payer is that the basis for the current plan  (and indeed, the rough consensus between the Clinton, Edwards, and Obama plans during the 2008 primaries), the Hacker Plan – was designed as a compromise measure between gradualists who favored things like the extension of SCHIP in the wake of the Clinton health reform disasters and single-payer advocates.

For those of you not familiar with the Hacker Plan (available here), it basically consists of three key elements:

  1. Employer Pay-Or-Play Mandate – Employers are required either to provide health care for their employees or to pay a payroll tax that goes into a fund for covering the uninsured.
  2. Individual Mandate Plus Sliding Subsidy – Individuals not already covered by their employer would be required to purchase health insurance, either from a public or private insurer; income-based subsidies would ensure that the cost of insurance would be reasonable.
  3. A New Public Insurer – A new, Medicare-like public insurer would be created to act as a competitor/yardstick to private health insurers and to ensure that there is an insurer of last resort.

With some alterations (a health care purchasing pool, new emphasis on reforming private insurance, new emphasis on reducing the growth of health care costs, new emphasis on cutting premiums and out-of-pocket costs for the insured, new emphasis on extending SCHIP/Medicare/Medicaid as part of the solution), this is essentially the plan that is being debated.

Single-payer advocates are upset that they are basically being shut out of the debate, and they have a right to be. However, I believe that a certain amount of the anger directed at advocates for public option reform is due to the fact that the Hacker Plan has become more or less consensus within a broad segment of the Democratic Party, from as far left as Ted Kennedy/EPI/labor to as far right as Max Baucus and Hillary Clinton, although there remains to be seen how extensive the Blue Dog/Evan Bayh contingent is, and how much they’re actually going to remain outside the consensus on this issue. This has meant that while the single-payer advocates have some base – especially with CTA/NNA (the nurses’ unions) and various health care grassroots groups (HCAN, etc.) – a lot of their natural supporters are now in the public option camp, which reduces the constituency for single-payer at the legislator and lobbyist levels. Even if single-payer was to get a seat at the table, they’d find that the other chairs – those not reserved for industry – are already taken up by public option advocates, and would find themselves on the losing side of a number of internal debates, and we’d probably end up exactly where we are today.

Like I said earlier, I feel very ambivalent about this, because I am ideologically and emotionally sympathetic to single-payer as a policy goal, but I feel really turned off when I see the tactics and strategies being carried out by single-payer advocates as they try to push their ideas back into the debate. For me, this isn’t a theoretical issue, it’s quite personal.

Humphrey Cooper Attewell, my great-grandfather. was elected to the British Parliament in 1945 as the Labor M.P for Harborough. As such, he cast his vote for the establishment of the National Health Service in 1946. The NHS was at the time and remains to this day the one of the most progressive health care systems in the world – a system in which the hospitals belong to the state, where the doctors, nurses, and other medical workers are public employees, and where health care is provided to all for free as a right. In a sense, therefore, the story of single-payer health care is the story of where I come from and who I am.

Yet I find myself oddly turned off when I listen to single-payer advocates, in part because I really disagree with the manner in which they are attempting to push their agenda, both in terms of their tactics and their larger strategy. I don’t find the tactics of single-payer advocates compelling in the slightest; I think direct actions and civil disobedience directed at the chairman of the committee who’s going to decide what health care bill will ever emerge on the floor of the Senate to be totally without merit. Simply put, it does not advance the cause of single-payer at all to piss off Senator Max Baucus, especially since single-payer advocates do not have the resources or the political strength necessary to seriously challenge him either in Montana or in the Senate Democratic Caucus. Strategically, I find the insistence on an all-or-nothing single-payer system to be utterly misguided and contrary to all the lessons that history can teach us about how advances in social policy actually happen.

Take a look at two of the most single-payer nations out there – Canada and the U.K.  The Canadian health care system emerged, not in a single all-or-nothing burst, but rather in a gradual process of expansion. In 1944, Tommy Douglas of the CCF (Canada’s socialist part at the time) was elected premier of Saskatchewan on a platform that included free hospital care to all citizens. In 1946, his government passed the Saskatchewan Hospitalization Bill, which provided hospital care (not including physicians’ bills, prescriptions, etc.) to most, but not all residents. It took time to build up enough finances to cover all residents, and to extend coverage to all services; full Medicare for the province didn’t come in until 1959. Other provinces began experimenting with universal health coverage; Alberta establishing a pre-paid system that covered 90% of their residents in 1950. It took longer for the system to spread across the country: the first Hospital Insurance and Diagnostic Act in 1957 merely provided 50% of the costs of running health care programs; in 1962, the national government passed legislation to include physicians’ costs in the federal subsidy; in 1966, the national government passed the Medical Care (Medicare) Act, which enabled provinces to establish full Medicare systems based on the Saskatchewan model;  and in 1984, the Canada Health Act established the modern system that Canadians know today.

In the U.K, the move towards single-payer began in 1911, with the introduction of the National Insurance Act by Lloyd George’s Liberal government.   This legislation established a national system of health insurance, funded by payroll contributions from workers, employers, and contributions from general taxation – quite different than the current system.  However, this system only covered certain trades and occupations of workers paid into the system, and the relatively low government contribution meant that coverage could often be quite expensive. During WWII, the pressures of the mass bombing of civilian populations led to the creation of the Emergency Health Service, which put all medical professionals into government service, created a coordinated national hospital system, and so forth. And finally in 1946, the new Labor government passed the National Health Services Act, establishing the modern National Health Service (NHS) on the basis of three central principles, that services should be free at the point of use, that general taxation should be the source of financing for the system, and that everyone would be eligible for care.

The point of this history lesson is that single-payer has historically developed in a gradual fashion – the Canadian system took forty years to develop into the modern Medicare system, and the British system took more than thirty years. In both cases, it wasn’t a single piece of legislation that made single-payer a reality, but the gradual achievement of partial steps that, like water dripping on a stone, wore down institutional resistance to single-payer.

Which leads us back to the current debate. I think that single-payer advocates should rethink their attachment to immediacy and to all-or-nothing when it comes to achieving their goal of a single-payer system; moreover, I think this will lead towards a re-evaluation of tactics, and the embrace of a strategy that emphasizes allying with public-option advocates to gain entrance into the coalition, so that they can begin pushing for those elements that would make the current proposal a true stepping-stone to single-payer. Here, I’m primarily thinking about ensuring the inclusion of a public option, making that public option as Medicare-like as possible, pushing for more generous income subsidies and more comprehensive minimum standards for health care plans, and support for states to experiment with single-payer. The passage of any major health care reform would in itself be a major step forward, in that it would break the now forty year gap in major social policy achievements, it would de-stabilize and de-motivate opponents to health care reform, it would create a political atmosphere more open to single-payer by making universal health care a new third rail and it would create pressures and interest groups to reform and improve and expand the new system.

Furthermore, in policy, passing the bill is only half the battle – implementation is the longer and more crucial phase. Here, I think one way that single-payer advocates can begin to broaden their base while pushing for their objectives is to begin a national campaign to sign people up for the public option, pushing the system closer to single-payer with every person signed up, and concretely solving the crisis of the uninsured. Here, single-payer advocates could usefully work with allies within the labor movement to push all 12.4% of the workforce that’s currently unionized into the public plan, and other social justice groups (union organizing campaigns, civil rights groups, GLBT groups, feminist groups) could plug into the campaign by folding signing people up for public health care as part of their ongoing missions. Moreover, single-payer advocates, by being slightly outside the coalition of public-option advocates, would then be free to begin raiding the private insurance market, taking the fight to the private insurance companies by mobilizing their friends, families, neighbors, and co-workers into switching from private to public insurance; you could target major employers with public insurance drives, especially focusing on corporations like GM, Ford, and Chrysler, where the argument for a single-payer (as opposed to employer-based) health care system might resonate.

In my mind, that’s the winning strategy for single-payer.

– Steven Attewell

  1. It’s a good thing you weren’t around during the civil rights era or women’s suffrage, cause it’s folks like you that would have prevented all that from happening!

    • First of all, thanks for being the first commenter. In honor of that status, I’ll respond to the content of your comment, rather than the phrasing.

      Second, the debate between gradualism and immediatism is not as clear cut in the history of social movements as you would think.

      For example, within the Civil Rights Movement, you had at the same time the gradual strategy of the NAACP Legal Defense Fund, which slowly and deliberately built towards Brown vs. Board by targeting specific areas where they thought they could win, pushing particular precedents, building on previous victories to get to new ones, and the immediate strategies of the sit-ins and the voter registration drives. The two were in fact complementary strategies.

      In the women’s suffrage movement, you likewise had divides between gradual reformers (who preferred a state-by-state approach) and immediatists (who preferred direct action). Again, the two actually lent strength to the other – having women registered to vote in western states built a Congressional constituency that could push forward legislation when the immediatists’ tactics succeeded in putting the issue on the agenda.

  2. […] Like Water Dripping on a Stone: Rethinking the Politics of Single-Payer […]

  3. […] Like Water Dripping on a Stone: Rethinking the Politics of Single-Payer […]

  4. Steve, I understand the political realism which you basically advocate – we are not going to get a one-shot health program so we should face it and inch our way forward. But what about the role of radicalism in the politics as the force that usually doesn’t get what it wants, but tilts the compromise solution to its side. You know, just as bargaining – you never put on the table what you think you might get, but you shoot for more in hope for settling for something that’s still good.

    How is your advocacy for gradualism different from bargaining with showing all of your cards?

    • I think radicalism can be an extremely useful force in politics, if it’s tactical radicalism. I fully agree that you should walk into negotiations asking for 200% of what you want to get down to 100%. But, and this is an important “but”, there has to be the understanding that after a certain point, once you’ve gotten down into the nuts-and-bolts negotiations, that radicals will eventually have to shift and support the compromise to make sure that it passes. What worries me about single-payer radicals is their attitude that, if something that doesn’t include single-payer is on the table, that they’ll vote against it and help it collapse.

      So the advocacy for gradualism is an advocacy for a specific mentality and theory of activism, focusing on the second step of starting with 200%, the what comes after.

  5. […] “a weak bill is worse than no bill at all” stems from a bad theory of activism. As I have argued before, the “big bang” theory that changes happens all at once or not at all is […]

  6. […] As I’ve stated on previous occasions, one of the most fundamental changes that comes with the passage of the current health reform effort is that Congress begins to get used to passing health care reform bills. This process will be greatly accelerated if Democrats are able to hang onto their majorities in the 2010 midterm elections, thus establishing the conventional wisdom that passing health care bills is not a recipe for electoral defeat, but once the foundation is there, it won’t make much of a difference in the long-term. Laws are continually amended, renewed, overseen, and so on, which generates a process in which health care reform becomes a normalized legislative area, like passing annual appropriations bills. […]

  7. Hi Steven,
    I am not leaving a comment about your article, interesting although it probably is, but just to say that I found this site whilst researching the British MP Humphrey Attewell. He was my mum’s great uncle, therefore my great-great uncle. He was the brother of my mum’s grandmother (Kate Attewell, married to William Hawkins). It’s a very small world isn’t it?
    From Tracey Langford

    • Humphrey’s my great-grandfather on my dad’s side. It is a small world.

  8. […] to health care. Indeed, one of my very first blog pieces ever was an essay that pointed out that single payer itself gradually emerged through a series of reforms that took place over decades and only gradually became systems like […]

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