OPINION- A skirmish broke out recently between Hillary Clinton and Bernie Sanders about the merits of single-payer health care, an idea that Mr. Sanders has long advocated.The candidates jousted about the financing of single-payer health care during theDemocratic debate Saturday night. The differences between the two candidates on single-payer health care paint Mrs. Clinton as more moderate and Mr. Sanders as more liberal (no surprise there).
The question is: Do any Democratic primary votes turn on this issue? Single-payer health care and the Medicare-for-all variant of the idea has generally been popular among the left, but not many votes will be moved by this issue alone.
Most Democrats either strongly favor (52%) or somewhat favor (24%) the general idea of Medicare for all. Meanwhile, 62% of Republicans either strongly or somewhat oppose the idea. But, as the chart above shows, even though single payer has long been a cause celebre for many on the left, just 5% of Democrats are pure “single-payer voters” who favor Medicare for all and say that the candidate’s stand on the issue will be the single most important factor in their vote. Thirty-four percent say it would be an important factor but not the most important, and 36% say that it would be just one of many factors they would consider. The poll did not test how much support for Medicare for all might diminish among Democrats in the face of arguments for and against the idea.
There is a large body of literature about the role of issues and single-issue voting in U.S. elections. In 2012, Gallup found that 17% of registered voters made a candidate’s position on abortion a litmus-test issue. My sense is that voters perceive a presidential candidate’s positions on issues as signals of the candidate’s beliefs and of the direction he or she will attempt to take the nation if elected. Yet voters focus less on the details of candidate’s policy plans, however much candidates and their staffs may slave over those details or the media may scrutinize them.
In his advocacy of Medicare for all, a policy that he recognizes cannot be achieved any time soon, Mr. Sanders is signaling his outside-the-box approach to policy and politics, while in opposing the idea Mrs. Clinton may have been signaling her more practical and incremental approach to achieving policy change.
Drew Altman is president and chief executive officer of the Kaiser Family Foundation. He is on Twitter: @drewaltman.
Comments
Moda collapse and healthcare reform
Is the slow moving collapse of Moda an example of "incremental approach to healthcare reform?"
It seems insane to me to believe that "healthcare" can be bought and sold like TV sets or cars. Health is not a consumer item, you can't legally sell "lower quality" healthcare, and you can't get used healthcare on the aftermarket.
People are fond of comparing "Cadillac" coverage to "Ford" coverage -- but in reality, there is only one standard of "quality" -- at least when you go to court. And if there are any savings to be realized from "reform" it can only be achieved in a whole-population application of the reform, that is "single payer".
The only alternative to that would be to completely deny care to those who can't afford it -- and under current US law, that is not possible. Perhaps, under a Trump presidency we really could eliminate the "useless" people who don't have the means to support themselves, but I have a sneaking suspicion that even under the most Draconian government some sort of "universal" healthare will eventually emerge from the current mess.
Why we really need a single payer
The notion that we cannot achieve a single payer is, to say the least, absurd. The only thing that stands between us and a single payer is widespread ignorance of basic insurance mathematics.
Insurance works because insurers combine the health care experiences of many policyholders, averaging out the health care costs of healthy and ill or injured policyholders. Most people seem to think that the advantage of more policyholders stops at some point. It does not. The larger an insurer becomes, all other things held constant, the more efficiently it manages risk.
A single payer, national health insurer, would be the most efficient risk manager possible, consistently achieving a loss ratio closer to that of the population served than would be achieved by any member of a collection of two, or more, competing health insurers.
This is critical because the insurer's loss ratio determines the well being of any insurer. Specifically the loss ratio determines whether the insurer earns profits, incurs operating losses, or becomes insolvent. The risk characteristics of the population AND the size of the insurer, also determine the maximum sustainable benefits the insurer can offer.
The mathematics isn't hard. We have had it since Gauss and Legendre's work on the theory of errors in the first decade of the 19th century.
Smaller insurers are less efficient risk managers than large insurers. Their greater spread in loss ratios mean that they have lower probabilities of earning modest, sustainable profits, than large insurers. They also have higher probabilities of operating losses than larger insurers, who benefit from more efficient risk management.
Likewise, when they adjust their benefits, as they must, to match the probabilities of profitability, or to match the probabilities of avoiding operating losses and insolvency enjoyed by larger insurers, they must make drastic cuts in benefits.
I discuss this in far greater depth in my book: Standard Errors: Our failing health care (finance) systems and how to fix them.
Dr. Thomas Cox
Sanders' support for single-payer health care may be "outside the box" for readers of the Wall Street Journal, where this article first appeared. But it is one of the major reasons that Sanders has the support, financial as well as vocal, of so many ordinary folk.
I do not believe that any incremental approach to health care reform that leaves us chained to the private health insurance companies can succeed in achieving universal access to health care. The ACA implemented an incremental approach, and 33 million Americans still remain uninsured. People with insurance are still facing bankruptcy because their out-of-pocket costs are so high; others with insurance can't afford to go to a doctor because their deductibles are several thousand dollars.
Should we ignore any idea that cannot be realistically achieved soon? Should abolitionists have been told to forget about abolition of slavery and try a more realistic and incremental approach? I don't think so. That's why I am an active member of Health Care for All - Oregon (hcao.org).
Jo Alexander