Will the attacks on Obamacare lead to a single-payer system?

The unrelenting opposition by American conservatives to Obamacare may have the unintended consequence of leading the United States to a single-payer system like Canada’s.

How’s that, you say? Isn’t the whole point of conservative opposition to Obamacare to drive home the point that the government is incapable of managing people’s health care?  Yes.  And aren’t conservatives effective in driving home that point? Yes, polls show that confidence in government is at an all-time low, no doubt related in some degree to the attacks on the Affordable Care Act and its chaotic launch.  (The VA scandals undoubtedly will also undermine trust in government, as I noted in a recent guest blog post for the Philadelphia Inquirer.)

Yet when future historians write the history of health care reform in the United States, they may very well report that Obamacare was a stepping stone to single-payer — not because liberals persuaded voters that we’d be better off with the government fully in charge (they’ve been trying to make that case for decades, with little evidence of success), but because conservative opposition to Obamacare ended up destroying employer-based private insurance, leaving the government as the only remaining payer.

Consider the following:

The Supreme Court ruling in the Hobby Lobby case is widely viewed as a victory for conservatives, since it reins in the ability of government to impose mandates on for-profit companies that violate their owners’ religious beliefs.  But Don Munro, a contributor at Forbesprovocatively asks if Hobby Lobby will “signal the end of employer-sponsored health insurance.” Fred Rotondaro and Christopher Hale from Catholics in Alliance for the Public Good persuasively argue that the Hobby Lobby decision:

… brings to the forefront something we’ve all known for sometime: that Obamacare — for all the good it’s done in increasing access to quality and affordable health care — is a messy law. It asks employees to be at the whim of its employers’ objectives and mission for what health care benefits they receive. It also asks employers to at times reject its deepest convictions in order to provide certain benefits to its employees.

This isn’t sustainable. A person’s access to quality health care shouldn’t depend on who their boss is. And an employer shouldn’t be heavily fined if they don’t compromise their religious convictions in providing health care for their staff. . . A single-payer public health care option eliminates such complications. No matter who your boss is or what business you work for, you get access to the health care you need. And employers will not be forced to compromise their religious beliefs while providing the public good of health care.

And let’s be clear, if you have something that is both supported by the United States Conference of Catholic Bishops and Planned Parenthood, you might be onto a plan that proves the angel Gabriel right: nothing is impossible with God.

Renowned health economist Uwe Reinhardt also believes that the Hobby Lobby rule may lead Americans to re-examine employer-based health insurance:

The ruling raises the question of why, uniquely in the industrialized world, Americans have for so long favored an arrangement in health insurance that endows their employers with the quasi-parental power to choose the options that employees may be granted in the market for health insurance. For many smaller firms, that choice is narrowed to one or two alternatives – not much more choice than that afforded citizens under a single-payer health insurance system …

… the Supreme Court’s ruling may prompt Americans to re-examine whether the traditional, employment-based health insurance that they have become accustomed to is really the ideal platform for health insurance coverage in the 21st century. The public health insurance exchanges established under the Affordable Care Act are likely to nibble away at this system for small and medium-size business firms, especially those with a mainly low-wage work force. In the meantime, the case should help puncture the illusion that employer-provided health insurance is an unearned gift bestowed on them by the owners and paid with the owners’ money, giving those owners the moral right to dictate the nature of that gift.

But it isn’t just Hobby Lobby where conservative opposition to Obamacare may help bring about single-payer.  CNBC reports that another pending court case against Obamacare’s insurance subsidies, instigated by conservative critics of the law, makes the claim that:

… those often-valuable subsidies are illegal because the Affordable Care Act only authorized such tax credits for people who bought insurance through one of the exchanges originally set up by an individual state or the District of Columbia — not the federal exchange. Nearly 90 percent of the people who enrolled in plans via the federal exchange qualified for those subsidies because they had low or moderate incomes. Take away those subsidies and many, if not most, of the enrollees on HealthCare.gov might not buy insurance next year because they will find it unaffordable at the full premium price. That, in turn, could create a much-feared ‘death spiral,’ where insurance pools have too many sick enrollees and not enough young healthy ones, and premium rates skyrocket. And if those subsidies are not available to individuals in the states served by HealthCare.gov, it would also mean that businesses in those states could not be mandated starting next year to offer affordable health insurance to their workers or pay a fine. That’s because the so-called employer mandate is linked to the availability of those subsidies for workers who opt to buy individual insurance.

A court ruling for the plaintiffs in this case (although considered unlikely) would be another huge blow to relying on private health insurance to make affordable coverage available to most Americans, because it would keep all Obamacare’s benefit mandates on the books, while making the private insurance offered through the exchanges unaffordable to the millions of people it was supposed to help.  But the “public option” part of Obamacare — Medicaid — would remain intact.

And let’s not forget that conservatives are stoking public opposition to Obamacare’s mandate that people buy private insurance — even though they once championed an individual insurance requirement as an alternative to either single-payer health insurance or requiring employers to provide coverage.

Now, I don’t see the United States rushing head-long into a single-payer system (although just about all Americans regardless of their political leanings love Medicare), because the country is deeply polarized, and people have little trust in government, and even less in politicians.

But it’s plausible that over time the unrelenting conservative attacks on Obamacare will end up showing Americans that it is just too difficult to provide affordable coverage through a system of regulated and subsidized private insurance and by counting on employers to continue to offer coverage, especially when employers can opt out if they have religious objections.   Conservatives then will not just have destroyed Obamacare — they will have opened the door to single-payer as the only feasible way to provide affordable health insurance coverage to all.

Bob Doherty is senior vice president, governmental affairs and public policy, American College of Physicians and blogs at The ACP Advocate Blog

View 32 Comments >