Saturday, June 17, 2017

An American road to single payer

Ezra Klein offers an astute political forecast:
...if Republicans leave Obamacare gutted and the political arguments that led to it in ruins, there’s not going to be a constituency for rebuilding it when Democrats win back power.

Instead, they’ll pass what many of them wanted to pass in the first place: a heavily subsidized buy-in program for Medicare or Medicaid, funded by a tax increase on the rich. A policy like that would fit smoothly through the 51-vote reconciliation process, and it will satisfy an angry party seeking the fastest, most defensible path to restoring the Affordable Care Act’s coverage gains.
A few thoughts:

1. If a Medicaid income-adjusted buy-in were offered only to nonelderly who lack access to employer-sponsored insurance or other government programs, it shouldn't require more funding than the ACA marketplace. OTOH, if the AHCA has passed, Democrats will need to replace the revenue provided by the ACA taxes Republicans will have repealed (close to $900 billion over ten years, rather than the $600+ billion Klein cites, if you include revenue from the repealed ACA mandates).

2. If a buy-in were subsequently offered to employers -- perhaps starting with small employers -- that buy-in would amount to a voluntary payroll tax.

3. If the program started by paying providers Medicaid rates or somewhere between Medicaid and Medicare (New York's Essential Plan, a Basic Health Program formed under the ACA, pays Medicaid + 20%), middle class enrollment would probably put upward pressure on rates, which would in turn improve the provider network.  Perhaps rates would stop somewhere south of Medicare. If the employer dam broke, who knows? -- what is a sustainable "blended rate" for the whole U.S. healthcare system? Perhaps we'll find out.

4. A strong public program with an employer buy-in was envisioned in early versions of the public option, such as the CHOICE program outlined by public option pioneer Helen Ann Halper in 2003.* Working from the bottom up via Medicaid or CHIP, with an employer buy-in, was envisioned in a pre-ACA plan for New York, the Cornerstone for Coverage Plan, authored by Elisabeth Benjamin and Arianna Garza of the Community Service Society.

A marketplace of "all-public" (or rather public-private) options for those who need it, followed by (perhaps incremental) employer buy-in.... that perhaps is the road to single payer, American style.

Medicaid is cheaper. Ergo...
Replacing the ACA marketplace with something terrific
What if all ACA marketplace options were public?

* Jacob Hacker's early (2007) iteration  of the public option was similar: employers could buy in by paying a payroll tax, or opt out by providing insurance on their own.


  1. Good thoughts, but regarding your Point No. 1---

    A subsidized buy-in would probably cost more than ACA subsidies, because I assume we would not repeat the penny-pinching idiocies like the family glitch and the cutoff at 400% of poverty.

  2. Please don't tell me the family glitch was deliberate. I'm not sure I can handle it after reading Dylan Scott's depressing vox piece.