Obama's Bad Case Against Single Payer

The Obama administration has broadened the scope of what it wants to dismiss as unrealistic, utopian and unpragmatic, i.e. as for all practical purposes impossible. These claims have typically been accompanied by the assurance that "This is not something that Americans would go for - it's not the American way." Obama's case against a single payer health care system is a conspicuous case in point. His position on this issue features weak arguments and serious factual errors.

The Alleged Impossibility of Universal Health Care

In May and August, 2007 Obama stated his position on single payer:

"If you're starting from scratch, then a single-payer system'-a government-managed system like Canada's, which disconnects health insurance from employment-'would probably make sense. But we've got all these legacy systems in place, and managing the transition, as well as adjusting the culture to a different system, would be difficult to pull off. So we may need a system that's not so disruptive that people feel like suddenly what they've known for most of their lives is thrown by the wayside." (May, 2007)

" [W]hen we had a healthcare forum before I set up my healthcare plan here in Iowa there was a lot of resistance to a single-payer system. So what I believe is we should set up a series of choices....Over time it may be that we end up transitioning to such a system. For now, I just want to make sure every American is covered...I don't want to wait for that perfect system..." (August, 2007, at an Iowa roundtable)

Obama offers 5 reasons for not supporting single payer.

First: "..we've got all these legacy systems in place" simply means that our system is not single payer, and we've had it for a long time. Obama has turned himself into a bent sort of Burkean conservative: we have been marinating in a tradition which so permeates our way of being in the world that to do away with it would upset social life as we know it. This tradition includes.... insurance-industry-based health care! More mundanely: we haven't got it, so we can't have it.

Second: it would be hard to "manage the transition" from a deeply flawed system to a much better one. Harder than it was to effect the transition to Social Security, Medicare, Medicaid, desegregation, etc.? In each of these cases, what many people had "known for most of their lives" [was] "thrown by the wayside". It belongs to the nature of any move from one way of doing things to a very different one that the transition will take some doing. That fact alone proves nothing. What matters is how urgent is the need for change. The US's irrationally costly system which leaves millions uninsured, a fate suffered by the citizens of no other developed capitalist country, is surely intolerable. We have been given no reason to think that the cost of a transition to universal coverage is so great as to outweigh the massive benefits of this tried and tested arrangement. Obama's excuses amount to a cleverly disguised a-priori argument against any consequential transformation of the status quo.

Third: the "difficulty" [i.e. costs] of "adjusting the culture to a different system", given that there is "a lot of resistance to a single-payer system" , outweigh the benefits of single-payer. But what matters is not what a few selected Iowans are alleged to have felt about universal coverage. The demonstrated preferences of the democratic majority can't be irrelevant.

On this issue Obama clearly means to imply that Americans don't support single-payer. This is factually false. It's improbable that Obama is unaware of the results of many surveys on this issue, the most recent of which was conducted between December 14-20, 2007. The results of this Associated Press-Yahoo poll are worth reproducing as they were reported:

Subjects were asked which of the following 2 views comes closest to their own view:

1. The United States should continue the current health insurance system in which most people get their health insurance from private insurers, but some people have no insurance.

2. The United States should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers.

A majority of 65% supported 2, 34% supported 1 and 2% did not respond.

Those polled were also asked "Do you consider yourself a supporter of a single-payer health care system, that is a national health plan financed by taxpayers in which all Americans would get their insurance from a single government plan, or not?"

55% answered Yes, 44% No and 2% did not respond. Single-payer still has a majority here, but a smaller one, probably due to the pollsters' use of (what is to some) the red-flag term 'single payer'. [View the full poll results at https://news.yahoo.com/page/election-2008-political-pulse-voter-worries]

Taxpayer funded, government-run health care insurance for all is a public, not a private, good, and it is the only political project that most Americans are on record as willing to pay higher taxes to achieve. There is in fact not "a lot of resistance" to a rational health care system. Obama knows this. But the interests of those who have heavily invested (literally) in him seem to carry more weight than do the most pressing interests of the rest.

The Ideology of Individual Choice and the Logic of Solidarity

Fourth: Obama claims that a health care plan based on "a series of choices" is superior to one that leaves no choice but instead saddles everyone with the burden of full and affordable coverage. Pity those poor Europeans, deprived of their right to liberty by forced access to first-rate health care. In US culture few things are more important than the right to choose: which health care system gives us the most choice? This way of thinking is saturated with the ideology of individualism and its private goods, and distracts us from solidarity, as opposed to self-interest, as a political and moral value. This is especially pernicious since, as we shall see, it is only concerted action motivated by solidarity that can bring about a health care system from which no one is excluded because they can't afford it.

When Obama contradistinguishes choice from universal coverage he unwittingly underscores the irrelevance of individual, self-interested choice to political goals motivated by a commitment to solidarity. Preoccupation with the choice between one doctor and another, one plan or another, conceals a crucial assumption, namely that the fundamental issue underlying the health care debate is one about choice and liberty. An individualist way of looking at things implies that our collective fate is a function of whether or not each individual member of society is savvy enough to make the free choices most likely to promote his or her self-interest. But are people who worry about access to health care really concerned with choice? What weighs upon them is that they can't afford health care. No individual can make on her own the choice to turn the US into a country that makes health care affordable, available to all. That choice is not a choice by an individual about her own well being. It is not even a choice about the sum total of each and every individual's well-being. It is a choice we make together about the kind of society we want to live in. To worry about health care because one cannot afford it is, on reflection, to lament the non-existence of a public good, universally accessible health care, one that can't be reduced to the sum of all individual goods. The survey discussed above indicates that most Americans implicitly know this. The majority endorse a universally applicable measure, taxation, as a means to institute a universally available, i.e. public, good, access to health care. A universal tax, as for education, roadways, health care, is not an individual cost; it is a social cost. Correspondingly, universally accessible health care is not an individual good, it is a public good. The majority would prefer to live in the kind of society that features that public good. It's a different kind of society from the one we're currently stuck with.

That kind of society, and the public goods it prioritizes, can be achieved only if it is pursued as a goal by people acting in concert. That's where solidarity is on display: in collective action motivated by the desire to achieve a public good.

The kinds of goals/goods in question typically involve bringing about a certain kind of society. For example: the kind of society that provides all with affordable health care, the kind of society that makes access to the means of life -e.g. a living wage- available to all, the kind of society that makes the meeting of human needs the principal motivator of economic production, the kind of society that assigns sufficient resources to the reduction of pollution and the preservation of nature,... Prattling on about individual choice creates a conceptual space within which considerations of solidarity and public goods cannot arise. Talking about solidarity in the language of individualism is like trying to score a field goal in baseball.

Obama references affordability in spite of himself when he claims (falsely) that he wants to "make sure that every American is covered". The fundamental virtue of single payer is that it detaches insurance from employment and thereby from one's level of income, so that everyone can afford health care. The question of choice doesn't even arise if you can't afford to keep yourself healthy. And come to think of it, were health care universally available, the question of affordability would not arise. Talk of being able to "afford" access to health care would be as misplaced as talk of being able to afford access to elementary education.

Solidarity As a Familiar Phenomenon

The issue is worth dwelling on. In everyday life we are all familiar with the pursuit of irreducibly social goods. Think of a family with kids. A rare and highly desirable work opportunity, but far from home, arises for spouse #1. Spouse #2 has come upon a comparable golden opportunity, also far from home. The family wants to stay together. A decision based on the good of either individual spouse would break up the family. What to do? It's not uncommon in such a situation for the adults to look to determine what would be good for the family. And what's good for the family is not the sum of spouse #1's good plus spouse #2's good, plus the goods of each individual child. We cannot commensurate and then sum up these different and sometimes incompatible goods. The good of the family is irreducibly social, just like universally accessible health care. Families and households act in solidarity all the time.

Obama's repeated insistence on the market as the primary agent in distributing resources precludes consideration of questions of solidarity from the outset. He is the instrument of domestic advisors benighted by now-discredited economic theories hailing the efficiency and liberty-promoting virtues of the market. For these economists the pursuit of individual self-interest, plus competition, makes the world go round and secures for us all the freedom we (are allowed to) want. As we have seen above, the restriction of human-welfare-enhancing political choices to the realm of competition and self-interest deprives us of the freedom collectively to choose to live in the kind of society that provides copious public goods. That's a big freedom lost.

The Political Psychology of Solidarity

A sense of solidarity is far more prevalent in much of Europe than it is in the US. In a New York Times article titled "For the French, Solidarity Still Counts" (by Youseff M. Ibrahim, Dec. 20, 1995), the author describes public reaction in France to a three-week strike by public workers supported by "hundreds of thousands of demonstrators who filled the streets of every major city in France." Workers were protesting then Prime Minister Juppe's proposal to slash medical, social welfare and benefit payments. According to the Times:

"Polls showed an astonishing amount of sympathy on the part of those who did not participate in the strike and who suffered the paralysis of mass transit and essential services. Many people explained that they supported the strike because the Government's austerity programs are stripping layer after layer of subsidies that permitted French families of even the most modest means to sample the cultural and culinary treasures that only the rich can afford."

One recipient of the social wage was a woman receiving the standard subsidy extended to pregnant women. The stipend will continue, for each child, until the child reaches 18. Said the woman: "This is the foundation of our Republican system... Equality and fraternity are not mere slogans here. For me the engagement by the state is an expression of solidarity that gives us values... I think most French people want France's values to be decided by this spirit, not by cold, remote, economic summits that speak of deficits and competition. That was the message of the strikes."

This past March one million demonstrated across France in protest of proposed cutbacks in the wake of the financial crisis. I am currently living in France for a stretch of time and have witnessed frequent strikes and other expressions of resistance to neoliberal austerity measures. A sad and stark contrast to the sitting-duck posture of so many US workers.

The Times article provides an implicit explanation of why it is that in France and other European countries there is no general resentment of social benefits available, for example, to single mothers, while in the US more than a few working people oppose this kind of support. The Times reports that the subsidy offered to the woman quoted above "is extended to every mother in France regardless of economic or marital status." In France benefits to single mothers are not regarded as "special treatment" denied to the responsible and hard-working. There is neither social nor psychological soil in which to plant the seeds of resentment, since the single mother is the recipient of a public good available to all mothers.

Fifth and finally: "I just want to make sure every American is covered...I don't want to wait for that perfect system..." If the president truly wanted to guarantee universal coverage he would not have taken single-payer off the table before discussions began. Whatever is finally settled upon, government will neither negotiate drug prices nor regulate premiums, so we know now that millions will remain uninsured. Obama has known that all along.

Obama rigs the game by characterizing single-payer as "that perfect system". One of the major weapons in the party-liners' arsenal is to portray those who believe in greater possibilities as naive utopians blind to the truism that a "perfect world" is impossible in what William F. Buckley liked to call "this veil of tears". The logic is fine: since there are no finite limits to the greater possibilities of goodness, and perfection is conceived as the greatest possible, it follows that perfection is impossible down here. But whoever introduced talk of perfection in the first place? Isn't the elimination of a great deal of unnecessary suffering enough? Last I recall, single-payer advocates claim merely (sic) that it is way better than what we are offered. That's pretty good.

Obama's case against single-payer frames health-care priorities in the language of atomic individualism. Hence, the range of possible outcomes is determined for the worse before discussion begins. I am suggesting that a good part of our resistance and organizing should consist in reminders that an alternative way of thinking and acting is already on display in some of our common practices, and in already existing benefits won for other populations by aiming at public goods to be achieved by concerted action in solidarity.

Hope that helps.