No, the Fall of ObamaCare Won't Lead to Single Payer Health Care


So the Supreme Court arguments over the 2010 health law didn't go quite the way that liberals expected. In response, a number of them seem to be attempting to console themselves with the notion that in the long run, a loss would actually be a win: If the Court overturns all or part of ObamaCare now, the argument goes, it will build support for true single-payer health care. Here's UCLA law professor Adam Winkler making a strong version of the case in article by TPM's Sahil Kapur:

"Conservatives may find that they weren't careful about what they wished for in opposing 'Obamacare,'" Adam Winkler, a constitutional law professor at UCLA School of Law, told TPM. "The economic, social and political pressure for health care reform aren't going to just disappear. There's a reason every major industrialized country has national health care. If the Supreme Court invalidates the Affordable Care Act, we are likely to see a government takeover of health care in the next decade."

…"The defenders of federalism will be rewarded with an even bigger federal government," Winkler said. "Wouldn't that be ironic?"

If it's really the case that liberals stand to win if the law goes down, then shouldn't ObamaCare's backers be hoping that the Supreme Court rules against the law? I suspect I don't see them rooting for the law to be overturned for a reason. 

Still, Winkler isn't the only one making some version of this case. The Nation's George Zornick declared last week that "if the mandate falls, single payer awaits." Columnist Eugene Robinson similarly predicted that if the mandate falls, "a much more far-reaching overhaul of the health care system will be inevitable." The "only alternative" Robinson sees to ObamaCare? A single-payer system.

If only there were alternatives to columnists (and presidents) who can't believe that there are health policy alternatives to increasing the government's control over the system. The United States has been steadily ratcheting up regulation of the health sector for nearly 50 years. At this point, the government is responsible for almost half of all health spending. Isn't it at least possible that the problems with the health system are not caused by too little government interference but by too much? Liberal health wonks frequently insist that they mostly want to make the system smarter and more effective, but they and their predecessors have been saying the same thing about every reform for decades—and yet it always seems that yet another fix, another tweak, another technocratic reform is necessary to finally rationalize the system.

The good news is that single payer isn't the lineup should any part of ObamaCare fall—at least not in the foreseeable future. The critics Kapur quotes, both supporters of the 2010 health law, do a good job explaining why:

That's far from certain, because the political obstacles to single-payer — vehement opposition from conservatives, the might of insurance and other health care industries and the difficulty of selling bigger government to the American public — may yet be too great to overcome.

"Not in my lifetime. There just isn't the political support," Tim Jost, a law professor at Washington and Lee University and a supporter of the Affordable Care Act, told TPM. "We could not even get a public option when the Democrats had 60 Senate votes. The alternative is to limp along with an ever larger share of Americans receiving ever less care. This doesn't seem to bother a lot of Americans, at least those who pay for political advertising."

"I think that is naive," Jonathan Gruber, an MIT professor and health policy expert, told TPM. "If you look at the history of health care reform, every time we come back to it the proposals are more conservative than the last time."

I don't know if I would use the word "conservative," though Gruber is correct to argue that ObamaCare's mandate/subsdize/regulate design was built partly out of a desire to appease Republican policymakers. But at least for the forseeable future, it's unlikely that if the health law is struck down its backers will have much success passing something even more ambitious, like single payer, in its place. 

Jost, meanwhile, is right to note public opposition to single payer as a major obstacle. If Democrats made a major push for single payer, Republicans would immediately trot out the familiar line about the plan being a "government takeover of health care." And this time it wouldn't be an exaggeration with elements of truth, it would just be the truth: The government would essentially be nationalizing the health insurance industry, and, by taking over the payment side of the business, centralizing control over the nation's health providers as well. 

Public opposition isn't all that single payer pushers in Congress would have to contend with. The health care industry would wage a lobbying World War III to prevent it from happening. Anyone who thinks that doesn't matter should remember that the White House made a massive effort to court the support of the major health industry groups— insurers, drug makers, doctors, and device makers. All would be adamantly opposed to a single-payer system, and would use every asset—from the public trust in doctors to the massive P.R. war chest of the pharmaceutical industry—to attempt to stop it. The White House was convinced that it couldn't pass the law without industry support, and plentiful handouts, last time around. During a single payer push, the handouts wouldn't exist—and neither would the support.