Sorry, Liberals: Obamacare Won’t Lead to Single Payer

If
you spend any significant amount of time talking to conservative
activists who oppose Obamacare, you’ll eventually hear some variant
on the theory that Obamacare was never meant to work. Instead, it
was meant to destroy the existing health care system, and in the
process pave the way for liberals to step in with the comprehensive
health care fix the far left has always really longed for: single
payer. 

There’s often a hint of conspiracy surrounding the accusation,
as if President Obama and the White House senior staff had hatched
some meticulous plot to spend a year struggling to pass a health
care law that they intended to fail in a series of carefully
planned disasters sometime down the road, which would create the
perfect opening for their true, secret goal.

I’ve always thought the notion was rather far fetched. Obamacare
was a stalking horse for a modified version of Obamacare, not a
single payer conspiracy scheme. But The New Republic’s
Noam Scheiber suggests that conservative activists worried that
Obamacare will lead to single payer might be at least partially
onto something—maybe not in their belief that Obamacare was
explicitly designed as a gateway to single payer, but in their
worry that the health law will eventually lead to some sort of
nationalized health system. And unlike those concerned conservative
activists,
Scheiber thinks this is a good thing.

The gist of Scheiber’s theory (delivered in response to
a griping Michael Moore op-ed about the health law  in

The New York Times) is that the law will create a
unified, organized constituency for change. Private coverage in the
exchanges will be too expensive for many, and dealing with private
insurers will upset some beneficiaries. That will make existing
government run health insurance options more attractive. “By
pooling millions of people together in one institutional home—the
exchanges where customers buy insurance under Obamacare—the
Affordable Care Act is creating an organized constituency for
additional reform,” he writes.

I don’t doubt that as Obamacare’s flaws continues to be exposed,
liberals like Scheiber, as well as a some Democratic legislators
and even presidential candidates, will push for a single payer
overhaul. But I don’t think it’s likely to happen in the forseeable
future.

For one thing, it assumes that irritation with Obamacare—a law
designed and implemented exclusively by Democrats—will somehow
generate public support for additional Democratic health
legislation that is even more sweeping. But judging by the beating
Democrats have taken at the polls over last few months, public
frustrations with Obamacare turn the electorate
toward Republicans. Democrats won’t be given a second chance,
with a mandate to do even more.

Scheiber’s theory also overlooks how tough passage of Obamacare
was in the first place—and how much support the administration had
to get from health industry stakeholders in order to eke out a
legislative victory. Single payer would be even tougher. Moderate
Democrats who were nervous about Obamacare the first time around
would be even less likely to support single payer, especially given
how the law
cost Democrats at the voting booth. And there’s no way that
doctors, insurers, hospitals, and other major health industry
groups would play nice with a single-payer push. Quite the
opposite: Even beyond the insurers, much of the industry would see
single-payer as a de facto nationalization of the health system,
and they would fight the transition with everything they could
muster.

Finally, Scheiber’s argument rests on the odd idea that
individuals with private coverage will become jealous of people
with Medicare and Medicaid.

I might be willing to believe that some people would prefer
Medicare to private coverage, but Medicaid isn’t going to become a
consumer favorite any time soon. Here’s Scheiber:

There’s the likelihood that, one day soon, especially if
Medicaid becomes more generous, the working-class person who makes
175% of the poverty level will look at his working-class neighbor
making 130% of the poverty level and think, wow, his
health insurance seems a lot better than my private Obamacare
plan.

That’s some rather wishful thinking. For starters, Medicaid
isn’t likely to become more generous: State budgets are already
straining under the burden of Medicaid spending, and the federal
budget squeeze means that it’s more likely that the federal share
of the program
will be cut back. Meanwhile, it’s hard to imagine someone with
private health insurance looking jealously at a program that has

no statistically significant effect on physical health
outcomes, and that has even been found, in a
couple of narrow instances, to produce health outcomes that are
worse than no insurance at all.

Might Obamacare lead to a handful of state-level experiments
with single-payer variants? Possibly,
although that mostly means that very liberal states with heavily
consolidated insurance markets will explicitly transform their
insurance industries into public utilities. 

There’s a weird overlap between conservative fears and liberal
hopes when it comes to single payer: Both seem to think that
Obamacare makes a universal government-run system more likely. But
both are wrong.