This morning’s post by Matt Yglesias notes a fairly obvious but important issue that bears attention.

The comportment of conservative Supreme Court justices in oral argument leads many people to seriously consider what would happen if ACA is crippled or struck down. (Like Jonathan Cohn, Henry Aaron, David Cutler, Charles Fried, and Jonathan Chait, I was appalled by the oral argument. You can read my column at healthinsurance.org for more on that subject.)

Several commentators assert, or at least have mused, that overturning ACA might improve the prospects for a single-payer system. It’s easy to see why one might think so. Single-payer is less vulnerable to the commerce-clause challenge that bedevils the mandate. Outright failure of ACA would discredit bipartisan, market-based strategies within many core Democratic groups. The political and organizational simplicity of single-payer is appealing, too. Killing ACA heightens the contradictions of our fragmented and costly health care financing system, while taking off the political table some of the most workable strategies for incremental reform. Absent a serious and workable alternative, Medicare for all might look surprisingly attractive some years from now.

Still… I just don’t see it.

In the first place, I am confident that a smart and determined conservative judiciary would entertain new constitutional challenges to a single-payer system. Such a system would end or would damage much of the private insurance industry. It would reorder relations between the states and the federal government. It would upend self-insurance arrangements under ERISA, and more. If you believe ACA’s 2,700 pages was long and complicated, wait until you see the junk DNA that would accompany a politically and administratively viable single-payer bill. That’s fertile legal ground for opponents, even absent the current political polarization of the federal judiciary.

Single-payer also runs straight into precisely the political and institutional obstacles Democrats precariously navigated with ACA. I was reasonably closely involved in the public option debate. Many people believe the public option failed because Senator Lieberman hated liberals, or because insurers opposed it. These things mattered. Something else mattered, too. Pretty much everyone on the supply-side of the medical economy—including many constituencies who were otherwise strong health reform supporters—was very nervous  about the federal government acquiring so much bargaining power to dictate prices and other terms of medical care.

When wheelchair manufacturers, your community hospital, insurers, and many medical specialties line up against a single-payer bill, the path to sixty Senate votes seems narrow indeed. Whatever the American voters might tell pollsters right now, a concerted ad campaign supported by these same constituencies would be quite damaging.

Finally, there is the legislative Vietnam syndrome sure to ensue if the Affordable Care Act comes to naught. Health reform supporters acted with skill and determination, spent hundreds of millions of dollars, and took huge risks by devoting much of President Obama’s first term to enacting path-breaking legislation that was only made possible through the largest, most cohesive Democratic majority since 1964.

A core of furious activists might be energized if conservative justices snatch away the football. It might even help President Obama counterpunch to victory this November.  More fundamentally, though, people are energized by the possibility and the experience of actually winning.  Health reform supporters will be quite dispirited by the opposite experience. Across the ideological spectrum, political pros will be quite leery of undertaking such a massive effort again. Maybe in 2030, America would make another concerted effort to cover the uninsured. For thirty million people, that’s a long way away.

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. An expert on the intersection of poverty policy and public health, he has served on three expert committees appointed by the National Academy of Sciences. Pollack is also an author of reputable blog, The Incidental Economist, where this post first appeared.

Share on Twitter

4 Responses for “No, Overturning ACA Would not Smooth the Way to Single-Payer Care”

  1. BobbyG says:

    “If you believe ACA’s 2,700 pages was long”
    __

    I believe it’s 906 pages long. No, I KNOW that; I have a copy.

    ” viable single-payer bill”

    It’s already written. 30 pages long.

  2. Dr. Mike says:

    Single payer would not in and of itself face any constitutional challenges. People object when things are taken away, not when given. Yes there will be new taxes to pay for it, but even PPACA would have fared better had they just called it a new tax on every citizen with an offset/credit for having insurance.
    Even though I prefer that the problem of the uninsured be solved by some mechanism of actually providing the care instead of just purchasing insurance on their behalf, I would find at least on benefit in single payer – since everyone coming into the office would have the same insurance, I would get to fire all the non-compliant patients as there would still be more left than I could possible care for.

  3. Words of wisdom rather than wishful thinking.

  4. So, to summarize, we are expected to just forgo what is clearly an optimal (and constitutional) solution, because “political pros” are fatigued (not fatigued enough to stop running and collecting bribes, obviously) and people that make wheelchairs or otherwise profit from sickness, have a need to continue stealing from the public. What country is this again?
    I thought this was America. Wishful thinking, I guess…..

Leave a Reply

FROM THE VAULT

The Power of Small Why Doctors Shouldn't Be Healers Big Data in Healthcare. Good or Evil? Depends on the Dollars. California's Proposition 46 Narrow Networking
MASTHEAD STUFF

MATTHEW HOLT
Founder & Publisher

JOHN IRVINE
Executive Editor

JONATHAN HALVORSON
Editor

JOE FLOWER
Contributing Editor

MICHAEL MILLENSON
Contributing Editor

ALEX EPSTEIN
Director of Digital Media

MICHELLE NOTEBOOM Business Development

MUNIA MITRA, MD
Clinical Medicine

Vikram Khanna
Editor-At-Large, Wellness

THCB FROM A-Z

FOLLOW US ON TWITTER
@THCBStaff

WHERE IN THE WORLD WE ARE

The Health Care Blog (THCB) is based in San Francisco. We were founded in 2004 by Matthew Holt and John Irvine.

MEDIA REQUESTS

Interview Requests + Bookings. We like to talk. E-mail us.

BLOGGING
Yes. We're looking for bloggers. Send us your posts.

STORY TIPS
Breaking health care story? Drop us an e-mail.

CROSSPOSTS

We frequently accept crossposts from smaller blogs and major U.S. and International publications. You'll need syndication rights. Email a link to your submission.

WHAT WE'RE LOOKING FOR

Op-eds. Crossposts. Columns. Great ideas for improving the health care system. Pitches for healthcare-focused startups and business.Write ups of original research. Reviews of new healthcare products and startups. Data-driven analysis of health care trends. Policy proposals. E-mail us a copy of your piece in the body of your email or as a Google Doc. No phone calls please!

THCB PRESS

Healthcare focused e-books and videos for distribution via THCB and other channels like Amazon and Smashwords. Want to get involved? Send us a note telling us what you have in mind. Proposals should be no more than one page in length.

HEALTH SYSTEM $#@!!!
If you've healthcare professional or consumer and have had a recent experience with the U.S. health care system, either for good or bad, that you want the world to know about, tell us about it. Have a good health care story you think we should know about? Send story ideas and tips to editor@thehealthcareblog.com.

REPRINTS Questions on reprints, permissions and syndication to ad_sales@thehealthcareblog.com.

WHAT WE COVER

HEALTHCARE, GENERAL

Affordable Care Act
Business of Health Care
National health policy
Life on the front lines
Practice management
Hospital managment
Health plans
Prevention
Specialty practice
Oncology
Cardiology
Geriatrics
ENT
Emergency Medicine
Radiology
Nursing
Quality, Costs
Residency
Research
Medical education
Med School
CMS
CDC
HHS
FDA
Public Health
Wellness

HIT TOPICS
Apple
Analytics
athenahealth
Electronic medical records
EPIC
Design
Accountable care organizations
Meaningful use
Interoperability
Online Communities
Open Source
Privacy
Usability
Samsung
Social media
Tips and Tricks
Wearables
Workflow
Exchanges

EVENTS

TedMed
HIMSS South x South West
Health 2.0
WHCC
AHIP
AHIMA
Log in - Powered by WordPress.