September 21, 2017
by Jim Kavanagh
It’s great that more than a third of Democratic senators have signed on to co-sponsor Bernie Sanders’s Medicare-for-All bill. It’s a potentially strong bill that’s been welcomed by single-payer activist organizations like Physicians for a National Health Program (PNHP) and National Nurses United (NNU), and it represents a victory for the tireless work of single-payer activists and the popular pressure they stoked. It is also, we must recognize, only possible because of Bernie’s insistent promotion of healthcare as a right, in a campaign that widened the field of American political discourse.
Above all, it is a result of continuing disgust with American for-profit health insurance system. It marks the exasperation with Obamacare’s half-assed attempt to patch up that system, and the rejection of the even crueler Republican schemes.
At the very least, this bill puts single-payer “on the table” of legislative action and public discussion. The “public discussion” part is perhaps the most important. People will now hear about single-payer, and its advocates will not be completely shut out of media coverage from Fox to PBS, as they are now. Even the Democratic Party will have to talk about it.
But please, please, do not be fooled. It does not mean that most, or any, of those co-sponsoring Democratic senators actually support single-payer. Most of those Democrats have signed on because they felt politically forced to, because they knew they could not face their constituents if they didn’t. But many of them do not support single-payer, have no intention of actually working to make it happen, and will, in fact, do their best to undermine and prevent it.
In Homer’s Odyssey, both Helen of Troy and King Priam’s daughter, Cassandra, tried to warn the king that the elegant Horse, which was presented by the Greeks as an emblem of surrender, was actually an engine of attack that would destroy the city if allowed in. Call me Cassandra.
The New York Times article of September 15th, “Buried Inside Bernie Sanders’s Bill: A Fallback Plan,” makes the danger clear. Duplicitous, Trojan-Horse Democrats like Al Franken and Kirsten Gillibrand are jumping into this bill to hollow it out from within, and divert the tide of single-payer into another disappointing dead-end.
Franken, who has always defined himself as “a DLC Democrat”[i]comes right out and says that he considers the bill only “aspirational,” a “marker,” and “a starting point for where we need to go.” In other words: This is not real legislation and a real policy that I’m really supporting, but a kind of thought-experiment that I’m going to use to lead you to something else.
And that “something else” is something less than single-payer. Gillibrand puts that lesser card on the table. Bernie’s bill, it seems, has sections that “help establish a road map for what some other strategies might look like.” Gillibrand herself wrote into the bill an option to buy Medicare-like government plans on the “already available” Obamacare exchanges.
This is the pernicious “public option” that the Times delicately and deceptively says “didn’t have enough support” to stay in the final ACA bill, (It didn’t have Obama’s support, and he killed it.) As Gillibrand describes it: “One part of the [Sanders] bill that I worked with my colleagues to put in was the ability for every American to buy into a nonprofit public option… This would create affordable, public health care that is available to any American to purchase in the already available exchanges.” This “public option” is going to be pitched by Gillibrand as another “transition to get to single-payer.” But it is no such thing; it is not a move toward, but a diversion away from, single-payer, and a damaging one.
The “public option” can be spun to sound like a reasonable and “realistic” progressive alternative, another Zeno step toward single payer, In fact, any “public option” with the real progressive intent Gillibrand claims would actually destroy the private health insurance industry and market rather quickly. But that is not what Gillibrand or any of these Democrats want. They want a public option that will preserve and stabilize the private insurance market.
There are a number of more specific reasons the public option cannot be the progressive “step” it is touted as. You can find them in the analyses of RoseAnn DeMoro, Russell Mokhiber, Margaret Flowers, Adam Gaffney, Physicians for A National Health Program, Naked Capitalism, and many others. I’ll mention a couple of them here.
First of all, the public option will not, and cannot, achieve universal coverage—something that single-payer advocates, including Bernie Sanders, have always presented as an indispensable goal. It will leave tens of millions of people without health insurance. Remember the vociferous moral outrage about the 24 million people Trumpcare would have taken coverage away from (and the missing moral outrage about the 28 million people Obamacare leaves uncovered)? Well, as Dr, Margaret Flowers asks, if Gillibrand and Franken think “it is acceptable to promote a policy that leaves some people out, then we want to know who should be left out.”
Second, the public option leaves a segmented, multi-tier healthcare system (including the tier of the uninsured). As RoseAnn DeMoro of NNU notes: “Medicare works in large part by including all the people it covers in one large risk pool so that healthier patients balance out sicker patients in costs that must be reimbursed to providers.” The public option scheme prevents the equalization and cost-cutting that would come from a fully public Medicare-for-all program. As Adam Gaffney says: “We don’t need competing public and private insurance plans any more than we need competing public and private air traffic controllers.” Throwing a public option into the mix on the “already available exchanges”—which are different in every state—is a scheme that maintains the waste and inefficiency of unnecessary parallel healthcare programs,
It also reinforces the class divisions and resentments those parallel programs create. One might be excused for thinking it maintains those wasteful inefficiencies in order to maintain those divisions. It would keep a “poor people’s” tier of healthcare (Medicaid, etc.) distinct from what people with extra money in their pockets can purchase in the exchange. Because it’s very important (for the intra-class division on which capitalism depends) for everyone to know, and continually parse, who gets “welfare” and who’s “paying their way.” Let’s keep some extra layers of bureaucracy just so desperately poor people can be reminded that they’re not precariously “middle-class,” and vice-versa.
Furthermore, as long as the public option is competing in a market—i.e.,” exchange”—system, the private for-profit insurance sector will be a rallying point for conservative wedge attacks to undermine the public program. Conservative Republicans and corporatist Democrats will conjure ways to create market advantages for the private plans, via subsidies, tax breaks, reducing the payments to providers from the public plan, etc. As the devolution of Obamacare has shown—with its skyrocketing premiums, narrowing networks, and the flight of many insurance companies—keeping the health insurance market profitable requires a lot of care and feeding.
It would be supremely foolish, for example, not to expect that “other strategies” coming from Gillibrand, Franken, and the neoliberal Democrats will be projects for “fixing”—more like resuscitating, at this point—Obamacare and its “exchanges” with a public option that, as DeMoro says: “becomes the ACA escape valve by welcoming in the sickest people selected out by the private insurers, in effect another bailout for a failed private insurance market.” What a waste of time.
Any way you configure it, a ““public option” integrated into a private market paradigm offers no discrete improvements they can point to that wouldn’t be better achieved with a full public single-payer program. The only reason Clintonite Democrats want to divert the Medicare-for-all momentum into the “public option” cul-de-sac is to save the for-profit private health insurance industry. (I’ll address the other ostensible reason below.) They oppose single-payer and are now presenting themselves as supporters of it in order to make sure no plan gets through that will actually break the for-profit market system.
Nothing indicates more clearly the fundamental commitment to the capitalist market paradigm the Democrats share with the Republicans than the game these Democrats are playing with healthcare. As Adam Gaffney points out, in 2016 Paul Ryan and the Republicans, insisting they only wanted to “save” Medicare, published a proposal by which “traditional Medicare would be transformed into a public plan that would compete against private insurance plans in a ‘Medicare Exchange.’” Every sentient person understood that as a plan to destroy Medicare, and the Democrats denounced it as such.
Well, the Franken-Gillibrand ”other strategies” Democrats are trying to do the same thing to the Medicare-for-all proposal as Ryan and the Republicans tried to do with existing Medicare. In other words, as Obama did in 2009, today’s Clintonites are taking a Republican idea and dressing it up in Democratic finery. Their “other strategy” for taking a “step toward” it is to stop the train in its tracks and push it in the opposite direction. This time, as everybody did with Ryan, let’s recognize this “support” for what is, and let’s not let them get away with it.
The fundamental character of these RepubliDem proposals is signaled in the language of “affordable” healthcare. The “public option” does not make healthcare a right; it maintains it as a commodity that you have to buy and “afford.” It’s more of the “Go shopping!”” mandate. As if people shopped for health insurance like they do for tomatoes. Maybe I’ll make some spaghetti sauce get some health insurance today. I’ll just buzz by Whole Foods and Trader Joe’s Aetna and Humana to see what’s on sale which policies are most “affordable.” Isn’t it great that they’re selling that store brand, too!
This paradigm is a cruel joke. Anybody who’s spent year after year “shopping” in this market—i.e., slogging through ever-changing, ever-costlier, ever-crappier, and ever-more complicated plans—knows that. Haven’t we had enough of it? Health insurance, which effectively means healthcare, should not be presented as a discretionary consumer commodity, “available to purchase” by individuals in some kind of shopping mall, according to “affordability.” It should be organized as a necessary right, available via a publicly-funded program, on the basis of one’s humanity.
This was the whole point of single-payer as Bernie Sanders emphatically presented it over the last two years. Putting a generic brand of bottled water on the shelf in the bottled-water store is not the same as providing a public water supply. Not the same at all. Not a “step towards.” Two entirely different principles at work.
“Affordable” and “access” are words to be refused whenever they appear in these discussions. In January, Bernie quite rightly slapped down Trump’s HHS nominee, Tom Price, in this exchange:
Price: I believe that every single American has access to the highest quality care and coverage that is possible.
Sanders. ‘Has access to’ does not mean that they are guaranteed health care. I have access to buying a $10 million home; I don’t have the money to do that.
Well, Bernie, make sure you tell that to Kirsten and Al and all the other Democrats who are crowding into your Medicare-for-All bill to make it the “starting point” for “other strategies” that will give “access” to healthcare—i.e., make it “available to purchase” for those who can afford it.
Of course, there is final ostensible reason these Democrats who claim to support single-payer insist on promoting “other strategies” like the “public option”—because that is all that’s realistic, feasible, politically possible, etc. It’s a clinching argument for a lot of people, including some Democratic politicians who sincerely want and are not trying to sabotage single-payer but are honestly persuaded that it’s just not feasible. The obverse of this argument is that those who are not so persuaded are incapable of being “pragmatic” or of compromising, and always ruin possibilities of reasonable change by making the perfect the enemy of the good, yada, yada.
To address this requires, first of all, to stop straw-manning. I’ve never met a leftist, no matter how radical, who rejects the general possibility of either reforms or compromises because they won’t achieve the workers’ revolution or some other state of perfection.
The question is always about political judgement and the principles that govern it, and how they apply to specific reform proposals. Do the reforms deliver a concrete benefit in a secure and permanent way? Do the reforms change the balance of economic, political, and/or social power in favor of the working-class? Do they at least move in the right direction?
In this regard, we might refer to André Gorz’s distinction between “reformist reforms” that stabilize the status quo and “non-reformist reforms” that advance real change. In the U.S. healthcare context, “reformist reforms” are those that seek to stabilize and protect the capitalist market healthcare system as well as the wealth and power of the class that controls it. “Non-reformist reforms” are those that establish new possibilities for a system that’s controlled by and for the public, and governed by “human needs and demands” rather than profitability.
Similarly, there are positive and negative compromises. The way to get a radical reform like single-payer is to fight for it, to work to bring people around to it, not to pre-emptively offer something else that you think will be more palatable to those who are resistant. And if, after fighting hard for it, the balance of forces requires you to compromise, you do so in a way that still achieves a net gain for your principles and position. Otherwise, it’s not a compromise; it’s a loss. In this context, for example, short of universal coverage, increasing the number of people covered by the public program, Medicare, and strengthening it, would be preferable to diverting public resources to subsidizing private health insurance programs and “exchanges” (because markets, it seems, need government support). Which is why Obamacare, which did the opposite, was not a compromise, but a loss, for single-payer.
So let’s, by all means, have reforms—even ones that won’t end capitalism and imperialism. Let’s just not reform the reform away pre-emptively. Medicare-for-all is a reform. As Bernie Sanders keeps pointing out, it’s the kind of system that’s standard practice in advanced capitalist countries. There’s no leftist or marxist who thinks instituting it will overthrow capitalism. We support it because it’s one of those “non-reformist reforms” that concretely benefits the lives of the great majority of citizens, and strengthens pubic control of an essential service, eliminating a needless and predatory capitalist industry. And that is why neoliberal Democrats reject it: they prefer a “public option” because it preserves the “profit option.”
It seems that these two kinds of reform, based on two opposing principles, ominously coexist within Bernie Sanders’s bill and the political strategy around it. It’s King Bernie who has welcomed the Trojan-Horse Democrats into his single-payer redoubt. He has let them bury inside his bill whatever poison pill they are going to try to extract and make us swallow: “It turns out that the Sanders bill also has provisions along those [‘more limited step’/public option] lines. (NYT)” The duplicity is inscribed within his carefully crafted Schrödinger’s bill, which is tamely “reformist” and/or radically “non-reformist reformist,” depending on who’s looking at it. And Bernie’s invited a lot of neo-liberal Democratic Senators to cast their defining gaze. That’s raised considerable suspicion about why he didn’t coordinate his proposal with the Conyers bill in the House, which has been “considered the gold standard” by the single-payer movement.
I worry, with Margaret Flowers, that: “Sanders has it backwards: Rather than starting from a position of strong legislation and building support for it, he is starting from a position of weak legislation that he considers to be more politically feasible.” Beginning with compromise, ending with loss?
Is Bernie again demonstrating his penchant for being an auxiliary Democrat, more eager to show his belly to the Party establishment than to be the leader of his change-hungry pack? Does Sanders think that allying with democratic legislators is more important than allying with a party-independent social movement? As Flower says, Bernie is “trying to walk the line between listening to the concerns of his constituency,…and… his fellow Democrats, whose campaigns are financed by the medical industrial complex…. Sanders must decide whom he is working for.”
If there’s one thing that Bernie has been consistently strong about, in a way that never caused me to doubt his commitment, it’s single-payer healthcare. But given the creatures gathering around his bill, it’s necessary to ask: Is Bernie shrewdly sheep-dogging the Democrats into supporting single-payer, or is he again sheep-dogging his constituency into supporting another Clintonite market-stabilizing scheme? I wish there were less reason to be suspicious.
Comes the cry: But is anything else possible? (From those who’ve done so well lately foreseeing what’s politically possible.) It depends on how you think about the relation between what is possible and what you can make possible.
Let’s, please, be realistic. The “public option” is impossible in this congress. Neither Bernie Sanders’s bill nor anything like it is going to pass this congress. Franken’s and Gillibrand’s “other strategies” are just as impossible as Bernie’s full single-payer in this congress, or in any congress that isn’t radically different.
If one thinks about that for a bit, one realizes that tabling the “public option” isn’t really for the ostensible purpose of helping make single-payer more congressionally feasible or moving it closer to political reality, but for the purpose of replacing it.
As mentioned above, any “public option” with real progressive intent would inevitably destroy the private health insurance industry. It would, for that reason, encounter the same stiff resistance from congressional Republicans who want to subordinate healthcare to profits. So why would anyone propose fighting the same “impossible” battle for a half-assed version of what you supposedly want, rather than for the full thing? Answer: Because those proposing it want the half-assed version, not the real thing; because they don’t want to destroy the private health-insurance industry; and because they, too, subordinate healthcare to profits.
Neoliberal Democratic legislators are not pitching “other strategies” in order to make single-payer more feasible to Republicans. They are not trying to persuade Republicans, or even the many Democrats who are dead-set against it, to vote for a single-payer bill. They’re trying to persuade you not to fight for one. They want you to accept that they are not fighting for it and are going to present something less, and they want you to agree with and congratulate them for doing so.
As Margaret Flowers says, introducing a public option will not convert any opponents, but it will “divide and confuse supporters of Medicare for all.” And that is its purpose.
The number of Democratic co-sponsors of Bernie Sanders’s bill, which they know has no chance of passage, indicates nothing in this regard. As they did in California, Democrats will proclaim their commitment to single-payer, as long as they don’t have the power to make it happen. In California, they started back-pedaling the minute they had that power. Here, they’re already back-pedaling pre-emptively, from the moment they sign on to “aspirational” legislation. It would be foolish not to hear what they are saying.
So the most difficult obstacle to single-payer isn’t that there are too many Republicans in congress. The most difficult obstacle to overcome is the commitment to capitalist market principles among Republicans and Democrats. Sure, the majority of Republican legislators adamantly opposed to any such thing makes single-payer impossible right now. But electing more Democrats won’t necessarily change that. If the congress were full of Bernies, I’m sure it would pass single-payer. If it were full of Cory Bookers, not so much.
Everyone, Bernie Sanders included, who wants single-payer healthcare should understand clearly that this fight is not between the Democrats and Republicans. Single-payer won’t come as a result of congresspeople talking and negotiating amongst themselves, or of Democrats either persuading or outnumbering Republicans, It won’t pass a Republican-controlled Congress or a Democrat-controlled Congress. We saw that in 2009, where no Republican vote was received or needed for whatever the Democrats wanted to pass—which was not single-payer. The Democrats’ shunning of single-payer wasn’t because of Republicans in 2009, and it’s not now.
The Democratic Party as an institution, as opposed to its constituency (to which it is opposed), is against single-payer. Through its financial infrastructure (and media assets), on which all of its candidates and legislators depend, it will pressure any of them who may have other ideas, and concoct any excuse or diversion, to prevent a robust and irreversible single-payer program. That’s what it did in 2009, and that’s what It will do again. If it can; if we let it.
Pace Bernie Sanders, recognizing neoliberal Democrats’ opposition to single-payer, and fighting it, will be much better for advancing the cause than buying their pretense of support, and letting it bend you to their will. The fight for single-payer requires a fight against the Democratic Party. Bernie Sanders kinda-sorta knows that, but really wants to avoid it. Without that fight, single-payer will never, ever happen.
This is a tough fight, because we’re asking capitalist politicians to sacrifice a capitalist industry for the social good. (And, yes, it can and will be argued, for the good of the capitalist economy as a whole—but there’s a stubborn resistance to any such class disloyalty.) The onlything that will get single-payer done in any congress is a massive, in-their-face public demand that politicians of both parties are too afraid of to deny. It will be done by a popular movement, independent of both parties, that creates a political atmosphere which encourages single-payer supporting candidates from both parties (yes, there will be Republicans) to come forward, and elects a congress where even some of those who don’t want to vote for single-payer, will.
That will only happen if single-payer advocates, many of them Bernie supporters, maintain a clear and consistent demand for publicly-funded, universal and equal coverage, for the easily comprehensible, proven-effective Medicare-for-all system—no if, ands, or doo-dads. That will only happen if single-payer advocates refuse to be divided and confused with any of the complicated schemes and doo-dads whose only purpose is to maintain a stream of payments to the private health-insurance industry. That will only happen if single-payer advocates, including Democrats and Bernie supporters, speak and act independently of the Democratic Party and Bernie Sanders, and in opposition to any dilution-complication either might put forward pre-emptively. There’s a reason—and it has everything to do with political feasibility—that there is not, never was, and will not be a “public option” movement. We cannot let anyone, even Bernie Sanders, try to turn the single-payer movement into one.
It’s important to recognize that we’re not in 2009, and we can’t let Franken Democrats drag us back into a poor sequel of Obama’s shunning of single-payer, played out within Bernie’s bill, as it were—which is exactly what they are trying to do. The bill really wants single-payer, but “it turns out that [it] has provisions along those [public option] lines.” With Bernie playing the 2017 version of Dennis Kucinich.
But Franken and Gillibrand are not Obama, and no cast of Clintonite characters today has anywhere near the political strength he had in 2009. Whatever hidden Easter egg neoliberal Democrats are hoping to hatch from it, Bernie’s bill has put single-payer front-and-center on the public agenda. The Obamacare can has reached the end of the road, and Trump and the Republicans can’t even find theirs. People are fed up with the half-assed schemes, and are open to, and literally dying for, the program that everybody needs: universal healthcare coverage as a right. It’s just about the easiest political sell one could imagine.
Because of that, Medicare-for-all is becoming quite feasible, and every Democratic and Republican defender of capitalist healthcare is realizing that and fearing it. Hillary’s “never, ever” cannot be said by Democrats anymore. Even Max Baucus, who had single-payer advocates arrested in 2009, is now saying “We’re getting there. It’s going to happen.” That is why neoliberal Democrats are conjuring new, indirect ways of pushing against it—not because single-payer is not possible but because, more than ever, it is.
If universal coverage, single-payer, Medicare-for-all is not a winnable “non-reformist reform,” there is none.
Let’s not be diverted from single-payer again, for another scheme whose only purpose is to keep the private health insurance industry sucking profits and life out of people for another ten or fifteen years—after which it will again be obvious that single-payer is the only reasonable alternative. How many groundhog days will we wake up saying: “We’re getting there. It’s going to happen.”? What a waste.
Let’s instead, right now, have a left-led movement, independent of any party or personality, that delivers something of material benefit to the entire working population of the country, irrespective of any half-assed ideas any of them have in their heads.
Class solidarity based on material interest. Imagine that.
[i] The Democratic Leadership Council was, from 1985 to 2011, the incubator of corporatist neo-liberalism in the Democratic Party. It nurtured the career of Bill Clinton, who became its Chairman in 1990. Clintonism screwed the Democrats: How Bill, Hillary and the Democratic Leadership Council gutted progressivism – Salon.com
This article first appeared in Counterpunch
Jim Kavanagh edits The Polemicist.