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The rough political road to optimal health policy

March 10, 2020

Topics: Quote of the Day

By Quoctrung Bui and Sarah Kliff
The New York Times, March 10, 2020

It is a common refrain from Bernie Sanders on the campaign trail: The United States is the only developed country that does not provide health coverage to all residents.

“Canada can provide universal health care to all their people at half the cost,” he said at a recent Democratic debate. “The U.K. can do it. France can do it. Germany can do it. All of Europe can do it.”

Mr. Sanders is right: All these countries provide universal coverage. But what he doesn’t talk about is the excruciating battle they went through to get there.

It took Canada more than a decade to move from a patchwork of insurance plans to a single-payer system. At one point, doctors were so incensed that they went on strike for 23 days. Doctors from the United States and Britain flew in to help keep the health system going.

Today, most Britons revere their National Health Service: One lawmaker has called it the closest thing the English have to religion, and the 2012 Olympic opening ceremony honored it with a four-minute song-and-dance routine.

But when it began in the mid-1940s, 89 percent of doctors were opposed. They raised £1.6 million (or £58 million today, equivalent to $76 million) for a “fighting fund” to protest the plan. Some patients showed interest in contributing, too.

Look around the world and you start to see a common theme: Creating universal coverage is hard. The countries with the systems that Mr. Sanders admires went through years of failed legislation, doctor protests and uncertain futures.

Abroad, the arguments made against universal coverage were similar to those we hear today: that it’s just too expensive, or gives government too much control over the practice of medicine.

“No country did this without a huge political conflict,” said Jacob Hacker, a professor of political science at Yale who studies the formation of international health systems. “But once they put in the strong, basic foundations, there was no going back.”

Mr. Hacker said: “People look at the current levels of support that other systems have, and extrapolate backwards to think that universal coverage was always popular. But that isn’t the case. Everywhere this happened, it was a very fierce fight.”

(The article discusses the struggles in Canada, Britain, and Australia.)

Australia, Canada and Britain all overcame enormous opposition to build health systems that their citizens now support. In each case, politicians stood firm, and eventually the outcry subsided.

Could something similar happen in the United States?

Those who study the history of other health systems say it is certainly possible — but will probably be more difficult.

The United States is different in that its medical industry is bigger and more powerful. Health care spending accounts for one-sixth of the American economy, and no industry spends more on lobbying Congress.

Another obstacle comes from the structure of the U.S. government, in which dueling political parties often wield partial control over different branches of government.

“The American political system makes this harder,” said Mr. Hacker, the Yale professor. “The kind of determined, take-no-prisoners approach that happened in some provinces like Saskatchewan doesn’t work as well here.”

That said, there is nothing so structurally different about the United States that leads historians to think of universal coverage as impossible.



By Don McCanne, M.D.

The lesson here is clear. All nations that have universal health care systems experienced significant political struggles to achieve them. The fact that there are political barriers ahead is never a reason to not move forward with reform.

In the case of the United States, the leading proposal for universal health care – the single payer model of an improved Medicare for All – once enacted and implemented would be the finest health care system in all the world – the pride of all Americans.

So what are the barriers? It costs too much? No, we are already spending enough to provide comprehensive care for everyone. Doctors and hospitals would be underpaid? No, the hundreds of billions of dollars in administrative waste that would be recovered is enough to adequately fund the system. Waiting times would be too great? No, resource allocation would be improved, helping to reduce some of the excessive queues we now have. Superfluous vested interests such as the private insurers would lose out? Yes, but that would allow health care dollars to be redirected to patient care, where they belong. Anti-government ideologues would be offended? And what is their counter-offer to ensure health care for all? Leave it to the marketplace? Kenneth Arrow taught us that lesson many decades ago.

So what about the politics of 2020? The Republicans wanted to repeal and replace the Affordable Care Act, but they have not found a replacement that would work. In the meantime there had been a crescendo of support for Medicare for All, but now the Democratic leadership has declared that, in order to defeat Donald Trump in the upcoming presidential election, we must abandon Medicare for All. What? That’s a non sequitur. Yet in only one week there was a massive shift of Democratic voters from the candidate supporting Medicare for All to a candidate who was outspoken in opposing it.

There is certainly strong opposition to President Trump within the Democratic Party, but how did the spinmeisters transfer that to voting against one of the most outspoken Trump opponents who happened to be the leading supporter for Medicare for All? As today’s article indicates, there will always be significant barriers to enacting a program of universal health care. We have to identify those barriers and knock them down.

PNHP advocates for a single payer national health program. We do not support any political candidates or any political parties. Rather we ask that all candidates and political parties join us in supporting health care justice for all though enactment of a single payer national health program.

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About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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