The central ethical and economic commitment of Single Payer national health insurance is to stabilizing and expanding the status quo model of marketized private medical care which ensures rampant rent-seeking and corporate capture, turning the whole case.

The 2016 election cycle has shown that health care is lining up to be a key fight in the next few years. The Affordable Care Act (aka Obamacare) is looking increasingly weak as soaring costs of insurance, drugs, and equipment are eroding whatever meager benefits there were in reigning in the all consuming burden of the American health system.⁠1 Bernie Sanders made a medicare-for-all proposal a cornerstone of his campaign, something which the National Nurses United (NNU) and Our Revolution has vowed to keep fighting for.⁠2 Colorado had a similar single-payer plan on the ballot where insurance bureaucracies would have been replaced by a state-run insurance program, but would retain private health institutions and medical industries.⁠3 Hilary Clinton fended off the insurgent challenge of Bernie supporters, but not without having to pay lip service to their cause.⁠4 Poll after poll demonstrates popular support for nationalized health programs across Americans.⁠5 While Clinton indicated a need to revisit the vague “public option” Wikileaks later exposed her method of dividing her private positions, disclosed to Wall Street firms in her infamous paid speeches, and a separate public one.⁠6 None of this is earth shattering, but it shows that all the power brokers have been honed in on health. A slow moving crisis It looks to become even more central however. Estimates are the medicare funds will have to reduce benefits within two decades.⁠7 States that did not expand Medicaid have offered private market based plans that within a few years are already not affordable even with subsidies.⁠8 Where Medicaid was expanded projections for expenses are to rise significantly putting strain on already underfunded systems that suffer from severe shortages of specialists and resources.⁠9 In reality we are witnessing the slow unfolding of a multi-decade health care crisis. Health-related spending makes up roughly a quarter of the entire federal budget and is expanding rapidly. Medicare, Medicaid, and Children’s Health Insurance Programs alone represent 16% of the federal budget and are projected to grow substantially.⁠10 It is the largest portion of federal spending outpacing both social security and the military. The drivers of this are our nearly singular combination of unregulated profiteering industries and particularly pharmaceuticals, medical equipment, and a multi-layered mediating bureaucracy that introduces inefficiencies into an already top heavy industry. The American health crisis is deepening not only because of excessive bureaucracy introduced by the byzantine insurance system, but also due to its embrace of both protecting industry through strict intellectual property rights and placing barriers to any regulation of prices for pharmaceuticals and equipment. It’s worth noting that health insurance and hospitals themselves are barely profitable with the median around 3% which is near inflation levels only. The profit tends to go to all the feeder industries selling products used by patients and purchased by health institutions.⁠11 An Institute of Medicine report identified nearly 800 billion dollars in waste created by unnecessary services, excess administration, inefficient service delivery, overcharging, fraud, and failing to utilize potential preventative measures.⁠12 These factors have made it the most expensive health system in the world.⁠13 The people of the United States pay more than any other country for our health care, and with poor outcomes across a wide array of metrics. The political implications of this are not hard to see. The more political discourse digs in around the health system as a test of capitalism itself, the stiffer the resistance to reforming the obvious and preventable issues with it. The main players still see defense of vested interests in health care as an ideological defense of capitalism. Holding to that position increases public spending however and is increasing the federal deficit each year. Dismantling the drivers of those costs, in private hands, would lead to real economic losses with implications for the world market. Some authors have noted that pharmaceuticals were the stars of the market for decades, and have been in a decline that has not been recovered.⁠14 Further cutting into those losses may have more disruptive effects in an economy that already has challenges ahead represented by geopolitical conflicts in Asia and Europe, and an anemic recovery to the global economic crisis of 2008. With the failure of Colorado is to forge ahead (and other states before it) and the victory of the Republicans across the board in this year’s election, meaningful reform seems quite unlikely in absence of a movement that can force their hands. Some other states may try the route of the ballot initiatives that failed in Colorado, Oregon, or Vermont’s legislature’s push. The disparity of forces between vested capitalist interests and their lobbying power and the electoral process itself makes it a near certainty of failure without a widespread popular change in attitude and action. Can single-payer save us? These problems will not go away for the rulers simply by ignoring them. With a single-payer program there would be substantial savings for the country as a whole and indeed millions of people will have their lives changed for the better. Any reduction in the vast waste that we’re chained to and an expansion in access to quality care is something we should cheer and fight for. Single payer would reduce some of these costs, in part through eliminating unnecessary layers of bureaucracy and negotiating lower prices through economies of scale. This has been the traditional progressive answer for these reasons to all things health related. Despite whatever positives however the fundamentals would remain, with much of the control in the hands of the same drug companies, equipment and product manufacturers, and broken institutionalized practices of American medical professionals (such as reliance on specialists, the persistence of fee for service payment, and over use of capital intensive health techniques). Cutting the costs of the insurance industry would be a positive step, but it’s not a panacea, and it’s not clear whether it could prevent a crisis that is already happening. Universal Medicare would certainly be more expensive than the system of the Veterans’ Administration (VA). One Congressional Budget Office study showed the VA to be twenty one percent cheaper than care under Medicare.⁠15 The VA which shares some similarities to the National Health Service of the UK wherein the system owns the entirety of health services from hospitals, pharmacies, equipment, and hires the staff. By eliminating paying outside private entities, the VA and NHS thereby reduces the profit otherwise paid to private companies at each stage. While Medicare-for-all would eliminate insurers as secondary payers, such companies are deeply entangled in Medicare itself. Private companies provide supplemental plans for necessary services not covered by Medicare and as well as processing claims for Medicare itself.⁠16 Without an elimination of private billing for services those additional administrative costs would remain. Medicare-for-all would not mean an end to Blue Cross, Aetna, or United Health necessarily. Nor should health advocates glamorize European style public health. Across the world public health is under attack. Right and left governments have target slashing spending and limiting access. Ideology certainly is a component of this, but objective budget pressures are driving these forces. Universal public health care is worthy, but it is not a panacea. Americans would likely face the same attacks even were there such a victory as institutional pressure to put the burden of care onto the working class will remain. If legislation granting universal Medicare is unlikely, VA-for-all is a lone voice in the wilderness. One could imagine the resistance likely to nationalizing private hospitals, clinics, and pharmacies. And yet if there is no substantial reform, what is the real cost paid to all of those services with a shrinking working population, jobs being lost to automation, and a growing base of those who will need care for decades? Should conflicts heat up, what would be the effect on the market if health advocates won such a struggle and take health institutions outside of the world of profit so to speak? Health care is at the center of stressing both market and state forces and this presents an opportunity for movements that challenge capitalism. This crisis in health is not just about the policies of different players (liberal and conservative, socialist and reactionary), but about more fundamentally capitalism’s capacity to provide for health needs. Market allocation and private industry are central to the failures of the American system, things not easily hidden when confronted head on. Globally speaking the industries that profit off health, both public and private systems, have been some of the leaders for investors generally. Losses within health care could spell deep trouble for the economy across the board and perhaps tip us back into recession or depression in the context of a world that has not fully recovered from the shocks of 2008. Even in countries with overtly state-provided healthcare similar elements of crisis have been building in the past decades around run away costs, shortages, and declining quality of care. Health care is a key sector for radicals to make our case and put the ruling class on the defensive. Health is bigger than our health care Demanding universal health care has been a broad call amongst US progressives for the past 50 years or so. Is that really the main issue though? At its heart single-payer is about how we allocate existing health resources. Yet we do not only want to more equitably and economically distribute health, but also improve it. If you think about it, universal health is a fairly open demand. It could be redirected to any number of outcomes including universally terrible health. There is an insidious medical apartheid that punishes various sectors (workers, women, blacks, latinos, and indigenous, etc.) while granting luxury health services to a tiny elite. There is a clear move towards diminishing care for the public in general with overall declining standards of living. This year life expectancy declined for the first time in decades without much protest or reaction from the political establishment.⁠17 Instead we are utilizing our collective resources towards the high-tech capital intensive care that benefits a tiny section of the population. Merely asserting universal care without contesting the monopoly on wealth and power that the entrenched capitalist class wields would not fundamentally change the exclusion of the working and under classes from quality health care.