The single payer negotiating strategy delusion

Revised on September 9, 2009

Even as Obama was hitting a home run tonight, I saw posts on Twitter and Facebook by usually savvy people who repeated what has become the latest delusion on the single payer left: that if Obama had started with single payer as his negotiating point, we would have no trouble winning a public option now.

That this is an error is easy to see if you recognize that Congressional negotiations are not at all like contract negotiations. It’s not a matter of each side making and offer and then moving slowly to something in the middle. There are two keys to success when Presidents try to build support in Congress.

The first is to create as big a block of supporters as you can to start with. Without a lot of supporters at the beginning of the effort, other members of Congress won’t think there is a real chance of enacting legislation. And if they see no chance of enacting the legislation, members of Congress who are not leading advocates for the legislation (1) won’t come out in support of it because they are  generally not willing to run risks if they don’t have to and (2) won’t start thinking  about whether the time is right to make a deal with Congressional leaders or the President to get something—either a shift in the legislation in their ideological direction or something for their district in return—for their support. (Remember, members of Congress generally don’t want to be the first or last member to make a deal because then you don’t get very much in return for your vote.)

The second is to have the public behind you so that you can convince members of Congress that they can gain political support, or at least avoid political damage, by supporting your policy proposal.

So the first task in negotiations for a President is not to take an extreme position that he can use as a bargaining chip. That does you no good because the other side—the side that doesn’t want the President’s legislation to pass—has no reason to bargain unless they think the President actually has a chance to pass legislation. And taking extreme position with little Congressional or public support doesn’t put you in that position.

Suppose Obama came out in his Inaugural Address for single payer. For the last few years, there have been 90 members of the House and 3 Senators in support of single payer. In Pennsylvania, single payer supporters worked for five years and got three Democrats to support them. Suppose a strong speech by Obama raised that number to 150 and 15. That would have been an incredible shift. And yet it would have left Obama far short of the number he needed to pass legislation. Why would Congressional Republicans, let alone moderate Democrats, have negotiated with Obama?

In contrast, in the first six months of HCAN’s work, we signed up all of the Democratic members of the Pennsylvania delegation and close to a majority in the House as a whole. And the first question every Pennsylvania member of Congress but three asked before they signed our statement of principles was, “this is not single payer, is it?”

The situation with the public would have been even worse. The Clinton reform plan died in part because of a series of commercials featuring Harry and Louise that scared people about having to give up their insurance and take a government insurance plan.

Why did this scare people? For two reasons. First, because ninety percent of voters have health insurance. Eighty percent of them like what they have, although they probably wouldn’t if they knew how bad it is. Of course, everyone knows that private insurance has problems. But they don’t think that their insurance has problems. That’s true both because most of us never really know how bad our insurance is until we need it and because most of us would prefer not to believe that they are at serious risk of, say, going bankrupt if we become ill.

It is very difficult to convince people who have insurance they know and like to give it up for an government plan. Yes, you can point to rising costs and slowly declining rates of employer coverage. But striking fear in people is generally not a useful way to get them to adopt radically new ideas. People who are afraid don’t reach out for something new but fall back into themselves and try to keep what they have.

And what’s worse is that there never has been all that much support for single payer in the public. Supporters of the idea say that nothing but single payer could win public support because of its “simplicity.” But this turns out not to be true.

Of the twenty five or so polls I’ve seen in the last five years, only one, by the New York Times, ever showed a majority of the country saying yes in response to a question that clearly laid out a single payer policy. Most of the polls that purport to show support for single payer actually ask whether something like, “should the federal government guarantee everyone health care” which does not actually say should the federal government pay for health care out of your tax dollars. And even the poll that shows support for single payer in the low sixties, was never stress tested. That is, no one asked different versions of the question to find out whether some peculiarity of the wording accounted for the result. Nor were follow up questions asked that raised potential questions citizens might have about a single payer program, such as whether it might be too bureaucratic or costly or inefficient. No one ever did polling that showed that single payer could survive these kinds of attacks.

These poll results are understandable in light of the satisfaction people have with their own private health insurance and with our political traditions. For we live in a political community with a long history of anti-statism, going back to the revolutionary war. We often like government in practice, because it does work for us. But we don’t like expanding government in theory and that is why, except for a brief time in the late sixties and early seventies when the great liberal Richard Nixon was President and Democrats held strong majorities in both houses of Congress, it has always been difficult to expand our government. It became harder again when distrust in government rose rapidly during the Johnson and Nixon presidencies due to the Vietnam war and the economic crises of the early seventies and became harder still with the rise of Reaganism in the aftermath of the failed Carter presidency. And to make matters worse, the Reagan-Bush-Bush disdain for government lead to them underfund and under manage it, making government far less competent than it had once been. So the great fear of health care reformers when they considered the consequences of supporting single payer is that the opponents of the plan would say, “government managed health care, by the people who brought you Katrina relief.”

So, again, imagine Obama putting forward a single payer program that initially had the support of sixty five to seventy percent of Americans. It would immediately have come under the attacks we have recently seen—for being bureaucratic and socialist. And those attacks would have done far more damage to a single payer proposals than they have to Obama’s plan.

The hybrid public-private model has always received a great deal of support. A comprehensive poll done by Celinda Lake for HCAN showed that over 77% of people liked the hybrid idea compared to about 15% who liked a purely private system and 9% who liked a purely public system. And that poll was stress tested in both respects and support for the hybrid system survived multiple ways of describing it and multiple attacks on the public component. Subsequent polls, including those done only a week or so ago show consistent support for public option.

The reason the public option does so well is not hard to understand. It can be defended, as Obama and HCAN have defended it, in terms of two ideals Americans cherish: competition and choice.

You can’t defend single payer that way.

So had Obama done what single payer supporters say he should have done, and started with their model, health care reform would today be dead. It would have at most 150 supporters in the House, while right now we have a majority for a good hybrid plan with a strong public option. (Note that there are less than 90 Representatives who have said they would vote against health care reform if it does not have a public option.) It would have 20 supporters in the Senate whereas right now we are very close to a majority in support of the public option. And while 70% of the public still supports the public option, by this point support for single payer would have dropped below 50%.

Starting with single payer was never a good idea as a negotiating tool. And while this is a topic for another time, there was no reason from a policy point of view to adopt single payer either. Single payer supporters often say, disingenuously, that we are the only country that does not have universal health care as if this means single payer. But the truth is that only two countries with something approaching universal health care have single payer—Canada and Taiwan. Every other liberal democracy has some hybrid public-private system. One, the Netherlands, actually insures everyone and controls health care costs with just private insurance companies competing in something like an exchange.

Now that Obama’s speech has shifted momentum back to our side, can we please stop recriminating about Obama’s strategic choices? He has been utterly consistent since he started running for president in adopting the same strategy that HCAN adopted. And he did it because it was the only way to build the strong majority in the public and the Congress we needed to roll the insurance companies, the ideological right, and Republicans.

And make no mistake about it that always was the strategy. Unlike those who think that winning majorities in Congress is similar to negotiating a contract, we always knew that the task before us was to build a strong enough majority to overcome intense interest group opposition on the part of insurance companies and ideological opposition on the part of conservatives. We’ve known for a very long time that there was no possibility of negotiating with them. The insurance companies and the right like the public option no more than they like single payer. And no one ever expected more than a handful of Republicans, at best, to support any health care reform. And if they do so, it will only be because of popular pressure in favor of reform. Without the popular pressure in their districts—which single payer actually would undermine—what possible reason is there for a Republican to want any kind of health care reform?

Insurance companies, conservatives and most Republicans will never support health care reform. So we have to beat them. And the only way to do that was to build a big movement outside Congress to help us build a large contingent of supporters inside it. Supporting single payer initially would have would have hurt that effort not helped it.

The only constructive role support for single payer has played is to allow President Obama and Congressional Democrats to portray themselves as more centrist than the supporters of single payer. That’s not a negligible role, and has done some good. Whether it makes up for all the, highly misleading, doubts that single payers supporter have created about the legislation before Congress in the progressive community is not yet clear.