Within a few days of its announcement, Bernie Sanders’ new Medicare-for-All bill, endorsed by a dozen other Democratic senators, has come under fire in the pages of newspapers across the country, from Philadelphia to Chicago to D.C. and elsewhere. The jury is in: it sounds nice, but it is a pie-in-the-sky delusion that is just technically not possible. There are a few things that are odd about this consensus.
The first thing, of course, is the peculiarity of declaring something impossible that in fact exists in reality, throughout the Global North, in countries that are less wealthy than the United States. And, of course, not only does it exist, but countries with single payer or at least a public option outperform the US healthcare system on practically every metric imaginable.
The fact that a multiplicity of other governments currently shoulder the vast majority of citizens’ health care costs while actually spending less on health care than the United States and saving more lives to boot is perhaps why, as Matt Bruenig observes, these op-eds have tended to actually be political arguments in technical clothes. Take off the mask of expertise and you find unsubstantiated assertions about what voters will or won’t stomach.
As Bruenig also notes, the current existence of Medicare-for-some is also troubling for declarations of prima facie impossibility. Clearly the United States government is capable of running a health insurance system; clearly people are capable of giving up their private insurance for government-provided health care; we know that this is true because it’s literally already happening. And the inconvenient truth for the anti-single payer pundits is that it’s incredibly popular, which of course is why Sanders is calling his plan Medicare for All in the first place. (One also thinks of the Affordable Care Act, which many pundits also declared that people would hate but has instead proved remarkably difficult for even a unified GOP government to pry from the hands of its recipients.)
Ah, but taxes will go up and Americans hate taxes. On the one hand, only the wealthy are likely to see their tax increase exceed what they’re currently spending on health care, which means this argument really relies on the conviction that most Americans would rather have less money in the bank than shift over any of their spending from corporations to the government. Even if one accepts that assertion, perhaps ponder why Americans are unenthusiastic about federal income tax:
So the typical working American only sees the benefits of a tiny fraction of their annual federal tax payment in the short-term. Of course, they’ll reap the benefits of Social Security and Medicare eventually; they already benefited from education spending; they do continue to benefit from spending on transportation, housing, and environmental protection; but in general, when most people send off their taxes every year they won’t see a direct, personal return from the majority of that payment for another several decades. Now imagine what Americans’ attitudes towards taxation might look like if instead they reaped an obvious, undeniable benefit only months later, during a life-threatening illness for themselves or a family member.
The other cost argument notes that potential savings from single payer will be offset from people going to the doctor more. This argument is interesting because it implicitly concedes that there are many millions of Americans who currently put off necessary doctors’ visits because they cannot afford to go. It is designed to conjure up racist images of mooching welfare queens, but instead just drives home the point that the ACA is still a tremendous moral failure that continues to condemn millions of people to die unnecessary deaths because of their socioeconomic status. A compassionate society should not wring its hands about too many people going to the doctor.
Furthermore, although I am straying out of my expertise here a bit, it seems to me like this argument massively overestimates the elasticity of demand for health care. I am a bit of a hypochondriac with access to a free university health center and I still rarely go to the doctor more than once a year. I would hazard that if there’s anyone who’d go to the doctor more often than they “need to,” it would probably be the wealthy — that is, precisely the people who would shoulder the heaviest (i.e. any) extra financial burden.
Speaking of expertise, this is what I find most fascinating about this whole dispute. It illustrates a remarkable and under-appreciated shift in the politics of expertise and “technocracy” over the last several decades.
This is obviously oversimplifying
a bit a lot, but I see a periodization of the politics of expertise (especially in American social science, which is what I study) that goes something like this.
- In the early twentieth century, scientific experts were generally also practically engaged activists, advocates, community organizers, and so on. The distinction between social work and social science was far less rigid. The idea was to document problems that could be addressed, and help to formulate solutions to those problems that movements could fight for. These early experts of course occasionally held wrong or even repugnant views, but when they did those views were typically widely shared by the social movements with which they were working.
- Beginning in the late 20s and early 30s, and accelerating with the start of the Cold War, many experts moved first into large foundations and then into the government and military. This kind of expertise was still about extremely ambitious social problem solving, but it tended to be newly unaccountable and even secret. The severing of the relationship with people “on the ground” led to a kind of overambition that was often disastrous: technocrats pursued agendas that people didn’t want and sometimes didn’t even know about. But this shift wasn’t totalizing: many scientists were at the forefront of new movements around disarmament and environmental protection, and new social movements from the New Left to ACT UP developed their own kind of “counter-expertise” to aid their causes, in a way that occasionally reverberated into academic disciplines like sociology that subsequently took on a more critical bent.
- Since the end of the Cold War, the politics of expertise has regrouped around shoring up the putative End of History. The unaccountable people who will address social problems out of the public eye are no longer the experts themselves but entrepreneurs and capitalists who can harness the power of the market to make incremental change. The role of experts now is to insulate market forces from democratic efforts at reform by explaining the limits to the agendas of social movements: for the first time expertise is primarily about what is not possible. The rise of poststructuralism among the academic left, dismissing notions of expertise, progress, and even change tout court has unwittingly collaborated with this shift, and its ideology that a better world isn’t possible.
To me, the rash of anti-single payer op-eds illustrates the extent to which this last mode of expertise has become taken for granted. Being in touch with “reality” means throwing a pail of cold water on any attempt to guarantee everyone health care, even when that means handwaving, mystical assertions about whatever it may be about America that explains why it cannot do what its peer nations have already done. “Seriousness” has become synonymous with slavish devotion to the status quo — which helps to explain why America’s op-ed pages have been so strangely devoid of columns in support of a policy that the majority of one of our two major parties supports.
Of course a transition to single-payer will have difficulties. The role of experts should be to figure out how to solve those difficulties, not to throw their hands up and insist that they are insurmountable.