There is no doubt that healthcare will be a big part of the midterm election debate both at the federal and state level. Government efforts to undermine enrollment gains spawned by the Affordable Care Act (ACA) are working. A Kaiser Family Foundation study reports that individual enrollment fell by 12% in the first quarter of 2018 following a 12% decline last year. Pressure on the system continues to heat up – zeroing out the individual coverage mandate penalty and liberalizing short-term insurance coverage and association plan rules will provide further anti-selection and cost increases to the individual risk pools. Prices will once again soar. Notably, the coverage declines have been traced to individuals not receiving federal premium subsidies since costs have become unaffordable. No doubt that some of those opting out will experience the type of catastrophic uninsured costs of care which were highlighted in the buildup to ACA.
So it’s no surprise that this week, Forbes Magazine reported that a recent poll of likely voters showed that 57% of Americans want direct government involvement in providing healthcare. Single-payer will not be cheap, and the contradicting expert studies are being rolled out by both sides. One such study, funded by the ultra-right-leaning Koch Brothers, calculates the increase to government spending at $32.6 trillion dollars over 10 years, should a government-provided single-payer system be adopted (to put this in perspective the budget for all U.S. spending in 2017 was $4.1 trillion). On the other side, New York single-payer advocate Assemblyman Richard Gottfried has rolled out a RAND Corp. study which says single-payer would save New York State $15 billion or 3.1% by 2031. Adding to the pressure in New York, gubernatorial challenger and Sex and the City star, Cynthia Nixon, has made single-payer one of her platform positions.
Single-payer would be a very long, uphill climb. In order for a state to make a change, federal waivers would need to be granted for Medicaid and Medicare as well as the ACA subsidy program. With Republican control in Washington, this is unthinkable; with a shift in the political tide, it would still be near impossible. And, before the federal obstacles are cleared, the state hurdles are equally implausible. For the Federal Government to adopt single-payer the rules would have to be rewritten, an infrastructure created, and every participant in the healthcare ecosphere would be turned inside out. In the past, I have dismissed single-payer as impossible – and not just improbable. But, there is a ripple in the tea leaves. If the establishment doesn’t come up with some lasting wins – who knows?