The paradigm shift we need for single-payer

In 1962, Thomas Kuhn published The Structure of Scientific Revolution a book that changed the way we think about scientific progress. Kuhn posits that scientific progress is punctuated progress where major advances are made by what he called “paradigm shifts”. These paradigm shifts open unexpected areas of enquiry, and allow scientists to accumulate knowledge in more gradual steps. These revolutions were often initiated by unknown scientists presenting radical ideas outside the mainstream. This powerful idea of “paradigm shifts” has since entered the general lexicon, but its implications are not always fully appreciated.

Though Kuhn applied his conception of revolutionary change to the project of science, it has a broader application and a longer history. In Capitalism, Socialism and Democracy, the economist Joseph Schumpeter outlined his theory of “creative destruction”. Schumpeter identified the periodic destruction of certain commercial ventures, so new ones could take their place.  In his analysis, a “gale of creative destruction” drives “industrial mutation that incessantly revolutionizes the economic structure from within, incessantly destroying the old one, incessantly creating a new one”.

Schumpeter owed at least part of his inspiration to Marx’s analysis of accumulation and destruction of capital. And we can go on, in the study of both human and natural societies, scientists and philosophers have remarked on concentrated periods of change. All observers of humanity understand that there are moments of profound regeneration when we see with new, clear eyes and the world is remade. The rest of the time, we plod along, one step at a time.

Sorting out bureaucratic details is not the biggest hurdle when implementing systematic changes. The challenge is to demolish unexamined assumptions that unduly constrain the range of possibilities. In the context of the US health-care system, the unexamined assumption is that health-care must be earned. That only those who are deserving should be able to visit a doctor and receive care for their bodies. This underlying, unsaid assumption has hampered universal health care proposals for decades. The same assumption also impacts proposals for public education and all other social programs. This concept of “merit” as applied to healthcare is the paradigm we must shift before we can have universal health-care.

The “merit/deserving” mindset rests on shaky ground, because for decades now we have demanded that all Emergency Rooms treat anyone who walks in. Clearly, in some remote corner of our brains, we do recognize the social and moral value of providing health care to all. But around this kernel of truth has been erected an edifice of artificial constraints placed by a health insurance industry that seeks the privilege of exploiting the sick and infirm.

The ACA delivered several much-needed improvements to health-insurance. From minimum coverage requirements, to abolishing the idea of pre-existing conditions, to expanding coverage. But it cannot serve as the path to universal healthcare because it never directly attacked this assumption of “worthy” and “unworthy” human beings head on. This is what made it, and still makes it, vulnerable. The ACA exists within the language of the “deserving”, as in we deserve access to health-care at a reasonable price. This weighing of human beings also finds expression in the individual mandate which posits a responsibility to purchase health-care (so as to not become a public charge by entering the emergency room). This is no accident, the ACA’s conceptual structure was taken directly from a Mitt Romney, Heritage Foundation plan. And yet, it has been relentlessly attacked by the right. The lesson we’ve learned is that if we give them an inch they will demand a mile.

If we are to have universal health-care, these modes of thinking need to be well and thoroughly smashed. As does the idea of “market solutions” to health-care and health-insurance.

Any health-care “market” is destined to be dysfunctional or imperfect. Neo-classical economic models assume buyers and sellers have complete information alongside the freedom to choose what they buy and when. There are further assumptions about the ability to defer purchase and the rationality of all actors. Health-care “markets” meet none of these criteria. Enormous information disparities exist between patients and providers. In many cases, health-care decisions are literally a life and death choice that cannot be deferred. Very few among us remain “rational” about cost/benefit when our loved ones are sick. Marginal analysis simply breaks down at these extremes. What is the marginal benefit of your life or your child’s? Everything you own, everything you can borrow? That is the choice many Americans find themselves making, with health-care costs leading to millions of bankruptcies a year.

With most goods or services, consumers can defer gratification to work towards a purchase. Perversely, when patients do defer care, the cost of neglect to their bodies and society overall, is enormous. Sick, fearful human beings cannot be the rational bean-counters neo-classical economics assumes we are. We are rarely in a position to question doctors and hospitals when they recommend a procedure or drug. Recognizing all this, and the fact that drug-makers and doctors have a unique ability to exploit the precarious position of desperate patients, most societies have regulated prices for health-care services. The US does the same, with Medicare setting prices for procedures that become the basis for most health-care pricing.

Health insurance “markets” inherit all this dysfunction and amplify it with other real world wrinkles like moral hazard, biased risk perception and information asymmetry. Limiting the terms of our debate to Republican “market-based” approaches perpetuates dysfunction.

So how do we get out of the trap created by these right-wing frames?

First, healthcare must be acknowledged as a right, and we have to talk about it in those terms. “Access” and “insurance” are not rights. Health care is. We need to keep reminding people that Republicans will take every opportunity to take away their health-care. We need to demonstrate that this right-wing plutocratic agenda is why we want a simple, universal program. Medicare for All, which would be untouchable (and cheaper to boot).

The question we need to answer now is not how we pay for universal health-care, but why we should pay for it. We have to sell the benefits of universal, single-payer healthcare first.

Here’s a story an acquaintance shared with me:

I was on the ACA for several years, and each year my policy was cancelled, but I was eligible for a new one from another company. The trouble was that each new policy had different coverage, doctors, formulary, etc. While they were more or less equivalent, the change in coverage was distressing and uneven, especially when my wife got breast cancer. To avoid disruptive changes in crucial coverage, I came out of retirement and got a job with bullet-proof, stable insurance, which I maintain to this day.

We need to show people a better future. A world where they can continue to go to their doctors and get high quality of care, even if they lose their job and can’t find another one before money runs out. A world where their employer can’t switch to a plan with weaker coverage at the end of the year. A future where an insurance company cannot be deny covering treatment because of fine print, where they don’t have to fear bankruptcy if their child get seriously ill. A world where they can focus on their health rather than worrying about bills. A future where doctors are helping patients get better rather than fighting with insurers to get paid.

Once people see these possibilities, together we will find a way to pay for it. We’ve sent people to the moon, we built the Internet, we can definitely do what every other major developed country does and provide universal healthcare. The good thing is that they are beginning to demand it. Medicare has always been popular. Medicare For All is becoming popular as well.

If we are to succeed, we cannot cede the debate to those who traffic in fear about the future of health insurance companies, or sow panic and fear about Medicare For All. Whether they know it or not, they are undermining the cause of universal health care and parroting right-wing talking points. Democrats who do this should be reminded that this job is best left to the Republican party.

The cruel reality is that tens of millions of Americans already live in a state of fear, about their health and paying for care. Those who have insurance worry about losing it, those who don’t worry about their health. These are the worries we need to concern ourselves with.

We do not have to worry about health insurance companies. If they disappear, they will join a long list of obsolete industries our society no longer relies upon. Buggy whip manufacturers did it, health insurance executives will find a way too. Workers will either find work in M4A, or new jobs they’ll receive transition assistance for.

We can safely ignore self-appointed “experts” who exclaim “How will you pay for it?” about every social program, but scatter like the wind when we spend trillions on wars of destruction. It is perverse that they never worry about cost when blowing up bodies, only when it is time to mend broken ones. It is illogical that they never ask this question when proposing massive tax breaks for the super wealthy. Their behavior reveals their values.

In any case, their question is a ridiculous one. We already know how universal care will be funded, via taxes. That is how we fund social security and how we fund Medicare, that is how we will fund Medicare For All. Taxes should be the one word answer to anyone who asks “how will you pay for it”?

The foundational enterprise of this country presents a conundrum. We declared it self-evident that all men are created equal and endowed with inalienable rights. But, for decades we recognized these rights only for some, the “deserving”, the “civilized”. If we are to build a better society, a society focused on allowing people to achieve their full potential, we need to break away from these caveats to our founding creed.

We made a more perfect union when we legislated free public education for all. Let’s do it again by caring for all bodies. Let’s make Medicare For All a reality.

— @subirgrewal