Perm do both – disability is a starting point for anti-capitalist solidarity.

Mitchell and Snyder 10. David Mitchell is a Professor of English at Columbian College of
Arts and Sciences. Sharon L. Snyder is Assistant Professor of Disability and Human
Development at the University of Illinois-Chicago. “Disability as Multitude: Re-working Non-
Productive Labor Power” in the Journal of Literary and Cultural Disability Studies, Volume
4(2), p. 179-193 https://muse.jhu.edu/article/390400/pdf “///” indicates paragraphs NT
17

Following out the logic of non-productive bodies allows us ways of conceiving of disability
as a potentially effective political foundation for new forms of resistance, particularly in
that disability (as those who refer to “TABS” [the temporarily able-bodied] remind us)
potentially cuts across all marginalities. Yet, its founding recognition of unity based in
difference (i.e. what we have called in another context, the politics of atypicality or
intensive individual singularities that cannot be neatly collapsed in a coherent
identity) could prove more effective than those diagnosed by Laclau and Mouffe and Ž ižek
as balkanizing identity-based approaches to difference that undermine more spontaneous
forms of collective action. /// Of course we do not mean to overlook the fact that disability
collectivities have discovered creative ways of fracturing their own collectivities,
particularly on the basis of unproductive debates over who is “disabled” and who is
“notdisabled,” disability hierarchies, tokenism, marginalization of expressive modes (i.e.
putting the pragmatics of policy over arts), the neglect of disabled people of color, old boys
and old girls networks of power brokering, and so on. But there is also a series of
productive ways to organize political constituencies that we owe to the creativity of
disability movements around the world—namely, since disability movements continue to
operate at the meta-national level, disabled people without borders. /// To return to Hardt
and Negri’s thesis explicitly, we stress that disabled bodies prove so integral to late
capitalism because the model upon which capitalist exchange rests has shifted so
dramatically. Disability may present the best intervention object of all in that it provides
an opportunity to renew capital in new geographies of the body. Because disabled bodies
persist throughout history, and in militarized economies we produce them in great numbers
at “home” and “abroad,” market economies increasingly reference them among their target
audiences. /// Marketing Imperfect Identities /// Nearly all of capitalism now finds itself
pitched toward imperfection as the standard with product supplementation as the
solution—diuretics, impotency, indigestion, mobility aids, depression, manias, hearing loss,
vision correction, chronic fatigue, etc. The body has become a multi-sectional market;
whereas Fordist capitalism cultivated divided worker populations by hierarchicalizing
the assembly line; postmodern capital divides us within our own bodies. We are now
perpetual members of an audience encouraged to experience our bodies in pieces—as
fractured terrains where the “bad” parts of ourselves are multiple. Whereas disabled people
were trained to recognize their disabled parts as definitely inferior, late capitalism trains
everyone to separate their good from bad—a form of alienation that feeds the market’s
penchant for “treating” our parts separately. The body becomes a terrain of definable
localities, each colonized by its particular pathologies dictated by the medicalized
marketplace. This late capitalist litany of bodily frailties, imperfections, and
incapacities gluts advertising networks as the hegemonic product pitch strategy of today.
Within this environment disability rapidly becomes synonymous with a humanity that we
are all seeking to overcome. The imperfect is our standard. /// The rise to legitimacy of
“comfort industries” results as the twentieth century closes. We are all subject to
disciplinary regimens of the therapies that have now transcended their subordinate
position within health science and medicine to become our cultural training gurus. Even
more than Medicine, the Therapies have now gone “cultural” and encourage our mass
dedication not to perfection but to the infinite pursuit of “improvement.” Once relatively
isolated disability rehabilitation regimens are now applicable to all citizens, just as all
citizens grow increasingly responsible for policing their own well being. Therapy is the
market, and the degree to which one resists therapy is the degree to which one
resists greasing the market. Refusal of our bodies as perpetual objects of professional
labors provides a model of resistance wherein the ways our bodies function does not
lead us to fall prey to regimes of standardization. We now find ourselves encouraged not to
conform to a general norm but rather conditionbased norms that others who presumably
share our disability group establish. This is really nothing but a move from a medical model
based on an elusive average body to a therapy-based norm of an elusive average disabled
body. /// Today late capitalism thrives on the production of “new spaces” for
exploitation—the promotion of the exotic as a strategy of consumption rather than the
promise of the homogeneous amid locales of difference. The body itself has become an
outpost for this strategy. An “intensive interior” is now cannibalized as new “erogenous
zones” of intervention. To combat this tendency, disability culture rises as a counter-
valuing mechanism; one that cannot afford to mistake its own artificial productions as
more “natural,” but rather, following Hardt and Negri, as a self-acknowledged product that
seizes the biopolitical terrain as revisable. “Non-productive bodies” work a revolution
within the conception of worker subjectivity. The non-productive body is not simply a
body incapable of working within the narrow standardization efforts of capitalism, but
rather, as Hardt and Negri explain, it represents “the way some deviants perform
differently and break the norms” in doing so (Multitude, 200). These differences may
result in a rigid exclusion from dominant economic networks but they continue to produce
and, in turn, be produced: thus, postmodernism may be generally described as a culture of
manufactured sentience: one that wires the life of feeling and flesh directly into the circuitry
of prosthetic supplementation (i.e. prosthetics from sip ’n puff systems to Xbox cyber
realities). /// Democracy and Disability /// A true democracy based on variation cannot be
collapsed into a totalizing essence/identity/unity. Based on their multiple formulas of
difference, disability organizations help to expose transcendence as a false dream of
market compensation. If we conceive of disability as a material expression of variation,
then embodied difference may be recognized as a paradigm for true democracy. Specifically,
those made expendable by late capitalism on the basis of a congenital or acquired incapacity
serve as an active recognition that normalization functions as little more than a façade
that disguises humanity’s defining heterogeneity. A “truer” disability-based model of
social production is better understood as the interdependency of intense singularities
working for common goals — rather than the obverse which is the functioning logic of
capitalism: intense singularities suppressed by common goals and imposed by
corporations upon those who produce products and profits from which they do not
adequately benefit. /// Politicized alternative disability-based social organizations have
tended to situate their counter-discursive productions at both the macro and micro levels of
experience. At the micro-level differences proliferate and disability dedicates itself to
unearthing the lack of duplication from one body to another; at the macro level disability
draws together socially debilitating experiences (i.e. lack of employment, ouster from
sexual circuits of interaction, exclusionary architectural standards, etc.) and identifies the
degree to which global oppression operates on disabled people across cultural contexts. As
a result, bands of disabled people have produced viable alternatives to the consumptive
models of capital and the expulsion of bodily imperfection in order to envision a
meaningful contrast of lifestyles, values, and investments adapted to life as discontinuity
and contingency. This is a material, albeit thoroughly subjective, realization of the World
Social Forums rallying slogan A Different World is Possible. ///

[Cai] Doctor Dropout: Doctors support single payer, and for good reason. It helps physicians
and doctors greatly. The Aff keeps healthcare running in the firstplace.
Cai: Cai, Christopher. M.D [Department of Medicine, Internal Medicine Residency Program
at Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA] “How Would
Medicare for All Affect Physician Revenue?” Journal Of General Internal Medicine July 2021.
https://link.springer.com/article/10.1007/s11606-021-06979-z JG

Organized medicine in the USA is shifting its position toward single-payer reform, one
version of which, “Medicare for All,” has gained substantial support in Congress. The
American Medical Association recently left the Partnership for America’s Healthcare Future,
a lobbying group that spent more than one hundred million dollars annually opposing both
a public option and Medicare for All in federal election campaigns. In 2020, the American
College of Physicians and the Society of General Internal Medicine went a step further,
endorsing both public option and single-payer reforms. Yet, physician opinion on
Medicare for All remains split, with most doctors concerned that such reform might
decrease their income. While physicians are highly paid, these concerns are understandable
given the burden of student debt, the length of medical training, and Medicare’s lower fees
relative to private insurers’. Are such concerns supported by evidence? The nonpartisan
Congressional Budget Office (CBO) recently estimated payments to physicians in 2030
under current policies and five options for Medicare for All. It projects that without reform
the weighted average of public and private payments to physicians will increase to 116% of
the 2019 weighted average, versus between 108% and 117% under the various Medicare
for All options analyzed.1 But because the CBO expects Medicare for All to increase
society-wide utilization of care, it also predicts that providers’ total revenues would
increase, even if fee levels were to decline. More specifically, the CBO projects that in
2030 providers’ total outpatient revenues would be between 5 and 9% higher under
Medicare for All than without reform; physician services currently account for 78% of
such revenue.1,2 These estimates assume that Medicare for All would not significantly alter
the supply of physicians, which is currently limited by the supply of residency and medical
school spots.1 Some scholars project even larger boosts to physicians’ take-home pay
because the CBO estimates may understate practices’ savings from streamlined billing. If, as
studies suggest, Medicare for All would free up roughly 5% of doctors’ work hours
currently spent on billing, allowing them to increase patient care, per-physician
revenue could rise by between $39,816 and $157,412 annually.2 While those figures may
be an overestimate, since some providers might choose to spend the freed-up time on
leisure activities rather than increased patient care, they may underestimate revenue
changes, as fee-for-service providers have, in the past, responded to decreased Medicare
reimbursement rates by increasing volume of services.1 The latter won’t apply to salaried
providers, such as those working in capitated healthcare systems, but these providers are
still likely to feel the benefits of administrative streamlining. Other prominent economic
analyses of Medicare for All have also projected net increases in physicians’ revenue, even if
current Medicare payment rates do not increase.3 Yet despite projecting increases in
physicians’ revenues, almost all estimates of the overall costs of single-payer reform project
savings, due to savings from administrative simplification.3 Hence, it appears possible to
design a single-payer reform that would offer universal coverage without cost sharing,
while increasing net revenue to providers and decreasing national health expenditures. 3
History offers hopeful messages about the likely effect of single-payer reform on doctors’
incomes. When Canada transitioned to single-payer in the mid-20th century, physician
income increased, and physicians remained the highest paid professionals in the nation.4
Since then, physician income in Canada has grown faster than the incomes of other workers.
Yet, caution is warranted in interpreting these trends, which may not be duplicated in a
reform initiated five decades or more after Canada’s system was fully implemented in 1971.
Medicare’s history offers mixed lessons. Limitation on increases in Medicare’s payments to
physicians (known as the sustainable growth rate or SGR) included in the 1997 Balanced
Budget Act threatened sharp cuts in Medicare’s fee schedule. Yet Congress annually
overrode the threatened cuts, and eventually repealed the SGR formula. How would
increases in revenue projected by the CBO be distributed among various physician
specialties? Since both Congressional Medicare for All bills provide comprehensive
benefits with little or no cost sharing (copayments or deductibles), individuals who
currently cannot get medical care because of cost would increase their utilization of
care. As a result, doctors who serve patients who are undertreated at present may
experience the greatest increases in demand for their services, and in their revenues.
Primary care providers are likely to fall into this category, given the degree to which
hypertension, diabetes, hyperlipidemia, and other chronic conditions are currently
undertreated. Anticipating this, the Congressional legislation would set aside funding to
establish an Office of Primary Care, charged with developing policies to increase the
number of primary care practitioners. Although primary care doctors might get the biggest
income boosts under single payer, specialists would continue to be high earners. The 1966
implementation of Medicaid/Medicare resulted in an increase in per-capita surgical
procedures among the elderly. 5 In Canada, the specialist:primary care income ratio has
remained quite high; in 2019, gross clinical payments to thoracic surgeons averaged
$588,000 (Canadian dollars) compared to $280,000 for family medicine physicians.
Malpractice insurance costs, currently the highest for proceduralists, would likely fall as
they did in Canada, since patients would no longer have to sue to cover future medical costs.
And in many doctors’ practices, the case mix is likely to change for the better. As patients
with unmet medical needs increase their utilization, the limited supply of hospital beds and
physicians would likely cause a modest decrease in the delivery of low-value services.5 In
essence, doctors could shift their efforts to address the greatest needs, without fear of losing
income. To prevent waitlists, an increase in residency training programs may be necessary.
Medicare for All may also decrease inequities in physician pay. Increased demand and
federal funding for primary care may modestly mitigate the racial and gender pay gaps in
medicine, as nonwhite and non-male physicians are more likely to specialize in primary
care fields.6 In addition, using a funding scheme called “global budgeting,” Medicare for All
would likely increase revenue for underfunded safety net hospitals and clinics, which
disproportionately employ physicians of color. 7 However, the root causes of such pay
disparities are racism and sexism, and thus, even with Medicare for All, additional anti-
racist and anti-sexist reforms will be needed in the workplace. Proposals for a Medicare
“public option” or “Medicare Advantage for All” would sacrifice most of the
administrative savings that Medicare for All could garner, making universal first dollar
coverage unaffordable, minimizing increases in the utilization of care, and hence
physicians’ practice revenues. Additionally, current fee schedules would likely persist
under a public option reform, preserving the status quo that offers outsized rewards for
performing procedures and caring for privately insured patients. In sum, the available
evidence—including the CBO’s authoritative estimate—suggests that physicians would
prosper under single-payer reform. By supporting Medicare for All, physicians—and
organized medicine—can get a twofer: acting in physicians’ self-interest while
advancing legislation that would be enormously beneficial to patients.

Solves doctor shortages and access barriers --- four warrants

Srivats Narayanan, Medium, 7-19-2019 Srivats is a Student at the University of Missouri-
Kansas City School of Medicine ["A Remedy for the Primary Care Doctor Shortage: Medicare
for All", https://medium.com/@srivats.narayanan/a-remedy-for-the-primary-care-doctor-
shortage-medicare-for-all-c2e811527546, accessed 10-9-2020] BH

Primary care doctors play an instrumental role in health care, with the majority of physician
office visits taking place in primary care settings. Primary care physicians (PCPs) are
patients’ main doctors and are equipped to deal with most health care issues. They are who
you go to if you want an annual physical exam, have a sore throat, or have been feeling back
pain for a few days. Over time, PCPs get to know their patients (and their patients’ health)
very well and develop close relationships with them. This prevention-oriented primary care
system has long been tied to increased life expectancy and improved cost efficiency.
Continuity of care is a big part of primary care that both patients and doctors desire — it’s
associated with higher patient satisfaction and better patient health. Usually, patients don’t
need to see specialist doctors, so they prefer to go to the PCP who they have a long-term
relationship with. Patients don’t want to unnecessarily hop from doctor to doctor and
struggle with disjointed care. It’s much easier for patients to discuss any concerns with their
PCPs, who can then refer patients to specialists if needed. Unfortunately, there is a shortage
of PCPs all across the US. This dearth is documented by the Health Resources and Services
Administration, which designates Health Professional Shortage Areas (HPSAs). Areas that
have more than 3,500 people per PCPs are labeled primary care HPSAs. There are over
7000 primary care HPSAs in the US which make up almost 80 million people. In some states,
such as Mississippi and Alabama, over 50% of the overall population lives in HPSAs. In
order to accommodate this shortage, nearly 15,000 PCPs would need to start practicing in
these HPSAs. Those who believe that there is no shortage fail to acknowledge that PCPs are
not well-distributed around the US, as evidenced by the large number of primary care
HPSAs in our country. Patient care would still not be ideal even if these areas reach below
3,500 people per PCP and lose their HPSA statuses. A physician’s panel size — the number
of patients that a doctor cares for — can still be too much to handle when below 3,500. Even
when panel sizes are below 2000 patients, “most physicians would probably tell you it
needs to drop more,” according to one doctor. This is especially true in areas that currently
have limited primary care coverage, since their patients are more likely to be in poor health
and require more attention and time from doctors. Other medical staff members, like
nurses, can certainly make larger panels more bearable, but health care nevertheless suffers
when there are too many patients and too few doctors. Even though some people claim that
there are enough PCPs in the US, there is solid evidence that the doctors are unable to spend
enough time with their patients. One publication in the Journal of the American Medical
Association that tries to debunk doctor shortages actually proves the problem — the article
says that a physician should only care for 1500 to 2000 patients, yet proceeds to note that
that the average panel size for PCPs in the US is nearly 2200 patients. PCPs’ massive panels
don’t disprove the shortage in the US; rather, they show that PCPs have more patients than
they should have. These PCPs are overworked with huge panels and can’t spend the
appropriate amount of time with their patients, which in turn diminishes quality of care.
There’s another big reason that PCPs don’t have enough time to see all of their patients:
administrative duties. Physicians are constantly dealing with paperwork and insurance
companies’ regulations. It’s no surprise that a whopping 79% of doctors reported that
paperwork and administrative burdens are what’s “ruining medicine for physicians.” PCPs
regularly have to fight with their patients’ insurance companies over what procedures or
medications will be covered by insurance, which takes a mental toll on doctors and also
wastes their time. One PCP made particularly scathing comments about insurance
paperwork in a newspaper editorial: “In just the last four years, bureaucratic paperwork
has contributed to a 25 percent increase in physician burnout. As a doctor, I have seen how
more and more time is taken up with duplicative forms, redundant paperwork and
unnecessary procedural rules, all of which have grown in direct proportion to the
complexity of today’s health insurance plans.” These sentiments are shared by plenty of
other PCPs — administrative and insurance-related responsibilities rob doctors of
extraordinarily valuable time that could be spent with patients. The shortage and
overburdening of PCPs is not expected to go away anytime soon. The Association of
American Medical Colleges estimates that the shortage will reach 14,800 to 49,300
physicians by 2030. It will be exacerbated since the baby boomer generation will start
requiring more care (and thus more doctors) as boomers age. Many baby boomer doctors
will also start to retire soon, which will only worsen the primary care shortage. Something
clearly needs to change to fix this. If we don’t have enough PCPs, patients will lose out on
needed medical attention and access to health care. Medicare for All, a popular policy
supported by a majority of clinicians and Americans, would be an excellent solution
to the primary care shortage. Although the policy has gained a lot of attention for its
ability to cut healthcare costs and expand access to care, conservatives at The Heritage
Foundation, Fox News, and The Federalist have alleged that the bill would worsen doctor
shortages. They contend that a single-payer healthcare system like Medicare for All would
reduce physician incomes and encourage doctors to leave the field entirely. However, the
opposite is true for a few reasons. First, Medicare for All would consolidate all billing for
PCPs, which would save a lot of time for physicians who unnecessarily spend hours every
week with insurance hassles and administrative concerns. Doctors would have streamlined,
straightforward billing services through a national health insurance plan like Medicare for
All, instead of the previously mentioned redundant forms and complicated procedural rules.
Under Medicare for All, physicians wouldn’t exhaust their time with administrative duties
and would have newly available time to see significantly more patients. Medicare for All
would ensure that many more people can afford care and would free up time for office
visits, so PCPs will get paid more. With single-payer, money that would otherwise be going
into the pockets of health insurance executives would instead go to medical practitioners.
Second, Medicare for All would include reimbursement reform for doctors. PCPs are some
of the lowest-paid doctors, but Medicare for All would restructure the US physician
workforce by having PCPs receiving higher reimbursements from the government. PCPs
who currently have panels with many uninsured patients or patients on Medicaid would
have a particularly large increase in reimbursement. Medicare for All would help strengthen
primary care by giving PCPs the reimbursements that they deserve. Third, PCPs would pay
much less in malpractice insurance under Medicare for All. A sizable portion of a PCP’s
income goes to malpractice insurance premiums, but other countries with single-payer
healthcare have far smaller malpractice insurance costs. Medicare for All would improve the
relationships that PCPs have with their patients since it would place an emphasis on
continuity of care, which lessens the risk of malpractice lawsuits. Malpractice settlements
are also not as large under Medicare for All, which means that PCPs will pay less in
malpractice insurance and as a result have more take-home pay. Fourth, the US would save
trillions of dollars if we had Medicare for All, according to the Political Economy Research
Institute. A national healthcare plan would drastically reduce overhead costs, since less
administrative staff and insurance staff would be required. Medicare for All would slash
administrative costs that are responsible for a massive 31% of healthcare spending,
because the private insurance industry wouldn’t be able to take control of healthcare
pricing. The trillions in savings that Medicare for All would bring about would mean that
PCPs’ salaries would be kept up. As Dr. Carol Paris, the president of Physicians for a
National Health Program, remarked, single-payer “works by cutting administrative waste,
not doctors’ income.” In general, Medicare for All would put more money in both PCPs’
pockets and their patients’ pockets. This has been proven in other countries that began new
national health insurance programs and simultaneously increased average physician
incomes. Medicare for All would give PCPs better salaries, which in turn would attract more
medical students towards primary care. As one medical student wrote in 2014, most
medical students think that PCPs have to work harder, but get paid less. This perception
keeps medical graduates from going into primary care, because they like the easier lifestyles
and higher pay provided by non-primary care specialties. Medicare for All would
successfully alleviate the many burdens of primary care (like large panel sizes and
administrative busywork) while also giving PCPs a pay raise. Medical graduates tend to love
primary care but are deterred by the high burnout rates and low pay associated with the
field — Medicare for All would encourage those graduates to pursue a career in primary
care. Clearly, there are other potential solutions to the primary care shortage. Experts have
recommended other strategies that could end up covering more patients, such as ending
funding restrictions on graduate medical education, expanding the roles of nurse
practitioners and physician assistants, and utilizing telehealth services. However, single-
payer would be the best way to fix the shortage while also cutting healthcare costs and
preventing administrative headaches for PCPs.

Single Payer resolves problems with the Insurance industry and prevents an economic collapse
Hacker 18| Jan. 3rd. Jacob S. Hacker is Stanley Resor Professor of Political Science at Yale
University, is the author, with Paul Pierson, of Winner-Take-All Politics: How Washington
Made the Rich Richer—and Turned Its Back on the Middle Class (2010) “The Road to
Medicare for Everyone” (http://prospect.org/article/road-medicare-everyone) ABaez

Of course, the ACA’s travails reflect in part the ceaseless Republican attacks. In addition to the
19 Republican-controlled states that continue to refuse to expand Medicaid, many
conservative states worked actively to undermine establishment of and enrollment in the
individual marketplaces. Congressional Republicans couldn’t repeal the law outright so long
as President Obama held the veto pen. (Not for want of trying: They voted more than 50
times to kill it.) But they sued the president to stop subsidy payments for private plans,
failed to appropriate funds to boost marketplace enrollment, and generally tried to turn
their warnings about the ACA’s imminent collapse into a self-fulfilling critique. Republicans
have also dragged their feet on re-authorizing CHIP, which once enjoyed broad bipartisan
support. Even with a willing ally in President Trump, Republicans’ repeal ambitions have
continued to fall short. But the president who had promised on the campaign trail to provide
“insurance for everyone” has done almost everything within his power to undermine the ACA,
and congressional Republicans have shown no sign they’re letting up. Witness their willingness
to add repeal of the individual mandate to their big Senate tax bill, which was being
reconciled with the House version at the time this article went to press. In short, many of the
problems with the Affordable Care Act are a product of Republican sabotage. In short, many of
the problems with the Affordable Care Act are a product of Republican sabotage. But there’s
another reason Democrats are gravitating away from the approach enacted in 2014. Those
once skeptical of the public option now seem willing to embrace it, and many on the party’s
left want to go much further. Those more progressive Democrats generally saw mandated
private insurance as a second-best route to expanded coverage and political
accommodation—one that had a chance of winning some Republican support, if not at the
outset, at least down the road. But if the expansion is lackluster and the political
accommodation nonexistent, why cling to the second best? To a degree that seemed
impossible even a year ago, then, the discussion within the party has come to encompass a
whole range of ideas for expanding Medicare, not just the public option. These range from
voluntary buy-ins for workers and employers, to lowering the Medicare eligibility age from
65 to 55 or 50, or all the way to Medicare for All. Indeed, to those pressing for single-payer,
the public option is small bore. It would provide a backup in parts of the nation at risk of
having no private plans, and bring some sanity to health-care prices for those it covered.
But it would only be relevant to the limited slice of the population getting coverage through
the exchanges. Something much bigger is needed, Medicare for All enthusiasts argue, to
rally the sustained enthusiasm of grassroots activists and progressive leaders and truly
achieve transformative change. They might be surprised to know I agree. The case for
single-payer is much stronger than it was during the strait-jacketed debate of 2009. The
question is whether it’s strong enough, and if not, what might be able to deliver on its
promise. Is It Time for Single-Payer? What is the case for single-payer? The term itself dates
back at least to the 1980s, when a small group of Massachusetts doctors founded Physicians
for a National Health Program and began calling for a “single payer” to replace all private
insurance and public programs. Unlike reformers in the 1940s and 1950s, they looked not
to Social Security for inspiration, but to the universal health systems found abroad,
especially that of Canada—which consolidated a system of universal government insurance
(at the provincial level) in the 1970s. Today, single-payer is generally a synonym for
Medicare, not the Canadian system. But the emphasis on foreign experience remains.
Introducing his plan, Senator Sanders declared it would “end the international disgrace of
the United States, our great nation, being the only major country on earth not to guarantee
health care to all of our people.” In fact, most major countries on earth don’t have single-
payer. They have multiple payers, but all the payers pay the same negotiated health-care
prices and play by the same strict rules to ensure more or less equal treatment of all
subscribers—rich and poor, well and sick, young and old. Even Medicare isn’t really single-
payer: A component of Medicare called “Medicare Advantage” allows beneficiaries to enroll
in private plans that meet strict standards, and roughly a third of Medicare beneficiaries are
in such plans. The defining feature of the systems found in other rich democracies isn’t the
way payments are channeled. It’s who’s covered and how medical prices are set. First, these
systems are universal. The government guarantees all citizens coverage and then figures out
how to pay for it. Only in the United States is the responsibility to get and pay for coverage
largely left up to individuals and their employers, leaving tens of millions to fall through the
cracks. The ACA dramatically improved things, but roughly 30 million Americans still remain
uninsured and the number appears to be rising again. Second, these systems use government’s
bargaining power to restrain health-care costs. In recent years, as Paul Starr discusses
elsewhere in this issue, a consensus has formed among health-care experts that the major
reason why U.S. spending is so high is that we pay such high prices for medical goods and
services and prescription drugs. When a nation’s leaders commit themselves to providing
insurance to everyone, they become much more aware of bill-padding and price-gouging.
They also discover that government has a unique capacity to do something about it: It can
require that providers charge uniform prices. Medicare doesn’t cover the entire population,
but it’s evolved in the same direction. At first, it paid whatever health-care providers
demanded, and costs soared. Since the 1980s, however, it’s increasingly improved its ways
of paying for care, and costs have risen significantly more slowly than in the private sector.
My Yale colleague Zack Cooper, a health economist, has gained access to the claims records
of some of the biggest commercial insurers. What he’s found is that the prices they pay are
much higher than Medicare’s. They also vary enormously across providers. Moreover, the
gap between Medicare and private insurance has been growing, as doctors and hospitals
increasingly consolidate into large medical systems demanding premium prices. In recent
years, Medicare’s overall tab has risen with the retirement of the baby-boom generation. Yet
its spending per enrollee, which is what really matters, has been essentially flat, rising less
quickly than either economic growth or inflation. AP Photo/Eric Gay Once people were
enrolled in Medicare Part E, they would remain enrolled for as long as they didn't have
verified alternative insurance. The experience of Medicare turns on its head the thinking
behind the Republican repeal drive. According to many conservative critics of the ACA,
patients should be left to pay for most care directly, so they have an incentive to shop
wisely. But patients want and need insurance, especially for the big-ticket items that
account for most health spending. And they need the expertise of providers to know what to
shop for, especially when they’re sick or injured. So insurance is going to pay for a lot of care,
and providers are going to make most of the decisions that determine how that money is
spent. This means, in turn, that someone has to put limits on what providers charge. The only
institution that has the proven ability to do that is the government. In short, Medicare for All
isn’t just a good slogan—and certainly a much better slogan than single-payer. It’s a policy
grounded in evidence about what works both here and abroad. It’s also insanely popular,
seen across the partisan divide as a vital part of the American social contract. Even voters
who hate Obamacare love Medicare. Medicare is also simple—or at least a lot more simple
than the Affordable Care Act or the complex tweaks to it now being debated. Everyone pays
in during their working lives, and everyone is covered at age 65 (or if they’re permanently
disabled). And unlike private plans, Medicare doesn’t limit which doctors and hospitals
patients can see: Virtually all accept its payments. It limits what prices those providers can
charge. The message that’s being sent by Medicare for All enthusiasts is that the days of
technocracy and triangulation are over. Stop offering Rube Goldberg contraptions that
Americans will barely understand and activists won’t rally behind. Stop trying to fill the gaps
in a flawed system and smuggle in cost-control through the back door. Just say everyone is
covered by Medicare, period. After all, Republicans are certain to call anything that
Democrats try to do a “government takeover.” So why not embrace the epithet and offer
voters a takeover they seem to like: Medicare? It’s a powerful message, and it counsels a
bold path. Unfortunately, that path is far more daunting than many embarking on it seem to
understand.