Single Payer and the Fight to Defend Medicaid

Peggy Kahn

On June 22, Michigan Governor Snyder signed Senate Bill 897 creating work requirements for those enrolled in Healthy Michigan, the Michigan Medicaid expansion. Michigan’s Medicaid expansion had been very successful, enrolling 700,000 new recipients, 83% of whom said they wouldn’t be able to see a doctor without it. Michigan has now joined Kentucky and Indiana in enacting work requirements, and about 8 other states are considering them. There have been other efforts to erode Medicaid, for example by block-granting states, legislating per capita caps, and limiting covered services. Meanwhile Virginia recently adopted Medicaid expansion through the legislature, a popular referendum in Maine returned a vote for expansion, and expansion is on the Utah ballot in November 2018. On June 29, a federal District Court sent Kentucky’s work requirement waiver back to HHS, saying that HHS had not demonstrated that Kentucky’s “work requirement experiment” adhered to the main purpose of Medicaid, furnishing medical assistance to those who qualify, both traditional beneficiaries and those who are part of the expansion population.  Whether this slows the Medicaid contraction train remains to be seen.

Medicaid is a critical part of the patchwork of U.S. health care policy, public insurance intended to furnish medical assistance to people whose income and resources are insufficient to meet the cost of market-based health services. Its beneficiaries tend to be those whose class, race and poor health make them among the most vulnerable members of the population. Medicaid expansion followed the 2010 Affordable Care Act and the 2012 NFIB v. Sibelius Supreme Court decision in 33 states and DC, with positive consequences — including higher insured rates among those newly eligible, those previously eligible but not enrolled, and many vulnerable populations including rural ones. Medicaid fills a gap in the absence of universal coverage, but it has been a vulnerable and often inadequate program, dividing citizens by political geography as well as household income and other factors.

Health care access, a basic need that should be recognized as a basic social right, is in shambles and under further attack from the right, but there are also incremental attempts to hold on to and strengthen coverage through Medicaid and other programs and to move towards a comprehensive single-payer system. Even after the Affordable Care Act, the U.S. health care system is skewed towards the market and corporate interests, has a patchwork of public and private programs with multiple insurance arrangements, spends much more for poorer health outcomes than comparable countries, perpetuates racial and class health disparities, and displays impenetrable complexity that makes it difficult to talk with the public about health care policy.  The fights to defend and expand Medicaid around the country are not merely a reformist distraction from the effort to build momentum behind single payer but an opening both to maintain access to health care for some of the most marginalized and vulnerable and to build momentum behind the single-payer movement.

Here are some reasons to fight for Medicaid, while also supporting single-payer health insurance:

Work requirements take us farther from the goal of universal coverage at the center of single payer

The Center on Budget and Policy Priorities estimated that Michigan’s Medicaid work requirements, as proposed in April (now somewhat modified), would lead to coverage reductions of 150,000 per month, including losses among many workers in unstable jobs who wouldn’t be able to meet eligibility requirements every month and people who are disabled but should be exempted and would fall through the cracks. In Kentucky, the state itself estimated that 95,000 residents would lose coverage after imposition of work requirements, while legal scholars estimated the loss at closer to 300,000.

Work requirements offend the principle of valuing people outside the labor market, while single payer recognizes the health needs and dignity of all regardless of employment

Work requirements are particularly offensive to those on the socialist left because work tests only regard people as deserving if they subject themselves to the labor market and employer power. The U.S. social safety net has already veered very far in the direction of only providing (meager) resources to those who are employed.

More fragmentation of the population according to categories of deservingness undermines solidaristic politics which is necessary for and will be reinforced by single payer

Work requirements encourage both administrators and the public to stigmatize those excluded. Their supporters present work requirements as rehabilitating the reputations of those who meet them, but they do not abolish the hierarchy of deservingness associated with those on market plans and those receiving low-income based public insurance and now those entirely excluded. As a universal system, single-payer does not separate people into categories of deservingness and need, involve arbitrary cut-offs that easily turn people above the threshold against those below, place public workers, often themselves low-paid and overworked, in positions of policing and disrespecting others.  Narrow categorical and complex means-tested programs are subject to instability and create insecurity among the low-income population. A universal program is more likely to maintain political support and stability over time, as have social security retirement pensions.

Medicaid work requirements waste resources, unlike single-payer’s more efficient use of health dollars for treatment

Medicaid work requirements add bureaucracy and administrative costs to an already overly administered and complex health care system. The Center for Budget and Policy priorities estimated that it would cost Michigan $20-30 million to administer the requirement. Physicians for a National Health Program argues that administrative costs, including those of Medicaid, amount to about 31% of total U.S. health care spending, and single payer would save the system more than $400 billion a year in administrative costs, releasing money for treatment rather than using it for unnecessary patient and provider surveillance, billing, advertising and marketing.

Medicaid work requirements shift costs in unacceptable and inefficient ways

Medicaid work requirements which exclude people from public insurance shift costs to other ledgers: households bear costs in basic well-being and stress, non-profits and for-profits absorb the costs of untreated disease, some of the insured may pay more, and hospitals face additional uncompensated care costs. Some of these costs are due to delayed, rather than preventive or prompt, treatment. Single payer finances itself through modest new taxes based on ability to pay combined with negotiated fees, global budgets, and bulk purchasing, and it allows for more coordination, consistency, transparency and accountability in the health care system.

Opposing Medicaid contraction can also help build the movement for single payer in concrete ways.

Stronger Medicaid empowers people for political action

Many low-income households rely upon Medicaid, and they know that Medicaid expansion has improved their health care access. On the other hand, Jamila Michener has argued that capriciousness and inadequacy in Medicaid provision disempower beneficiaries and make them less likely to participate in politics (both because of health and everyday life challenges and because of growing mistrust and political hopelessness). If Medicaid erosion can be staunched, there may be more possibility of mobilizing populations for Medicare for All.

Fighting for Medicaid brings single-payer campaigns into low-income communities and collaboration with other organizations

If low-income households and communities can be mobilized into fighting for Medicaid, it is more likely that they can be brought into a movement for Medicare for All, which at this stage is an abstraction in relation to many everyday lives and a political goal for the future. Fighting alongside people with claims to Medicaid supports the idea that people can claim rights from the state, and Medicare for All requires that people are  able to imagine and fight for an expansion of public provision. Many groups that do not openly endorse Medicare for All are fighting against Medicaid restriction and for expansion. The single-payer movement has an opportunity to work inside, and learn from, groups defending health care for low-income households:  The Poor People’s Campaign, community organizations, many county health plans and public health staff, associations that work to defend and support the disabled, children’s rights groups, and many faith-based organizations. In some organizations or for individuals within those organizations, opposition to immediate cuts could be extended to support for single payer. There is a lot of strategic work and relationship-building to be done here.

miscellaneous medical symbolsThose committed to directly and primarily advancing single-payer options—through door-to-door educational canvassing, public meetings, legislative work and political candidate campaigns—can on the one hand recognize the achievements and importance of Medicaid but at the same time hold up its inadequacy and instability as reasons that we need a unified system of public insurance based on social rights and sound policy reasoning. The campaign around single-payer is vital and gaining momentum, and it should incorporate current attacks on the safety net in its work. If the left in Michigan continues to mobilize around and canvass for single-payer independently of, or as part of, its electoral work, the state-level Medicaid experience is a resource.

Peggy Kahn is Professor of Political Science at the University of Michigan-Flint.