On Tuesday, former CMS administrator under Obama Andy Slavitt announced United States of Care, a “non-partisan non-profit” with undisclosed funding that plans on “building and mobilizing a movement to achieve long-lasting solutions that make health care better for everyone.”
“We can’t just wait for politicians in DC to come together solve our health care challenges,” it declared in its inaugural tweet. “Let’s put #healthcareoverpolitics and build a movement for quality, affordable health care for every American.”
I will admit I was quick to scoff at what I consider toothless mushmouthed nothingspeak. After all, what’s the point of a healthcare initiative that claims to recognize the massive inequality in American health but is unable to demand even “universal coverage,” a figurative watermelon on a tee-ball-tee among American policy goals, as a desired outcome?
Scrolling through United States of Care’s list of members, it’s easy to feel that kneejerk reaction: that USC is by and large a collaboration of insurance executives, superpowerful healthcare providers, Republican lawmakers, and figures included mainly to lend it some veneer of credibility, like chronicler of American health Atul Gawande, led by ostensibly well-meaning Democrats who had banked on positions in a Clinton administration and now need paychecks to pay their own insurance premiums. It is also easy to assume that these people have joined together in part to counteract the explosive “Medicare for All” movement.
But perhaps that’s too easy a criticism, and too cynical. Let us presume good faith. What, then, is the United States of Care, in its own terms?
USC lays out three core principles to its mission:
- “Affordable Source of Care: Every American should have an affordable regular source of care for themselves and their families
- Protection from Financial Devastation: All Americans should be protected from financial devastation because of illness or injury
- Political and Economic Viability: Policies to achieve these aims must be fiscally responsible and win the political support needed to ensure long-term stability”
I don’t like that. “Affordable” care is at best an ambiguous goal, and “political viability” smells like an excuse to not try very hard to win popular support. So far, bad—off to a bad start. But let’s move on.
What does USC’s work entail?
- “Harnessing On-the-Ground Learning: Listening to personal stories and local experts and harnessing public opinion to shape policies that reflect the hopes and concerns of the majority of Americans who don’t want to be without the care they need.
- Providing Policy Support: Providing resources and actionable approaches to state and federal policymakers, drawing on a wide range of expertise, facilitating stakeholder engagement, and connecting the dots between the interests of citizens and their elected representatives.
- Developing New Ideas: Identifying and developing new solutions that make progress toward the principles of expanding access to affordable care.
- Driving Real Change that improves the health and well being of Americans now and on a lasting basis.”
Despite the aggressive consultant-speak, which holds sacred the idea that any noun can be forced into a verb, these are reasonable methods for learning about healthcare in America.
In fact, I agree with “on-the-ground” learning. Over the past four months, I have spoken about healthcare inequity with thousands of people in 24 states—doctors, nurses, social workers, and laypeople; people with disabilities or otherwise enduring constant health crises and the temporarily healthy or able-bodied; the wealthy and the poor; people in urban Democratic areas and people in rural parts of red states. They have brought me into their homes and shared with me their suffering; their degradation at the hands of a healthcare model that systematically (if not violently) rejects basic human dignity in the service of private profit.
It is by these encounters that I am convinced—along with hundreds of thousands of nurses and tens of thousands of doctors—that a federal single-payer is the only tool by which we can begin to define a just healthcare model in America.
By and large, the costs of receiving healthcare are much more than any individual person can afford by themselves. Not a lot of folks need healthcare in a given year, but those who do can be very expensive to care for—50% of costs in a given year come from a twentieth of the population; 80% of costs come from caring for a fifth of the population. Meanwhile, those costs skyrocket annually—much faster than inflation—for a tangled mess of reasons. Some physicians and providers treat large populations of people who are unable to pay, so they are dependent on government subsidies to make up the gap, or they try to compensate by charging more to those who have insurance. Other providers just artificially inflate their prices, or shift services offered to those for which they can bill the most, and nobody has the leverage to stop them. If the question of “who gets to receive healthcare, and when?” is determined by private profitability, we are left with a heinous paradox: If you are an insurance company, like Aetna, it is simply not profitable to insure people who are sick. If you are a provider, like a hospital CEO, or an equipment manufacturer, or Martin Shkreli, it is extremely profitable to charge sick people as much as possible, so long as someone is paying the bill.
Thus, the fundamental questions of healthcare reform are coverage and cost. How do you ensure coverage for all people, while controlling costs, while ensuring that providers are paid justly for their work?
The multi-payer for-profit model of private insurance has had fifty years to address these questions, and the results speak for themselves:
- America spends more than any other country on healthcare—almost twice as much per-capita as the next biggest spender—while getting abysmal population health results.
- This spending will only grow—we’re projected to spend $4.3 trillion a year in a decade.
- 75% of our spending goes to chronic conditions that are preventable, but nobody paying the bills really has the incentives to prevent them.
- Quality of care stagnates for the most vulnerable among us.
- 58 million Americans live without access to basic primary care.
- More than 28 million people are still uninsured.
Undergirding this is our distinct national system of for-profit multi-payer private insurance, a healthcare financing model unlike any other in the “developed” world. It is fundamentally negatively redistributive. It takes money from the poor and gives it to the wealthy, and, in 2014, it pushed 16.3 million people into poverty and damned almost four million more to extreme poverty.
We have delegated the payment of healthcare costs to private insurers, who seek to avoid the responsibility of paying for unprofitable sick people. Because consumers are likely to change insurers every few years, and eventually go on Medicare, insurers feel no pressure to provide people with care that will keep them healthy in the distant future. We understand the causes of long-term healthcare costs—unsafe or unaffordable housing, domestic violence, food insecurity, the ravages of the opioid epidemic, the carceral state. We understand that broken septic tanks in the backyards of rural South expose hundreds of thousands of people to hookworm; we understand that people with disabilities are treated like an underclass and coerced into nursing homes against their will for private profit; we understand that rural clinic shutdowns make people sicker, and force them into fewer, more crowded hospitals for more expensive care. But we have built a system in which these problems are “nobody’s problems,” and so we perpetually pass the buck, letting the federal government find more ways to massively subsidize private companies in a pitiful attempt to prevent sick people from getting kicked off their insurance plans.
A federal single payer, also known as an improved “Medicare for all” (improved, that is, compared to the Medicare we currently have), eliminates much of this stupid, unnecessary horseshit. A single payer is a publicly owned, publicly funded insurer with a legislated mandate to cover, in full, all care for all people—including medical, mental, and long-term care. By negotiating on behalf of 300 million people, it can serve as a de facto price regulator—the most important actor in driving healthcare costs down—while ensuring fair reimbursement for healthcare providers. Most importantly, it cannot shirk its responsibility to long-term population health.
Through this obligation, through forcing the government to bear all the costs of providing care and the risks and costs of not providing care, we turn the federal single-payer into a tool for something bigger: a vision of health justice. If people are getting sick and dying because they don’t have a place to live, or if the places they live are unsafe, then housing is healthcare, and we must build free or affordable housing to bring healthcare costs down. If people are getting sick and dying because they don’t have have access to healthy food to eat, and they’re getting diabetes and comorbidities like cardiac failure, then food is healthcare, and we must provide affordable or free food options—and the time, space, materials, and community with which to prepare them— to bring healthcare costs down. If people are getting sick and dying because they don’t have access to needle exchange programs, therapy, or counseling, then rehabilitation is healthcare, and you build full-cycle addiction treatment programs—the social structures required to help people handle addiction, or perhaps not fall prey to it in the first place—to bring healthcare costs down.
This is not a radical proposition among the people it affects. It is the preference of 63% of Americans, more by the day, who feel the crisis of American healthcare in their bodies. They want relief from medical debt, freedom from fear of coverage denial, full provider choice, access to primary care, and no cost-sharing.
So why is United States of Care fleeing from single-payer?
Let me reiterate the table stakes. Among so-called “developed” countries, America is the most dangerous place to be sick. America is the most dangerous place to be black. America is the most dangerous place to be pregnant—with the highest maternal mortality rate of any comparably wealthy nation, of which 60% are easily preventable. America is the most dangerous place to be a woman; to be trans; to be disabled; to be elderly; to be poor.
Last year, life expectancy at birth fell for the first time in almost 30 years by a tenth of a year. Across the four million people born last year, that constitutes a theft of 400,000 years. And I do mean theft—because the wealthy men in America get to live fifteen years longer than poor men; wealthy women, ten years longer than poor women.
Against this, United States of Care posits that the solution to our national suffering is to play nice with the people who exacerbate these problems in the first place.
Even if it doesn’t want to champion single-payer, USC can, doubtless, advocate for undeniably good things. It can harness its resources to advocate for Medicaid expansion, without exception or means-testing, in states that have rejected federal funds—this leads to a reduction in the mortality rate, especially among communities of color. It can demand comprehensive reproductive justice (including both abortion, a basic and essential medical procedure; and medical and social support for people who struggle during pregnancy) or the funding of home health support for disabled people, where we have chosen to deny it. It could throw itself behind Virginia’s HB 1466, which prohibits insurance discrimination on the basis of gender and trans identity. It could even lobby for municipal issues that advance the cause of health justice, like the upcoming city council vote on paid sick leave in Austin, Texas. These things provide immediate material benefit to people who need them and it is our collective responsibility to put our shoulders to the wheel for them whenever and however we can.
United States of Care could back any of these reforms—but if we take them at their word, they probably won’t. Because all of these reforms are political.
And USC would be the first to point out that incremental reforms, if unconnected to a broader popular movement, are easily peeled away by those powerful prosecutorial perverts who delight in the stigmatization and punishment of people in need. They acknowledge it in their own marketing materials: “Given the recent trajectory of polarization, there is a greater potential now that the country will end up with a cycle of more partisan policies that depend only on which party is in power. Those policies will be considered valid only until the next election.”
Their solution, though—to try to place the heathcare battle above partisan politics—makes no sense. It makes no sense because the fight for universal care is a fight against a powerful cadre that opposes that goal.
“Healthcare over politics” is easy to tweet when you don’t have to spend dozens of hours a week pleading with insurers for basic care. It is the domain of those who view justice as the result of incremental policy fixes, debated about in salons by Very Serious People compromising to build a mythical Third Way toward a shared goal—a notion of America as debate club. While the dweebs twiddle their thumbs and hope for a slightly better tomorrow, they ignore the brutality and severity of the consequences forced upon the masses by Republicans who understand in their bones that politics is about manifesting power. Health justice — the reform of 18% of our national economy — is inherently political. These are the policy choices which determine who is permitted to live and die in America; whose suffering is afforded dignity; whose bodies are made safe to inhabit.
USC envisions a world in which healthcare is fought for and won by technocrats, a small corpus of the benevolent and powerful. These are the same people who have, through pre-concession, lost any battle they’ve focus-grouped their way into meekly accepting over the past thirty years.
There is too much at stake to believe their promises for the future. Too many have suffered while the incrementalists have bargained away the lives of the systematically marginalized to those who worship the wealthy. They have long since abandoned the path of justice.
But we—the people of America—have a chance to stretch toward something different; something greater. We will not fuck it up.