The Feminist Case For Single Payer

December 11, 2017

The Feminist Case For Single Payer

BY

NATALIE SHURE

It’s time to take health care away from the power of bosses and spouses.

In the spring of 1969, a dozen feminists gathered at a women’s conference in Boston and came to a sober conclusion: their encounters with the United States health-care system had been overwhelmingly negative. They felt unsettled by doctors, alienated from their bodies, grifted by fees, and altogether powerless to navigate an industry they believed objectified them just as popular culture did.

The conference launched a years-long project, with each participant delving into some aspect of anatomy, sexuality, or society related to women’s health. The result was a self-published volume of essays called Women and their Bodies, which the Boston Women’s Health Book Collective used to provide women with a resource produced from their own perspectives and experiences. Within a few years, the landmark feminist booklet was re-dubbed Our Bodies, Ourselves, released by Simon and Schuester, and sold millions of copies. In 2012, the Library of Congress named it one of the most significant works in American history. In recent years, it has inspired Trans Bodies, Trans Selves, which similarly seeks to be a health-care guide “by and for” the transgender community.

While Our Bodies, Ourselves is remembered for its role in the history of women’s health and culture, less attention is paid to its political context. In the 1970s, the small collective became one of the first feminist organizations to demand a single-payer health-care system:
“Suffice it to say that capitalism is incapable of providing good health care, both curative and preventive, for all people,” one entry read. “Cost-benefit analysis trades off the benefit to the people of collective public health in favor of the cost to the people of private, patch-up medical care. The capitalist medical care system can be no more dedicated to improving the people’s health than can General Motors become dedicated to improving the people’s public transportation.” In a subsequent edition, they expounded: “We believe that health care is a human right and that a society should provide free health care for itself . . . Health care cannot be adequate as long as it is conceived of as insurance.”

If the book’s then-radical content has so permeated mainstream culture that it would strike readers as obvious today, the same is not the case for its authors’ critique of American health care. In fact, nearly fifty years after the collective articulated its vision for a universal system, “feminist” arguments against single-payer pepper politics and the media.

In June, Planned Parenthood of California refused to endorse a bill for a statewide single-payer system, contending that it was critical to focus on defending the Affordable Care Act (ACA) against GOP attacks instead. Vice cast it as a job-crusher for the mostly women of color who work in healthcare administration. In 2016, presidential candidate Hillary Clinton — whose campaign foregrounded her feminist credentials — famously declared single-payer would “never, ever come to pass.” More recently, Senator Bernie Sanders’s release of an expansive Medicare for All bill has been met with skepticism by media personalities who backed Clinton for her feminist credentials. At the very least, it seems clear that single-payer health care is rarely framed as a feminist issue.

Some mainstream feminists knock single payer as a distraction from the fight to defend the ACA. But while the Affordable Care Act undeniably improved some women’s lives, it could not dismantle gendered barriers to care.

Of all systems, single-payer is capable of going furthest to eliminate them. That’s the vision that Our Bodies, Ourselves adopted nearly half a century ago, and it must be taken up again today.

The Double Bind

One of the pervasive ways women are disadvantaged under the ACA is its reliance on employer-based coverage. In the United States,

World War II–era wage freezes helped entrench a system of employer-provided health insurance, a perk meant to attract workers in a squeezed labor market.

“Divorce leaves women uninsured with men likely to maintain after their dissolve. Eventually, Medicare and Medicaid were devised as a safety net for those shut out of private plans, and the ACA expanded that safety net.

Still, job-based plans remain the bedrock on which our insurance system is built.

Under this system, it’s harder for women to get health insurance in the first place. The strains of childrearing and elder care make women more likely to seek more flexible employment, like part-time, remote, or freelance work. These forms of employment tend not only to pay less, but are less likely to include health insurance benefits.

Those that do provide inferior ones: companies with majority-female workforces tend to offer less generous health-care coverage than those that are majority male. And less than one-third of low-income workers receive any health insurance through work. Jobs paying at or around the minimum wage are most often occupied by women, the majority of whom are women of color. Trans women face even higher levels of poverty than cis women, and are frequently saddled with impossibly high out of pocket costs.

Then there are the 25 percent of non-elderly adult women insured as dependents of a working spouse, which weakens their control over both their insurance coverage and their relationship. Health insurance has been found to be a common reason for getting married — and for staying married when one would rather not — especially among low-income people. Upon the loss of a spouse’s coverage, it’s difficult and expensive to continue receiving the same care. COBRA coverage — a program that allows people who lose employer-based insurance to remain on it, so long as they pony up the amount formerly contributed by employers — is often the only way to maintain provider networks, but it’s wildly expensive and eventually expires. Ultimately, divorce leaves some sixty-five thousand women uninsured each year, with men being far more likely to maintain coverage after their marriages dissolve.

Women’s unpaid domestic work puts further pressure on the contradictory demands of home, work, and the need to access coverage. Women disproportionately shoulder the responsibility of caring for others, putting them in an impossible situation when it comes to child and elder care: in order to maintain health insurance, they can’t take too much time off work. As a result, they’re forced to spend a significant portion of their wages on private care for the hours they’re on the job. For low-income women who don’t qualify for insurance through employers, the problem can be severe, made worse still by right-wing efforts to impose higher copays and out-of-home work requirements on Medicaid recipients, or to defund programs like CHIP that help parents pay for their children’s health insurance.

During particularly urgent health episodes, like childbirth or a relative’s protracted illness, women opt to take unpaid time off instead of risking their jobs. Notoriously, the United States is one of only a handful of countries that doesn’t guarantee paid maternity leave, exacerbating the financial stress of an already pricey phase of life. The Labor Department has found that nearly one-third of women who take unpaid time off for their own or dependents’ health issues fall into serious credit card debt.

Our Health, Our Selves

None of this is to say that the Affordable Care Act was a total wash for women. The ACA’s Medicaid expansion provided public health insurance to anyone with income below 137 percent of the federal poverty line, and federal subsidies (however inadequate) to anyone making below 400 percent. Because of the gendered wage gap, the effect was to extend insurance to more women than men. The law also took on health discrimination, by mandating that men and women pay equal premiums, ending gatekeeping based on preexisting conditions or the ability to become pregnant, and requiring that plans sold on state exchanges cover maternity care and birth control.

The ACA’s overhaul of the individual insurance market has helped somewhat to delink insurance from employment. Before the ACA, reproductive-age women faced considerable difficulties getting coverage on the individual market, since insurers were free to charge skyhigh premiums to hedge against the possibility of having to shell out for maternity care. But even if premiums are more highly regulated, increased cost-sharing still means that patients pay stiff prices simply for getting the care they need: reproductive-aged women still spend over 60 percent more than men do in out-of-pocket health-care costs.

At the same time, while state ACA exchanges offer an alternative to employer-provided plans, the exchange plans remain inferior. Both tiers of insurance are plagued by narrowing provider networks, and ever-rising out of pocket costs – leading millions to forego insurance because it’s too unaffordable, or find themselves stuck with plans they can’t even afford to use. And that’s with the ACA.

In short, the dynamics that make the American health-care system so hostile to women remain largely unscathed after the ACA: the pervasive commodification of healthcare and dependent care in the United States, coupled with employment-based gatekeeping, engineers an impossible bind for women: they face more challenges accessing the health-care system and pay more for their care when they do, out of lower incomes that are further squeezed by child and elder care costs.

By removing power over health care from employers and spouses, and replacing unequal tiers with one unified insurance pool, we could fund our health-care system with progressive taxes. That way, we could guarantee everyone the care they need, and make it free at the point of service. Ability to pay, pre-existing conditions, employment status, and gender would cease to be barriers. Building Medicare for All — with robust guarantees for tougher-to-access services like abortion and gender affirming care — would force American society as a whole to address the care disparities women face.

ABOUT THE AUTHOR

Natalie Shure is a TV producer and writer whose work has appeared in the Atlantic, Slate, Pacific Standard and elsewhere.

John Conyers Resignation, and HR 676

December 8, 2017

Barbara,

John Conyers, who has been the lead sponsor of the Expanded and Improved Medicare for All Act (H.R. 676) since its introduction to Congress almost 15 years ago, resigned Tuesday amid allegations of sexual harassment made by former staffers. You may have heard about this and wondered what it means for the bill.

It’s important as leaders of the single payer movement that we stand in solidarity with victims of sexual assault and harassment. We at Healthcare-NOW take these allegations very seriously and support Conyers’ decision to stand down.

Regarding H.R. 676, the bill remains in Congress through 2018, and reps can still sign on as cosponsors. Right now we’re working with other national groups to look for a new lead sponsor for the bill, but until then rest assured that H.R. 676 remains active. We hope you’ll still continue lobbying your members of Congress to sign on to this and the Senate Medicare for All bill, S. 1804!

Yours in solidarity,
Ben and Stephanie
Healthcare-NOW! National Staff

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How do you give thanks when you can’t pay your deductible?

November 23, 2017

No Co-pays, no Deductibles, Lower Property Taxes sound good?

November 16, 2017

How to Think about “Medicare for All”

October 27, 2017

http://www.nejm.org/doi/full/10.1056/NEJMp1713510

James A. Morone, Ph.D.

October 25, 2017DOI: 10.1056/NEJMp1713510

In April 1946, President Harry Truman introduced a single-payer health plan and met the same reaction that would greet Senator Bernie Sanders (I-VT) and his colleagues when they proposed “Medicare for All” in September 2017. “It is believed by competent Congressional observers to have little chance of approval,” reported the New York Times back in 1949. Newsweek was blunter: “No chance at all.” Neither Truman nor Sanders even bothered to include financing for their plans. Truman had no more success with a scaled-back proposal to cover only people over 65 years of age, but 13 years later President Lyndon Johnson signed the Truman revision into law as Medicare, declaring that the United States was finally harvesting “the seeds of compassion and duty” that his predecessor had sown.1 A proposal with no chance in one era had become law in another. Medicare proved so popular that it came to be a third rail of American politics — dangerous to touch. What lessons does Truman’s success hold for today’s “no chance” Medicare for All?

The usual metrics for evaluating policy proposals — vote counts, Congressional Budget Office scores, and tax calculations — are misleading because Medicare for All is an idea for the long run. For a more accurate assessment of its prospects, keep an eye on four key questions.

Is there a right to health care? The Affordable Care Act and the efforts to repeal and replace it raised fundamental ethical questions about whether Americans have a right to health care and, if so, whether government should secure it. The Medicare-for-all proposal responds with a strong claim for a right to roughly equal health care coverage for everyone. The American patchwork — superb health insurance for some; no health insurance for 30 million others; and shaky high-deductible, high-premium plans on the individual market and in many workplaces — is not just poor policy. It is wrong. It violates the norms of communal decency. Late-night talk-show host Jimmy Kimmel distilled this view when he tearfully responded to the House repeal-and-replace plan: “No parent should ever have to decide if they can afford to save their child’s life. It just shouldn’t happen. Not here.”

Medicare for All is, first and foremost, an exercise in moral persuasion. It will become a serious policy proposal if it creates a major surge in public opinion. That’s how “no chance” reforms win in the United States, whether it’s the passage of Medicare or the right of same-sex couples to marry. On this measure, Sanders is making progress. Last time he proposed his plan, he stood alone; this time, 16 Democrats crowded beside him — including some leading contenders for the next presidential nomination. The difference sprang from the 12,029,699 votes Sanders racked up in the Democratic presidential primaries. To handicap the future prospects of the plan, watch what happens as candidates take it to the voters.

Won’t the cost savings eventually convince skeptics? International comparisons reveal that other wealthy countries cover most of their populations with much lower spending. Although every country is unique, no other nation supports the sprawling administrative, insurance, and billing bureaucracies that reach into every U.S. clinic and practice; moreover, single-payer systems offer budgetary levers that our own fragmented nonsystem does not have.2 The results are striking. For example, Canadian health costs were indistinguishable from those in the United States until Canada finished introducing its national health insurance program in 1971; then, health care’s share of the Canadian economy flattened out dramatically. By 2014, according to the World Health Organization, Canada spent 10.4% of its gross domestic product on health care, as compared with the 17.1% we spent in the United States. Closer to home, our own single-payer plan, Medicare, appears to constrain rising costs more tightly than private insurers do.3

The data tempt advocates to push Medicare for All as an efficiency fix for U.S. health care. However, mere efficiency arguments are unlikely to propel a change this big through the multiple checks and balances of U.S. politics. In politics, good data are not enough. They are a necessary but not sufficient condition for winning major legislation. Proponents will first have to create a movement.

Still, the efficiency claim always lingers in the middle distance: like Charles Dickens’s ghost of Christmas yet-to-come, single-payer plans challenge us to change our ways. If more conventional approaches fail to control costs and offer Americans more reliable access to health care, Medicare for All will continue to beckon as the fairer, less expensive, cross-nationally tested alternative.

But what about the taxes? Skeptics emphasize the new taxes that Medicare for All would require. In a white paper accompanying his proposal, Sanders fills in some vertiginous details: raise marginal income tax rates to 40% on incomes from $250,000 to $500,000; raise rates to 52% for incomes above $10 million; and tax capital gains and dividends like income from work. Do those kinds of increases doom Medicare for All? Perhaps just the reverse, for this is one of the few policies that directly confronts American inequality.

No other country has experienced a rise in inequality as steep or as high as the one we’ve seen in the United States. In 1970, standard inequality measures pegged the United States at roughly the same level as France and Japan; almost 50 years later, U.S. inequality levels are closer to those of Mexico and Brazil than to those in Northern Europe.4 Today, the top 1% of households control 38.6% of the country’s wealth, far more than the bottom 90% (which controls just 22.8%). The median white family (in the exact midpoint of the income distribution) is 10 times as wealthy as the median black family. Intergenerational economic mobility has stagnated.5 Political scientists generally believe that rising inequality and slowing mobility have a destabilizing effect — and they may be driving the angry populism that is now stirring on both the left and right ends of the political spectrum.

Medicare for All offers politicians a way to squarely address the issue. It would lift a substantial financial burden from low- and middle-income families — their health insurance premiums — and shift the weight to wealthier Americans by raising their taxes. In reversing inequality, taxes are not a bug but a populist feature. Disruptive populism ended past American gilded ages, and it shows signs of challenging the current one. If so, Medicare for All is on a short list of available policies designed to push back on inequality.

Isn’t Medicare for All politically implausible in antigovernment America? It is easy to forget how dramatically U.S. politics changes from era to era. New issues rise onto the agenda, different national values grow more (or less) important, underlying political assumptions evolve, and an entirely new coalition grows influential. What seems impossible in one generation is taken for granted in another. The kind of turbulence we are experiencing in contemporary party politics often signals precisely this sort of sea change. One necessary condition for a breakthrough change is already in place: a righteous band of reformers, deeply committed to a cause, pushing against all odds.

Medicare for All fits awkwardly into the Washington conversation because it is more than a health policy prescription. It aims to foster changes on three different levels of analysis. It is a policy proposal designed to improve health care delivery, an ambitious claim about equality and social justice, and an effort to usher in a more progressive era in American politics. Each is a long shot, but Medicare for All and its advocates stand in a venerable reform tradition that has rewritten U.S. politics many times in the past. It would be a mistake to dismiss them now.

Disclosure forms provided by the author are available at NEJM.org.

This article was published on October 25, 2017, at NEJM.org.

SOURCE INFORMATION

From the Department of Political Science, Brown University, Providence, RI.

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