With yesterday's passage in the House of the Obama administration's health care reform bill, it would seem at first glance that the movement for national, single-payer health insurance has been seriously derailed. After all, if all of the hype and adulation surrounding the bill's passage is to be believed, the fight for universal health care is basically over, except for necessary technical tweaks that will "fix" and "improve" the bill in the coming years.
However, there are many serious flaws in the bill that will put single payer back on the political agenda sooner than we may think. The indispensable and indefatigable folks at Physicians for a National Health Program (PNHP) cataloged many of them in a press release earlier today, but they only briefly touch on an issue that I think could potentially be a central aspect of single-payer strategy in the coming years: Medicaid and the fiscal crisis of the states.
Under the plan that Congress will pass, about half of the roughly 30 million people that would gain access to health insurance coverage would be placed in Medicaid. Medicaid is funded jointly by the federal government and the states, but the combination of dwindling tax receipts and surging enrollment - an estimated 3.3 million people joined the program in the last year alone - has severely impaired the states' ability to meet their Medicaid obligations. This has forced many states to cut Medicaid reimbursements to doctors, resulting in drastic hardships for many Medicaid recipients. And last week, Arizona completely eliminated funding for the state's Children's Health Insurance Program, leaving 47,000 children without health insurance coverage. Besides, even before the recession, Medicaid was a badly underfunded and often inadequate program, even though five to seven million people that are Medicaid eligible are not even currently enrolled in the program. It's true that under the plan that will be passed by Congress, the federal government will cover the cost of Medicaid expansion until 2016, but after that the cost burden will begin to shift back to the states. Since state budgets are not expected to return to health any time in the foreseeable future, Medicaid expansion could potentially break the budgets of many states around the country.
So what does this all have to do with formulating a winning strategy for the single-payer health care movement? To begin to answer this question, we need to look back at an old strategic proposal that I think has acquired a new relevance in the political terrain created by the passage of the Obama administration's health care reform bill.
In 1966, scholar-activists Richard Cloward and Frances Fox Piven (a long-standing DSA member) wrote an article for The Nation called "The Weight of the Poor: A Strategy To End Poverty." In the mid-sixties, Cloward and Piven found that only about half of the families eligible for Aid to Families with Dependent Children (what welfare used to be called), were actually enrolled in the program. Recognizing the political opportunities this gap between welfare law and practice presented, they formulated an analysis that became known as the "Cloward-Piven strategy." As they explained in their book Poor People's Movements, the strategy had two main components:
If hundreds of thousands of families could be induced to demand relief, we thought that two gains might result. First, if large numbers of people succeeded in getting on the rolls, much of the worst of America's poverty would be eliminated. Second...we thought it likely that a huge increase in the relief rolls would set off fiscal and political crises in the cities, the reverberations of which might lead national political leaders to federalize the relief system and establish a national minimum income standard. It was a strategy designed to obtain immediate economic aid for the poor, coupled with the possibility of obtaining a longer-term national income standard.
The Cloward-Piven strategy to win a guaranteed minimum income for all Americans failed for a number of historically specific reasons, and a discussion of why this happened is beyond the scope of this piece. But the parallel between the premises of the original Cloward-Piven strategy and the situation we find ourselves in today in the fight for single payer presents itself fairly clearly. As efforts to win single payer through traditional organizing techniques and engagement with the established political system fail to bear much fruit, the crisis provoking strategy proposed by Cloward and Piven may be our best way forward.
So here's what I would propose as the next step in single payer strategy: explode the Medicaid rolls. Single payer activists should organize in their communities to sign up as many eligible people as possible for Medicaid - if the administration wants to expand Medicaid coverage, then let's give it to them. Many people would get the health coverage they need in the short term. In the longer term, the system would probably not be able to support all of them when the financial burden shifts back to the states. Popular pressure could then be mobilized to force drastic federal intervention to deal with the ensuing crisis, possibly including the implementation of single payer.
Of course, there are some serious potential disadvantages to this strategy. For it to be successful, the balance of political forces at play when the crisis is provoked would have to be favorable to the left and to poor and working people so that it is not settled on right-wing terms. Needless to say, the prospects for creating such a balance doesn't seem to be terribly favorable right now. I think, however, that engaging in unorthodox and frankly risky strategies like the one proposed here can help to create the conditions for its own success. In any case, if meaningful progress toward the establishment of a national single payer health care system is to be made, it's clear that we need a new strategy. Challenging the administration's health care reform on its own terms could be a very good place to start.