A Provocative Question

[David Morris]

For Laura.

https://www.balloon-juice.com/2016/11/23/amendment-69-single-payer-and-plausible-option-space/

Amendment 69 was the Colorado Care amendment.  Ballotpedia has the language
the results:
<https://ballotpedia.org/Colorado_Creation_of_ColoradoCare_System,_Amendment_69_(2016)>
A *“yes”* vote supported creating ColoradoCare
<https://ballotpedia.org/Colorado_Creation_of_ColoradoCare_System,_Amendment_69_(2016)#Overview>,
a healthcare payment system designed to finance universal healthcare for
Colorado residents partly through an additional 10 percent payroll tax—two
thirds paid by employers and one third by employees—providing approximately
$25 billion per year in revenue.
A *“no”* vote opposed this proposal, leaving the Colorado healthcare system
unchanged.

No won by more than 3:1 over Yes.

It was not just Trump supporters who voted no.  Mechanically well over half
of Hillary Clinton’s vote in the state voted against Amendment 69.  I
probably would have been one of the Clinton-No votes
<https://www.balloon-juice.com/2016/08/31/a-note-on-colorado-care/>as I
could never figure out the financing of the proposal.

So what are the lessons that need to be learned?

First, single payer has a concentrated and motivated group of supporters
but they are not a majority of the Democratic party.  We have revealed
preferences on this in the 2007-2008 health policy proposals.  In that
election cycle there were three viable candidates offering healthcare plans
(Obama, Clinton, Edwards) and none of them offered single payer.  We also
have Amendment 69 failing with at least majority Democratic opposition.  We
saw major Democratic influencers not come out for Amendment 69.

Secondly, this is the second major single payer failure in the past three
years.  Vermont stopped their exploration process because they could never
make the money work well enough to get a viable proposal to send out for
approval.  Colorado resoundingly rejected their proposal.

Single payer, behind a Rawlsian veil of ignorance and starting fresh, makes
a massive amount of sense.  We do not operate in that world.  The world
that we live in has a healthcare system that produces winners and losers.
Providers and healthy people with good insurance through either work or
Medicare are either actual winners or apparent winners.  Most of the losers
of the current system are either amazingly diffuse (lower cash wages for
most workers), already somewhat covered (disabled on Medicare or Medicaid)
or politically powerless.  The challenge is how to get a policy that is
disruptive as all get out that mainly benefits people with low political
salience and power while either hurting or causing fear in people with high
political salience and power through?  I don’t know how to do that.  This
needle threading exercise is one of the many reasons why the ACA was
designed as it was as it sought to keep the status quo as visibly
entrenched as possible while improving things for low political power and
salience groups.

Third, single payer is hard.  It is not something that can just be hand
waved into existence.  It is something that needs a lot of high quality
nerds and experts working through odd scenarios, looking at interactions
and then presenting their thoughts to the general public for a long and
hard listening to the concerns, questions and suggestions of the people
that will actually have to use the system.  One of the major reasons why I
was not gung-ho for Colorado Care is that I had not seen them do the actual
financial math.  They assumed they could get a 1115 Medicaid waiver and a
1332 ACA waiver even as the waiver granting authorities were indicating
reluctance to grant the needed expansive waivers.  They just assumed the
money would be there instead of lining up cash commitments ahead of time.
They also assumed Hyde and current Colorado state law would not apply to
abortion and other female reproductive health care procedures.  There were
a lot of assumptions on the mechanics of implementation.

Single payer is hard work to implement.  Lazy work turns off potential
allies that may not be sufficient to form a minimally viable winning
coalition but definitely necessary to that coalition.

Given today’s politics, single payer advocates will have a decade to get
the hard work done of designing a plan, figuring out implementation and
persuading the public including people who are current winners that this
plan is better than the status quo and the uncertainty is low.  That works
needs to be done and Colorado is a source of good information for that work.
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