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So this probably isn't the best time for a single-payer advocate to look for the bright side, and it seems even more of a delusional exercise to try to lay out a path from the Rube Goldberg contraption cooked up by House and Senate Democrats towards a sensible system of health care delivery.
But let's try, nonetheless. How do we get to single payer from here?
First, let's start by recognizing one of our strongest allies in the push for single payer, the insurance industry itself. If we can count on anything, we can count on the greed and short-sightedness of the health insurance industry to do a large part of our work for us.
Imagine you're an insurance company CEO, and you've just been handed tens of millions of new compulsory customers, all forced to buy your defective products. And, thanks to the small army of lobbyists you enlisted, you've completely escaped any meaningful cost controls. How would you respond to this situation? "Wait a minute..." you say, "People have to buy my product, no matter how much I raise the price, and there's no limit on how far I can raise the price?" The 40% premium hikes we saw earlier this year are just a small taste of things to come.
Of course, the price of health insurance has been increasing at far beyond the rate of inflation for decades now (more than doubling in the past ten years), but the difference now is that the government is on the hook for those price increases in a way it was not before. Under the new legislation, costs to individuals forced to buy private insurance are capped at a percentage of income, and real incomes aren't going to increase any time soon, so that leaves the feds picking up a larger and larger share of premium costs.
So we can expect the federal costs of this "reform" to skyrocket, as insurance CEO's do what they do best - raise their prices and profits through the roof. This will inevitably set up a tension in the House and Senate between fiscal conservatives, opposed to these rapidly escalating costs, and corporatists, both liberal and conservative, who want to keep shoveling taxpayer money into the for-profit insurance industry.
Whenever you're facing the overwhelming power of a corrupt government-corporate "partnership" (as we increasingly are these days), it's important to look for a wedge issue that can split the partnership apart, and get the cronies fighting among themselves. Escalating federal costs - tied to escalating insurance-industry profits - are that wedge.
But squabbles among corporate elites and government elites aren't enough. We need a strong, broadly-based popular movement to hammer the wedge in further. Where will that movement come from?
Here, I'm sorry to say, some patience is required. Over the past year, there has been enormous opposition to the Obama bill, both from people like me on the left, and from the entire Republican party on the right. But, as we all know, this opposition alone wasn't enough to prevail. One key reason was that the opposition was ideologically based, and therefore easily divided along ideological lines. A "movement" that requires me to work with Glenn Beck is obviously never going to get anywhere.
How do we build a stronger and broader movement against mandatory for-profit insurance? Here, it's important to recognize two points:
1) Whenever we're talking about a bill that has not yet become law, opposition will inevitably form along ideological lines, because arguments pro and con will be based on predictions about what may happen in the future, which are in turn dependent on our assumptions about how the world works, which are naturally dependent on one's ideology.
2) The number of people involved in an ideologically-based movement will always be much smaller than the number of people who join in a self-interest-based movement, especially in a depoliticized nation like the United States. The vast majority of Americans -- who listen to neither Glenn Beck nor Amy Goodman -- tend to take a "wait and see" approach to legislation, a position they're encouraged to take by our media, which provides virtually no useful information about a bill until the bill is passed. Our government and media elites treat us as spectators rather than participants in the process of governing, and most Americans accept the spectator role, whether reluctantly or willingly, until their own personal interests are directly threatened.
In short, no strong popular movement until self-interest begins to bite. And the bite won't come until 2016 (remember, I said some patience is required). Around 2016, millions of Americans will be receiving letters from their favorite government agency, the IRS, notifying them that they must either spend thousands of dollars out-of-pocket to buy insurance from insanely profitable - and insanely unpopular - for-profit insurers, or pay a fine to the IRS and get nothing in return (the bill actually sets the start date for the individual mandate at 2014, but serious fines for non-participation don't really kick in until 2016.)
How will those millions of Americans respond? Some will respond ideologically, of course, and we will surely see a populist movement on the right based on civil disobedience and non-participation in the hated Obama plan.
The right-wing populists will win the bulk of the media attention (as they always do) but the response of most Americans to the insurance mandate will be based on rational calculations of self-interest rather than ideology. Most of those facing the mandate will compare the costs and benefits, and if their need for insurance is great enough, and their ability to pay is great enough, they will enroll. Many will even be grateful for the opportunity to buy insurance that they could not afford previously.
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