House hagglers zero in on single-payer and it all comes down to two little words

Reviewed by James Ives, M.Psych. (Editor)May 23 2019

A powerful congressional committee holds a hearing on single-payer health care.

It sounds like the perfect place for lawmakers looking to score easy political points and cut new sound bites for one of the nation's biggest policy debates. Right?

Not if you're talking about Wednesday's hearing in the House Budget Committee. Members from both political parties questioned Congressional Budget Office officials in a quest for new ammunition in a health care fight that has already lit up the 2020 campaign trail.

Would single-payer severely weaken the economy, or drive doctors out of business? Would it result in better, more affordable care for all Americans, or even save lives?

And, consistently, they were thwarted by two deceptively simple words.

"It depends."

Deployed in various forms by three of Washington's top number crunchers, that caveat underscored a point the same office made three weeks ago: "single-payer," or "Medicare for All," could play out in countless ways. And before policymakers can prognosticate about what such a shift would do, they need to answer some more basic questions.

No matter what, said Mark Hadley, the CBO's deputy director, "Moving to a single-payer system would be a major undertaking."

Unanswered questions, he said, include what kinds of benefits would such a system cover, what would it pay doctors for those services, might nurse practitioners or physician assistants play a greater role under that system, what kind of cost sharing would be left intact and who might pay more in taxes under that system?

Just the term "single-payer" — a system in which health care is paid for by a single public authority — leaves those nuances murky.

This open-endedness is why the CBO hasn't put a price tag on what it might cost, which is its job. That point came up repeatedly Wednesday, with Republican committee members suggesting the office look at the progressive-backed Medicare for All bill spearheaded by Rep. Pramila Jayapal (D-Wash.), also a Budget Committee member.

Democrats didn't request an estimate on any single single-payer bill because "there are so many ways of doing this," said committee Chairman John Yarmuth (D-Ky.). "It would be an enormous matrix of a lot of different numbers on it."

It's unclear, Hadley emphasized, whether single-payer would cost more in health care spending than the current system does. Medicare pays far less on overhead and administration than does private insurance. But still, that's only one variable.

Even without those numbers — or much cooperation from their witnesses — members did their best to try out attack lines.

Republicans painted a picture in which doctors would face pay cuts and abandon the practice of medicine, Americans would languish on waitlists for lifesaving medical care, and Washington bureaucrats would decide what health care is covered.

"Americans would have no choice but to wait longer and pay more for lower-quality care," argued Rep. Jason Smith (R-Mo.) — despite Hadley's repeated response that, actually, wait times, cost and quality would all be products of choices Congress makes in designing any single-payer plan, and not inherent to the system itself.

Democrats showed their own division.

Rep. Seth Moulton (D-Mass.), who is also running for president, argued that the CBO framework supported the need, not for single-payer but for the government to offer a so-called public option - a government health plan that competes against private insurance. Many a Democratic candidate has already backed this approach on the campaign trail.

Other members, like Rep. Ro Khanna (D-Calif.), focused on more sweeping changes, such as those backed by Jayapal and, on the Senate side, Vermont independent Bernie Sanders. (Khanna is a co-chair on Sanders' presidential campaign.)

Khanna argued that single-payer health care would increase wages for the lower 50% of workers, since their employers would no longer have to subsidize health care and could instead pay higher salaries.

"It's possible to design that system, yes," Hadley said.

But that possibility depends on several other factors: for instance, how much employers pass those savings back to employees, and how any new taxes to finance the new health care system are structured.

Or, to put it another way: "It depends."

Wednesday's hearing marked the second House discussion of single-payer — but it won't be the last time the Budget Committee discusses it. In her remarks, Jayapal called for the committee to hear testimony on her specific Medicare for All bill at a later date.

Republicans, including the committee's ranking member, Steve Womack (R-Ark.), support this idea, which could help them tie more moderate Democrats to the single-payer issue.

If they do, members will once again have to confront an inconvenient fact: Actual health reform is complicated and won't reduce to easy sound bites.

"The effects of such a system," as Hadley put it, "could vary greatly depending on the details."