A Spending Machine

The private health insurance industry is, as many have observed, one of the primary drivers of health care costs. We spend far more on health care than any other advanced capitalist country and end up with inferior health outcomes.

The Affordable Care Act (ACA) kept that basic system in place. For all the talk of mandates and cost curves and exchanges, Obamacare massively increased spending in the health care system. When more people get health insurance, more people use health care.

The Medicaid expansion and the subsidies for coverage on the individual market funnel tens of billions of additional dollars into insurance companies and health care providers every year. In 2014, the first year that the ACA was more or less in full force, net expenditures on health care rose 4.6 percent. In 2015, they jumped 5.6 percent. The same year, the federal government estimated that outlays would expand “1.2 percentage points faster than Gross Domestic Product” over the next decade. By 2025, it projected, health care would no longer make up one-sixth of the American economy. It would make up one-fifth.

Much of this spending results in new jobs. From 2011 to 2016, overall job growth in the US sat at 8.3 percent, but the number of health care practitioners rose 15.8 percent. Nurse practitioner jobs increased 76 percent. Speech-language pathologist positions expanded by 29.6 percent. “Medical records and health information technicians” went up 58.6 percent. In the health insurance industry, “insurance claims and policy processing clerks” went up 11 percent.

As long as the ACA fire hose keeps spraying money at the health care industry, jobs will balloon accordingly. If the water pressure drops, the consequences will be real and drastic, even if the overall result is more equitable and more affordable health care.

Medicare for All wouldn’t just scrap Obamacare — it would uproot the entire industry. It would be a huge efficiency savings. But it would also be devastating in the short term for hundreds of thousands of working people whose only crime was getting a job at an insurance company, and the hundreds of thousands more who work as billing specialists for clinics and hospitals (the number of medical assistants shot up 44 percent between 2011 and 2016). Yes, the CEO of United Health Group made $101 million in 2011. But few of the 230,000 other people working for the company saw money like that.

Bernie Sanders’s recently announced Medicare for All plan asserts that we “need a health care system that significantly reduces overhead, administrative costs, and complexity,” and projects that his plan would save $6 trillion over ten years.

Those trillions — currently being sucked up by a bloated, profit-hungry industry — could do amazing things. Infrastructure. Education. Housing. Insurance for all, in and of itself, would be remarkable.

But you don’t save $6 trillion just by getting rid of the insurance industry. The US has 35.5 MRI machines per million people. The UK, with its National Health Service, has 6.1. Single-payer Canada has 8.5. We don’t need as many as we have. We can deliver complete patient care with many fewer machines. But fewer machines means fewer manufacturing jobs, fewer technician jobs, less need for new construction for new facilities, and so on.

And MRIs are just one facet of a huge health care system that will see efficiencies across the board in a single-payer system. The benefits of those efficiencies will be felt by all, the harms by few, but they will feel them hard.

The effects of these changes would be highly local. Some of the campuses of large health insurance companies employ thousands. Shuttering them would be like shuttering a steel mill or auto factory — the shockwaves would reverberate through the whole community. Like laid-off autoworkers, employees of insurance companies would be pushed onto the job market with a set of skills and experiences unsuited to most other occupations. The color of their collar wouldn’t change that.

And that disruption would have serious political effects.

The 2016 election hinged on the Rust Belt, states like Michigan, Ohio, and Pennsylvania that used to be home to huge numbers of unionized, high-wage blue-collar jobs. As those industrial jobs disappeared, cities across the Midwest sustained hits from which they still haven’t recovered.

The Democratic Party’s prescriptions — like trying to encourage fifty-year-old autoworkers to go back to community college to study IT — were both condescending and impractical. Many saw no reason to back a party that hadn’t done anything for them, and that left them exposed to the nativist economic nationalism of Trump.

We can’t risk the same thing happening because of single-payer.

Possible Prescriptions

Legislators in two of the states most seriously looking at Medicare for All, California and New York, don’t seem to have considered the job loss problem at anything more than a surface level.

The California bill simply requires that the state “provide funds … for a program for retraining and assisting job transition” for people who lose employment because of single-payer. The amount of money isn’t specified, isn’t guaranteed, and there’s no sense of what “retraining” means in any real sense. The New York legislation contains very similar language.

What’s more, any solution can’t just be about individual workers. It has to be about communities. Rochester, Minnesota has a population of 115,000; the Mayo Clinic employs 34,000. If Mayo shed five or ten thousand jobs because of single-payer’s efficiencies, all the retraining in the world wouldn’t avert a sizable blow to the local economy. And what good would it do for a Rochester resident to get a degree in something new, when the job market has basically dried up?

US representative John Conyers’s Medicare for All bill takes a more direct approach: it throws money at the problem. The legislation allows “clerical, administrative, and billing personnel” displaced by the law to receive their old salary (not to exceed $100,000) for two years, and to receive priority in job training. Even that bill, however, wouldn’t do anything to save communities — many of those displaced workers would take their money and move, only exacerbating the challenges of the Rochesters of America.

Any serious Medicare for All plan needs to include investments in affected communities on a scale this country hasn’t seen since New Deal projects like the Tennessee Valley Authority. In addition, any attendant growth in federal employment would need to be funneled back into the same communities that shed jobs. And that’s just for starters.

Medicare for All is a moral imperative. But the urgency of passing it doesn’t mean we can forget about the details. Otherwise we’ll send the message that our support for single-payer is more aspirational than practical, substituting hope for policy depth and leaving health care workers out in the cold.