Cross posted from Pruning Shears.

Here is an interesting thing about the new health care law: News stories on it sometimes conflate flaws in the existing system with those in the new one. Many complaints about Obamacare are actually complaints about America’s health care system.

The administration bears some blame for that; the White House has done some conflating of its own. Most famously, the president assured us we would be able to keep our plans. That was never a promise he was in a position to keep. The new program still goes through the private insurance market, which means they decide what customers are restricted to.

But that has always been the case. Insurers playing around with provider networks, policies etc. is a longstanding feature of the system. It’s not as though Obamacare introduced it. It was foolish, though, for the president to speak as though he was the one in charge of that. The only way to guarantee that is to prohibit insurers from altering their policies.

Here is another example of bad policy that predates Obamacare. As the saying goes, programs for the poor are poor programs. Meaning, there will never be a formidable Big Poverty lobby on K Street, so programs that are means tested will not have natural allies in the halls of power. However well intended (and effective) they are at launch, over time they will languish and get chipped away at. Universal programs are much more robust and likely to not just survive but thrive over the long term.

We have something like a controlled experiment in that when it comes to the federal government and health care. There’s a universal program (Medicare) and a means-tested one (Medicaid). Any politician who supports Medicare cuts immediately becomes an endangered species. Medicaid cuts, though, are fair game.

Washington state, for instance, expanded its Medicaid “estate recovery” provision in 2004 to include all medical expenses, not just long term care. So should your net worth not be entirely wiped out by that end-of-life nursing home stay, should you have some small amount left over that you were thinking might help your survivors defray the cost of, say, your funeral: Forget it. The state will also charge you for the aspirin you popped along the way.

But because this happened to a means tested program, not a universal one, who (that matters, anyway) was going to raise a fuss?

Fast forward to Obamacare. Medicaid expands and begins taking in people at higher incomes. Suddenly, people scraping the lower end of the middle class are eligible for benefits. While this group is not exactly calling the shots, it can create at least a little noise:

The state issued notice Monday that it will amend its estate recovery policy to avoid “unintended consequences” for people who enroll in Medicaid for health care under the expansion made possible by the Affordable Care Act.

And the state basically admitted, as diplomatically as possible, that no one really cared when only the desperately poor were getting that treatment:

The agency said the new rule was “largely non-controversial” for most of that time, but that “new concerns were raised recently due to the different population of uninsured, non-disabled adults now being served under Medicaid expansion.”

Just like with private insurance companies jerking people around, this really bad policy was only highlighted by Obamacare – not created by it. Yet fairly or not, in the popular imagination it’s all getting filed under “Obamacare sucks.” Many people discovering, as though for the first time, the shortcomings of for-profit health insurance and means-tested health care. They might therefore be especially receptive to expanding a program that shares neither of their weaknesses: Medicare.

An emerging theme on the left is that national single payer, forever praised to the skies in theory, is not achievable these days because that energy is better directed towards single payer efforts in states. Two responses to that: First, the most likely states for such efforts are still years away from achieving that goal, and in any event success is not guaranteed. Vermont has actually passed a single payer bill, but it cannot be implemented until a federal waiver is granted in 2017.

What is the advice for uninsured Vermonters for the next four years? Don’t get sick? As for the states that are supposed to follow in short(ish) order, I’ll just note that California twice passed single payer when it faced certain veto. Now that a presumably friendly governor is in office the road is apparently clear, but still nothing. States might act with what the state-by-state theory would find a curious slowness.

Second, even if states like California followed Vermont’s lead, there is no inexorable logic that would force all the other states to do so. The domino theory won’t work on health care any more than it did for communism. State-by-state single payer will improve health care in states where it passes, but it will consign those in states hostile to it to ongoing misery. Proponents of the strategy should be honest enough to acknowledge that, not pretend that Alabama is somehow obligated to ape Vermont.

We are forever told by our political betters in the church of the savvy that Medicare for all is a noble pipe dream, and only the unserious agitate for it. Of course, that was the conventional wisdom about expanding Social Security until not too long ago. Suddenly it has become acceptable to talk about it though.

There will be midterm elections in under a year. Do you know what might be savvy? To run on a Medicare For All platform – a promise to actually do something, not just belch out bromides – and jam the hell out of Republicans who are preparing to ostentatiously campaign on their love for the program. Of course, that’s provided that the party in question actually believed its rhetoric and was not simply deploying it to forever dupe the rubes.

The only way that change happens is to keep pushing. And in any event, it’s always good to favor the best actual policy. Things are impossible until they are not. Ideas are outrageous until they cease to be.

Photo by Patrick Giblin, used under Creative Commons license