October 15, 2017


Jonathan Oberlander, PhD
Professor of health policy and management
Professor and chair of the Department of Social Medicine, UNC School of Medicine


The Affordable Care Act (ACA) has an recent years. A bipartisan agreement to repair the ACA impressive record of survival. It has managed to overcome legal challenges, state resistance, controversy, unpopularity and a disastrous rollout of healthcare.gov. At least for now, it has survived efforts by Congressional Republicans and the Trump administration to dismantle it.

Yet, following the implosion of Republicans’ repeal efforts, the ACA’s future remains uncertain. The Trump administration already has taken steps, including defunding efforts to promote enrollment, to weaken “Obamacare.” Will President Trump choose to take more dramatic steps, such as refusing to reimburse insurers for the cost-sharing reductions they give low- income enrollees in ACA plans, something that could further destabilize the ACA’s troubled marketplaces?

Alternatively, it is possible that a bipartisan agreement could emerge that would strengthen and stabilize insurance marketplaces. In theory, Democrats and Republicans could come together to improve the law. Republicans could acknowledge that the ACA is here to stay and pursue reforms rather than repeal. Democrats could acknowledge that the ACA has serious problems that require attention.

However, bipartisanship in health-care politics has been seen in Washington about as often as unicorns in would require a suspension of the existential politics and partisan polarization that have pervaded health-care policy. I hope it happens – but common sense does not tend to prevail in U.S. health-care policy.

Q: There is a lot of attention to single payer as an alternative to Obamacare – could it happen at the federal or state level?

A: The American health-care non-system is, even after the ACA, extraordinarily dysfunctional, costly, complex, wasteful, inefficient, irrational and inequitable. Therefore, the appeal of single payer arrangements (think “Medicare for All” or Canadian-style national health insurance, with the government as the sole insurer) is understandable.

Dissatisfaction with the ACA’s limitations have fueled interest in single payer insurance, as has the prospect of Obamacare’s repeal. Those limitations include the facts that health insurance remains unaffordable for many Americans; we still have nearly 30 million people who have no coverage; many who are insured face rising out-of-pocket costs for deductibles and copayments; and under-insurance is increasing, even as lack of insurance has dropped substantially.

In 2014, Dr. Jonathan Oberlander explained how to enroll for insurance coverage through the Affordable Care Act. (Photo © University of North Carolina at Chapel Hill)

In 2014, Dr. Jonathan Oberlander explained how to enroll for insurance coverage through the Affordable Care Act. (Photo © University of North Carolina at Chapel Hill)

Bernie Sanders’ presidential campaign also gave a boost to the idea of single payer. Some polls show increasing public support for the idea. Still, political obstacles to single payer – including fierce opposition from the insurance industry and other stakeholders, the well-insured’s fear of changing health plans, Americans’ deep ambivalence about government, the political difficulty of raising taxes to a level necessary to fund single payer – remain formidable.

Even liberal states predisposed to single payer face the difficult fiscal and political question of how to finance such a plan, an equation that no state has solved to date. Given the current Congress, single payer has no immediate prospects in Washington.

Will the Democratic party turn to single payer in the 2020 campaign? That might be possible, as candidates try to appeal to the liberal base of the party whose members vote in primaries. However, for all the recent momentum, none of the barriers to single payer has eroded substantially.

Democrats instead could consider “Medicare for More”– expanding the existing Medicare program – rather than “Medicare for All” as a goal. For decades, some health reformers in the United States have framed the debate as single payer or nothing, and generally, they have gotten nothing. Given the constraints of U.S. political institutions and our patchwork health-care system, any reform that passes must be a compromise, just as the ACA was.

It is easy to design on paper a better health insurance system than we currently have, but it is much harder to enact such a system through Congress. Whatever the long-range aspiration, reformers need to grapple, in the short term, with ways to improve our health-care system and strengthen its ability to serve all Americans.


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Carolina Public Health is a publication of the University of North Carolina at Chapel Hill Gillings School of Global Public Health. To view previous issues, please visit sph.unc.edu/cph.