Blog: A Brief Response to Dave Kamper’s “Taking Single Payer Seriously” in Jacobin

Yesterday in Jacobin, Labor organizer Dave Kamper had a good article arguing that single-payer supporters need to have a more robust plan ready to deal with the expected displacement of administrative and billing workers that would result from implementation of a Medicare-for-All system.  As he puts it:

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…

And Kamper is correct here.  The elimination of administratively inefficient private health insurers, the transition to global budgeting of hospitals, and simplified billing requirements for physicians’ practices would translate into huge efficiency savings, which is part of the very raison d’etre of single-payer.  The latest number on administrative savings from David Himmelstein and Steffie Woolhandler, published in the Annals of Internal Medicine, is $503.6 billion/year.

This clearly would result in job losses for billers, coders, and insurance workers on a significant scale, and so a concrete plan to deal with this displacement is necessary.  Now, as Kamper notes, Representative John Conyers’ HR 676 “Medicare-for-All” bill does have an explicit plan for this: it would provide these workers with salaries for two years as well as prioritized job training.  Perhaps that is not enough, as he contends.

But I would take slight issue with one aspect of Kamper’s argument, which seems to suggest that efficiency savings in single-payer would result in job losses beyond administrative workers to the larger healthcare workforce (he notes, as one example, that we may need fewer MRI machines).

This issue actually relates to the broader debate about the costs of single-payer healthcare that is currently ongoing.  I and others argue that in the short term, we should not expect major net savings from single payer.  Yes, there will be large savings on administration and on pharmaceutical expenditures, but at the same time, we are going to be providing more healthcare overall, not less.

Currently, 28.6 million people in America lack health insurance coverage.  The uninsured are going to use more care, more medications, and more services of every type (potentially including more MRIs!) once they are insured (although there are supply constraints that limit this on the system-wide level).  And the elimination of cost sharing for the rest of us—together with the inclusion of new benefits that today are often uncovered, like universal dental care and long term care—are also going to cost money and require a larger, not a smaller, clinical workforce (points made here and here and elsewhere).

The idea here is that efficiencies balance new costs, not that we suddenly slash overall US healthcare expenditures as a percent of GDP to Canadian levels (although moving forward, cost growth can certainly be better controlled on single-payer, which may be the most important issue, and does not have the sorts of workforce implications under discussion here).

In other words, while we need less billers and coders and clerks, we will most likely need more clinical workers.  Retraining non-clinical healthcare workers to be clinical healthcare workers may not always be possible, but it is not impossible either.  And with overall healthcare spending remaining roughly unchanged during the transition to single-payer, there would no reason to predict disruptive changes to the communities that are based around large healthcare delivery systems.

I agree with Kamper “that any attendant growth in federal employment would need to be funneled back into the same communities that shed jobs.”  However, the transition to single-payer will simply not be akin to the fall of manufacturing in the neoliberal era: think more of a deliberate, thoughtful transition from fossil fuels to green energy than the gutting of an entire industry.