“Show Me the Money”: Labor and the Bottom Line of National Health Insurance

A well-known political scientist once declared that the definition of the alternatives is the supreme instrument of power. The simple question—single-payer or not—conceals major differences over whether to frame the health care issue primarily as an economic question or a moral one. Economic considerations are critical to propelling the cause of universal health care. But advocates of universal health care should not cast the economic competitiveness of U.S. business as the central economic issue at stake in the debate over health care reform.

If we are to finally achieve a fair, affordable, and truly universal health care system, other economic considerations need to frame the debate. These include: How efficient is the U.S. health system? How is the health care cost burden distributed between business, government, and the public? What are the trends in health care cost shifting? What is (and what should be) the role of insurance companies in the U.S. health system and the wider political economy? To their credit, single-payer supporters have been some of the loudest and most articulate voices raising these important questions.

In bringing up these issues, advocates of universal health care need to be wary about emphasizing the economic rationale for health care reform at the cost of the moral rationale. The two cannot be disentangled. All of these economic issues in some way touch on how to redivide the economic pie—and that raises basic questions about economic and social justice.

Organized labor has enormous potential to be the pivotal player in raising these economic and moral questions and anchoring a reform coalition that fundamentally reshapes the health care debate. For well over a century now, labor has been instrumental in the development of the U.S. health system. It established some of the first prepaid group practices and health maintenance organizations, was the leading voice for national health insurance up until the mid-1970s, and was decisive in the establishment of Medicare and in the expansion of other major social programs, like Social Security and the Great Society. The employment-based system of health benefits is largely the product of a collective-bargaining regime established during and immediately after the Second World War. That system is under siege today. Without unions to act as a brake, today’s downward spiral in health benefits for union and nonunion workers would be even faster.

Divided and hemorrhaging members, organized labor still has formidable resources to influence the course of health care reform. The membership rolls and resources of the major unions dwarf those of most public interest groups. Labor’s lobbying capacity has expanded dramatically as the American Federation of Labor-Congress of Industrial Organizations (AFL-CIO), other labor groups, and individual unions have invested more heavily in lobbyists, enlarged their research departments, and developed grassr...