There's an argument making the rounds that the Hobby Lobby decision proves the necessity of single payer. "The only way to resolve this mess is to take employers and their 'sincere beliefs' completely out of the picture," writes Michael Hiltzik in the LA Times. "Remove employers and the insurance industry exits with them. What's left is single-payer healthcare, which is the right way to deliver services that are matters of life and death."
For all the virtues of single-payer health care — and there are many — the Hobby Lobby decision underscores one of single-payer's real problems.
At the core of the case is the fact that Obamacare had to decide which health-care services absolutely needed to be covered and which services didn't. One of the services Obamacare deemed essential was contraception. That's what led to the Hobby Lobby case: prior to Obamacare, there was no federal law forcing employers who offered insurance to cover contraceptive care, and so no need for employers to seek exemptions to that law.
A single-payer system heightens the stakes on this kind of decision. The assumption behind some of the Hobby Lobby-based arguments for single payer is that a single-payer system would cover contraception and that would mean everyone's insurance covers contraception. But a Republican-led government could decide that taxpayer dollars shouldn't be going to cover contraception at all, and then a single-payer system means no one's insurance covers contraception.
An example comes from one of America's current single-payer systems: Medicaid. While Medicaid does cover contraception, Congress decreed years ago that it can't, under any circumstances, pay for abortions. So while people buying private insurance can choose a plan that covers abortion if they want (and, in fact, about two-thirds of private health-insurance plans cover abortions), people in the Medicaid system have no option to choose a plan that covers abortion.
Or look at the states. As Sarah Kliff reports, "states passed a record 205 abortion restrictions between 2011 and 2013, more than the entire 30 years prior." Imagine if the Congress controlling the benefits package under single payer looked more like one of those legislatures.
So the question with single payer isn't just whether you like the model. It's whether you trust the US government to implement the model. This was driven home to me during a conversation with Uwe Reinhardt, a Princeton health-care economist who supports single payer. "I have not advocated the single payer model here," he said, "because our government is too corrupt."
The point here isn't that single payer is a bad way to structure your health-care system. As other countries show, single-payer systems can work beautifully. But a single-payer system can only be as good as the government that runs it. So how good do you think the US government is?