While some employer-insured Americans are satisfied with the health care they receive, tethering health insurance to employment generates enormous economic anxiety and insecurity, shaping and constraining the life choices and aspirations of millions of people. People take jobs they find otherwise undesirable and stay in ones they’d otherwise quit. They curb their demands on the job for fear of getting fired and losing their health insurance. They’re prevented from realizing their potential not just because they might not get the care they need or because they might still end up in bankruptcy, but because of the oppressive hoops they must jump through to acquire health insurance.
For most Americans, a job is a job. This isn’t to say that people at all rungs of the economic ladder can’t derive meaning from their work (among non-elite professions, clergy and firefighters stand out in job satisfaction studies). But for the majority of Americans, work is more of an obligation than a passion. They do it to survive.
This compulsion creates a relationship of subordination: workers, to varying degrees, are forced to accept terms of employment that they wouldn’t agree to voluntarily. In the US — unlike other advanced capitalist countries — the need to obtain health insurance through employment introduces an additional source of leverage for employers. After salary or wages, the most significant part of the employment contract tends to be health insurance. And employers know it.
The resulting dependency and vulnerability is especially acute when a worker’s entire family relies on them for health coverage (particularly if one of their family members has a chronic or life-threatening disease). In such cases, health insurance surpasses even monetary compensation as the primary motivation for maintaining employment. When your child has cancer, it’s that much harder to speak up about your boss’s sexual harassment.
On top of that, job security isn’t a certainty in many segments of the American job market. While those in the top tier of society rest easy knowing they will be paid for what they know, who they know, and who they are, many workers routinely worry about losing their jobs due to mass layoffs, a failed drug screening, a conflict with a superior, a business closure, or outsourcing — as well as the ensuing specter of a long and drawn-out job search that may end up dumping them into the ranks of the long-term unemployed. At-will employment, a fixture of American law, is a godsend for employers and an albatross for employees.
Given this landscape, enacting a single-payer system would be one of the most liberating policy advances the US has seen in decades. While other types of incremental health reforms (including Obamacare) claim to move toward universality and affordability, only a Medicare-for-All system would sever the connection between health insurance and employment. It would dramatically change the employment calculus for every working person in the country, shifting power away from the boss.
The workplace might remain a realm of “private government,” as Elizabeth Anderson puts it, but it would become a little less autocratic. No longer would health insurance be something companies could dangle over workers’ heads. (This might be why, despite potential cost savings, most employers aren’t exactly rushing to wave the single-payer flag.)
Often we view progressive economic policies solely through a material lens: workers need higher wages, pensioners need better benefits. This took a crude form in 2016, when then-presidential candidate Jeb Bush suggested that Democrats won over black voters by offering them “free stuff (and Hillary Clinton attacked Bernie Sanders for “promising free this and free that and free everything”).
But what the political class misses is that “free stuff” is about more than just money — it is about freedom and liberty for ordinary people. Lack of health insurance (and college debt, and middling disability benefits — the list goes on) severely limits a person’s ability to choose which career to pursue, where to live, when to start a family, how many children to have, and what types of hobbies to take up. In short, it’s not about free stuff — it’s about a free life.
Given that the propaganda campaign against Medicare for All will surely invoke the bogeyman of a tyrannical “government takeover,” fashioning an alternative frame — one that casts the private, employer-based insurance system as the true affront to freedom — will also be of immense practical use.
Health care, as single-payer advocates remind us, is a human right. But it won’t be enough to simply state that health care must be a right. We will also need to make clear why it must be a right: because without it, it is impossible to direct one’s life. It is impossible to be free.