Why Not Single-Payer?

The question most frequently asked by progressive activists at last week’s America’s Future Now conference [1]was this: We hear Obama and congressional Democrats talking about a public health insurance option, but why aren’t they talking about a single-payer system like H.R. 676 [2]sponsored by Rep. John Conyers? Why is single-payer “off the table”?

Let’s begin with an obvious truth, stated here by Nobel Prize-winning economist Paul Krugman [3]:

The alternative [to the Democrats’ public-private health care plan] would be single-payer, aka Medicare for all: a payroll tax on everyone, and a government insurance program for everyone. Wouldn’t that be simpler, easier to administer, and more efficient? Yes, it would.

Single-payer is the cheapest and simplest approach. So why aren’t Obama and the Democrats pushing it?

Some say it’s because the Democrats don’t want to offend the for-profit health care industry—that Democrats in Congress have taken too many campaign contributions from insurers. As Marcia Angell [4], former editor of the New England Journal of Medicine, argues:

Single-payer is simply considered not realistic for a politician. The medical industrial complex just won’t permit it.

Well, it’s certainly true that health care executives, lobbyists, and their hundreds of thousands of employees [5]don’t want to be put out of work. They would all fight their hardest against single-payer. But that’s really not the main reason why Democrats are avoiding such legislation.

Some say it’s because we can’t convince moderate members of Congress to vote for single-payer legislation within the next few months. Darcy Burner, executive director of the Progressive Caucus Foundation, published an important diary on Daily Kos [6] urging progressives to stop “attacking progressives [who are] fighting for a public option” because:

There are not 218 votes for single payer in the House. Single-payer cannot happen in this environment right now, regardless of how passionately its advocates want it.

Darcy, the Progressive Caucus, and everyone on Capitol Hill know this is so. But again, that’s really not the main reason why Democrats focused on a hybrid plan a few years ago.

The main reason is—American voters are scared to death of single-payer.

Even though I’m sitting in a quiet room writing this, I can hear some of you objecting loudly! Friends, we are on the same side. We all know that health care should be recognized as a human right. We all know it is a national shame that more than 50 million Americans are uninsured [7], and 25 million more are underinsured [8]. We all know that even Americans with insurance are struggling with soaring health care costs [9], and that insurance and drug companies are putting profits before people. We all know that we need to change the system.

But we progressives are not the ones who need to be convinced. In any great national political debate, there are partisans on our side and partisans against us. To achieve victory, we have to persuade people in the middle—and they don’t know what we know about health care.

Consider three central facts:

• Nearly all persuadable voters—those who don’t automatically side with or against us—have health insurance. (In fact, about 94 percent of voters are insured [10]. The uninsured, unfortunately, don’t tend to vote.)
• About 3/4ths of insured Americans are satisfied [11]with their health insurance.
• When Americans hear about a health care proposal, they immediately think “how is it going to affect me and my family.” That’s their overarching, overwhelming concern.

That means when average American voters consider a new health care policy, their paramount concern is that the policy allows them to keep the health insurance they have. Union members—who usually can be counted on to support progressive policy—are among the most adamant that they be permitted to keep their health insurance. Why? Because unions tend to negotiate better insurance for their members than the rest of us have!

No matter how good a single-payer system might be in theory, these voters are easily turned against any plan that they think might force them off their current health insurance. That’s what the 1994 “Harry and Louise” ads were all about—claiming that the Clinton plan would force Americans to “pick from a few health care plans designed by government bureaucrats.” The Harry and Louise ads thoroughly scared voters—and that’s why they were so effective.

How do we know this? Over the past two years, progressive groups have conducted an unprecedented amount of public opinion research about universal health care. Usually it’s the conservatives who have all the polling data. This time, our side has the upper hand. In fact, I believe progressive advocates have more polling, focus group, and “dial group” research on this than on any issue in history. That research shows that, even if a single-payer proposal starts out with a majority of Americans in support, it won’t hold majority support after the insurance industry clobbers it with ads.

When voters hear this debate, they already have preconceptions and stereotypes in their heads. A proposal that’s anything like single-payer makes them see negative images—long lines, surly bureaucrats, and denial of services. It will take years to “educate” voters that single-payer wouldn’t do that. And we don’t have years—if we fail to pass health care reform this year, the opportunity may not present itself again for a generation.

The bottom line is that in order to get persuadable voters on our side, our health care plan must give everyone the choice to keep their private health insurance if they want to. If voters think we’re giving them the Canadian or British health system, we lose—that’s why Obama talks about creating a “uniquely American solution.” And we also lose if voters think we’re offering “Medicare for All”—the phrase has been thoroughly tested and it just doesn’t work.

That brings us to the idea of a public health insurance option. If you support single-payer, the very best thing you can do is fight like hell for the public option. Just as Americans overwhelmingly want the choice to keep their existing private insurance [12], they also overwhelmingly want the option to enroll in a government-sponsored insurance plan [13].

Single-payer describes a financing system. It’s the most efficient system. But the important goal isn’t financing, it’s coverage for every American. A couple of years ago, Paul Krugman concluded [3]that:

In an ideal world, I’d be a single-payer guy. But I see the chance of getting universal care, imperfect but fixable, just a couple of years from now. And I want to grab that chance.

I agree with the Nobel Prize-winner.

DEAR READERS: I want to hear your response about single-payer versus the public health insurance option. Please weigh in by clicking "discuss" and posting a comment, or you can email me at bhorn@ourfuture.org [14]. And if you're for the public option, please sign Gov. Howard Dean's petition at Stand With Dr. Dean [15].