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Paths From the Swamp of Substandard Health Care Toward a Single-Payer System

There is a consensus that, in terms of health care reform, we are at a watershed moment that comes around only ever decade or so. It is imperative that some form of inclusive, affordable, and quality health care be legislated now or we will all suffer the consequences of delay.


This article is intended to identify and reference some of the major bills related to health care and to briefly discuss the dual dilemmas of “the best being the enemy of the possible” as well as the idea that “half a bridge” may not get us where we need to go. Progressives are likely to favor single-payer (SP) health care, emphasizing that it is the most cost-effective, inclusive, and consumer-oriented model since this would eliminate, or minimize, the role of the for-profit health insurance companies. Thus, they may strongly urge advocates to hold out for this option—or at least to hold out as long as they can in order to get a “pragmatic alternative” as close to this model as feasible.

This writer believes that there are principled, credible advocates of alternative proposals who agree that SP is the best policy solution and disagree only on the strategy for achieving it. They believe a pragmatic, incremental program approach is a likelier route to single payer than holding out for full enactment in one fell swoop.

Current Legislative Proposals for Health Care Reform
In the House, John Conyers, Jr.has a single payer bill (HR 676). In the Senate, Senator Bernie Sanders (I-VT) has introduced a single payer bill as well. A sample single-payer rationale, this one from the healthcare advocates in the labor movement.

A powerful coalition of left and center Democratic leaders including President Obama and the chairmen of the five Congressional committees with jurisdiction over health reform (George Miller, Henry Waxman, Ted Kennedy, Charles Rangel, and Max Baucus) appear to have agreed on a broad outline endorsing :

  1. mandatory insurance for all, with employers required to pay part of the cost; and
  2. a government “public health insurance plan option” (e.g. Medicare or the Federal Employee Health Benefit Plan) as an alternative to private insurance.

Payment for coverage of the uninsured is a major difficulty that has not yet been resolved, especially since Republicans are seeking to block the public health insurance plan option on the grounds that it would compete with private insurers. The differences between a single payer plan--the Sanders single-payer bill in this example--and the more centrist bills by some of the legislators noted earlier are summarized by the Physicians for a National Health Program. A key issue here is whether or not Health Care Committee Chairman Max Baucus (D-Montana) will allow or be able to preserve the public health care option in the face of resistance from the insurance industry opponents.

The Strategic Case for Single Payer HC
For those who favor SP, the thorniest question is timing: how long will it take to educate the public sufficiently to win SP over a well-funded campaign by the insurance and drug industries and anti-government conservatives? Proponents argue that:

  1. if the public could be educated to understand its practicality, it would be accepted despite fierce industry resistance; and
  2. the adoption of a “half a loaf ” can also make things worse since the public may wrongly equate the half-measure with actual SP.

This could also set back incremental reforms. SP advocates recognize that there is no magic bullet or one-size-fits-all SP plan. This individualized approach can be used to good advantage by having a state plan that can coordinate with consumers at the local service delivery level. This may be more acceptable (or make it harder for conservatives to fight) since conservatives argue—at least in theory—that they favor “smaller, more local government.”

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Above all, SP advocates should oppose premature compromise in any case. If they must adopt a “pragmatic alternative” it needs to be something close enough to SP to make it a viable stepping-stone toward a plan with increased public control in the future. Indeed, this seems to be one area of commonality with progressive supporters of incremental approaches, and could be the basis for working in coalitions to build broader public support for the idea of increased public control of health care. Each has a stake in a “bridge that goes far enough” to maintain their credibility.

In this writer’s experience, some SP advocates are mistrustful of incrementalists who seem too ready to compromise and/or are recipients of funds from the private sector and/or industry opponents. When the Obama administration would not allow SP representatives into his Healthcare Summit on March 5, (including Senator John Conyers, Jr.) this action fed the mistrust of SP advocates. The fact that Obama’s forces later relented under pressure and eventually admitted a few representatives may or may not have dispelled some of this mistrust.

The Strategic Case for Alternatives to Single Payer Care
The centrist approach being developed by President Obama and Democratic leaders includes a “Medicare for all” component in the form of the “public health insurance plan option.” The word “option” reflects the conviction of many Democrats that voters (the majority of whom have employer-based health insurance) will reject health reform out of fear unless they are first reassured that they can keep the plan they now have if they so prefer.

Advocates of this approach believe that the public plan option provides an opportunity to move single payer forward strategically by creating a single payer system within a system. This would show the superiority of single payer to the next generation experientially, not just rhetorically. Given the opportunity, they argue, who would choose to pay private insurance rates over public insurance ones? This is why the private insurance companies—and the GOP—have made defeat of the public option plan a top priority this year.

Some 190 Members of Congress have endorsed this public-private approach in the form of the Health Care for America Now principles.

It is worth noting that the popularity of Senator Ted Kennedy, with his desire to leave a popular legacy, may be another encouraging sign that such a center-left, incremental approach to single-payer might be able to succeed.

Finally, it should be noted that perhaps the strongest argument for this pragmatic approach is the fact that the medical insurance industry and "Big Pharma" seem to be aware that this could be a “path to single payer” and, therefore, are opposing it bitterly.

This writer has seen evidence “in the trenches” of a backlash against some single payer or progressive advocates when rude and unruly advocates have made harsh verbal attacks on public officials perceived as “soft on single payer.” On such occasions, too much heat, rather than light, has led some legislators and their supporters to become leery of SP advocates due to the actions of a few overzealous advocates. This author concurs that a clear, empirically based approach for SP needs to be presented calmly, yet forcefully. At the same time, efforts should be made to defend SP with little or no compromise unless and until it is found that this approach is no longer viable legislatively.

As for our opponents, a good question to ask might be: “Why can’t ordinary people have the identical health care coverage that our representatives in Washington DC have- i.e. “Cheney Care?” If the GOP, Blue-Dog Democrats and others won’t tie benefits of the legislators to the general public, dollar for dollar, the next question might reprise the Labor refrain: “Which side are you on?”

Gene Rothman

Gene Rothman is active with the Social Action/Social Justice Council of the National Association of Social Workers (NASW), California.