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Single-Payer Health Care versus Individual Mandates: A Dilemma for Democrats

A wide array of labor unions, health care providers, and consumers--including the California Nurses Association and the Physicians for a National Health Program (PNHP) favors a single-payer (SP) “Medicare for All” system as the most cost-effective, comprehensive, and outcome-effective health care proposal. “Everybody in, nobody out” is the principle. By reducing or eliminating the role of the middleman (insurance companies), it is estimated that administrative costs could be reduced up to thirty percent. With reallocation of such savings to areas such as direct patient care, employment of health care providers, research on treatment outcome effectiveness, preventive care, and other program elements, long-term costs would be reduced even further.


Liberal Alternatives to Single Payer
Some liberals, including some who favor SP, argue that this approach may be politically unattainable unless interim, incremental steps are taken first. Nobel Prize-winning economist Paul Krugman, featured on, is one spokesperson for this approach:

“…the [incremental plan] offers choice – so that people won’t feel that they’re being forced into a government plan. Over time, I suspect, many people will choose the government plan or plans. . . . 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.”

In short, this is seen as a potential bridge to a single-payer plan.

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Risks on the Road to the Single Payer Model
Proponents of an incrementalist strategy portray their approach as the best way to win. Their argument has some merit, but the risks of a “half-a-loaf” plan are numerous and profound. No mandated insurance program has been able to provide universal coverage. Any multiple-player scenario would require substantial subsidies to the poor and the medically indigent. Moreover, as Luke Mitchell has noted in Harper’s Magazine, most of the approximately twenty percent of national costs for health care would be spent “not on basic care or preventative treatment, but on expensive new technologies.” Only a single-payer system is capable of generating major savings by eliminating administrative costs incurred by the wide range of billing systems of multiple insurers. Similarly, the public option (government insurance) bill proposed by Max Baucus (D-MT) may not cut any costs since many of the categories of care “involve significant increases in costs, especially through additional and more complex administrative functions,” according to Dr. Don McCanne of PNPH (emphasis in original).

Hidden Costs of Settling for Alternatives to Single Payer Plans
President Obama initially excluded SP advocates from his health care summit. Senator Baucus has not only arrested medical advocates of SP seeking representation, but has also held a secret, closed-door hearing, apparently for industry-based health care advocates only. These undemocratic tactics impede the unity that will be needed for any public option, whether or not SP is ultimately on or off the table. Instead, it drives a wedge between public health care advocates and may well be a formula for depressing the party’s base rather than energizing the forces seeking health care reform.

Recommendations for Action
Citizens favoring single payer owe it to themselves to take action on this issue. Contacting the California Nurses Association or Physicians for a National Health Program (see opening sentence) is one option. Finally, whether you support Single Payer or an incrementalist public option plan, anyone favoring free speech and representative democracy should also contact Democratic party leaders to insist that all ideas must be on the table. In addition, if advocates of single payer are ejected from Congressional meetings for requesting representation, Democratic party officials should be urged to work with local police to avoid arrests for such advocates. Finally, the practice of closed-door, secret meetings with health-industry-only representatives must be ended immediately.

Gene Rothman

Gene Rothman, DSW, LCSW, is a retired social worker active with interfaith groups in Culver City and with the Social Action/Social Justice Council of the
National Association of Social Workers.