clock menu more-arrow no yes mobile

Filed under:

Single-payer isn’t the only progressive option on health care

There are several routes to universal coverage — some more politically feasible than others.

Sen. Elizabeth Warren has embraced Sen. Bernie Sanders’ single-payer plan.
Sen. Elizabeth Warren is the latest high profile Democrat to embrace Sen. Bernie Sanders’ single-payer plan
Win McNamee/Getty Images

Yesterday, Senator Bernie Sanders and approximately a dozen other Democratic senators introduced a single-payer bill that is intended to become a focal point for discussion about the future of US health care.

Coming less than two months after progressives and America’s families won a huge victory by preventing GOP efforts to repeal the Affordable Care Act and to decimate Medicaid, the bill marks a new, less defensive Democratic position. Vigilance and unity are still needed to protect against attempts to undermine recent historic health improvements. But this bill aggressively advances the debate over how best to advance the progressive goal of achieving high-quality, affordable health care for everyone.

Maybe we should hit pause before we get on this bandwagon. The overriding goal among progressives is to ensure that health care becomes a basic human right — truly and affordably available for all, irrespective of income, race, ethnicity, gender, sexual orientation, immigration status, and geography.

But there are several paths to universal health care coverage. Single-payer can be one of them — but it isn’t the only one. Indeed, many countries have reached the goal using methodologies other than single-payer, including varying blends of public and private coverage.

Too many progressives and others fail to distinguish between “universal coverage” and “single-payer.” The terms are used interchangeably in private conversations and in the national arena.

As we consider the most effective strategy for achieving universal coverage, progressives should keep two admonitions in mind. First, we must not conflate our foremost health care goal (universal coverage) with competing pathways toward achieving that goal. Second, recognizing that our differences are about strategy and not final goals, the dialogue should be undertaken with mutual respect.

The strategic impediments to the single-payer pathway

Nations that have achieved universal health care coverage chose their distinctive pathways based on a host of factors, including cultural, historical, and political contexts. We must pay attention to such factors in the American context, too.

America’s unique history and politics make the successful promotion of a single-payer system an unlikely pathway to universal health coverage. There are three reasons. The first involves the inevitable strong and well-funded opposition of special-interest groups.

Since the 1930s, associations representing the pharmaceutical, insurance, hospital, physician, and medical-device industries have consistently and vehemently opposed attempts to reform health care through any approach perceived as leading to single-payer. Their only defeat on this front occurred in 1965, after President John F. Kennedy’s assassination and the Barry Goldwater electoral fiasco, when Medicare and Medicaid were enacted at a time of huge Democratic majorities (68-32 in the Senate, 295-140 in the House). Such Democratic dominance of national politics seems unlikely in the foreseeable future.

The second political impediment is the potential backlash to the cost of single-payer, and how it will be financed. Although a single-payer system would almost certainly be more efficient than the continuation of a multi-payer system, such a system would require a tax increase of a scale likely to cause the public to balk — especially when anti-tax groups mobilize.

The size of the necessary taxes cannot yet be determined, since it would depend on the precise design of the new system (such as the benefits covered and the portion of those benefits paid through consumers’ premiums, deductibles, and copayments). But the failed attempt to establish a single-payer system in Vermont, perhaps the most progressive state in the union, gives a sense of the challenges ahead.

The cautionary tale of Green Mountain Care

Former Gov. Peter Shumlin and many in the mainly Democratic state legislature crusaded for a single-payer system dubbed Green Mountain Care. But, after four years of tireless efforts, Shumlin reluctantly ended his quest when his analysts concluded it would require an 11.5 percent payroll tax plus a sliding-scale income tax that peaked at 9.5 percent. Polls told him that even the state’s mostly liberal constituents were unlikely to embrace single-payer at that price.

Finally, as both Democrats and Republicans have now learned, once people have health care coverage, they are sensitive about efforts that might take it away or potentially diminish its quality. Today, approximately half of the US population receives health coverage through the workplace. If that coverage is replaced with a single-payer system, workers will be vigilant about making sure the new coverage is at least as good as what they had before.

Will the new coverage be as comprehensive? Will they pay more in premiums, deductibles, and copayments than they do today? Will they get to keep their doctors? The answers to each of these questions will vary based on the design of the new single-payer plan and on people’s current coverage.

While there likely would be many “winners” under a new single-payer system, there no doubt would also be a significant number of people who perceive themselves as “losers.” The latter would become a very vocal and active oppositional force — probably more vocal than the “winners.”

Asking people to pay higher taxes for coverage they fear is inferior (and in a few cases is inferior) is a recipe for a backlash.

The viable alternatives to single-payer

Concluding that it is highly unlikely that a single-payer system can be adopted in the foreseeable future does not mean that we should give up on our goal of universal coverage. Quite the opposite! There are other, more politically achievable, pathways.

As long as Democrats don’t hold unusually large majorities in Congress, plus the presidency, the pathway to universal, affordable health coverage won’t be through one omnibus new law. We must have the persistence, and the commitment, to take incremental steps toward that goal.

Incrementalism should not be considered a four-letter word. It produced numerous expansions and improvements in Medicaid, which now covers more than 70 million people. It led to the Children’s Health Insurance Program (CHIP), which resulted in historically low uninsured rates among children. It added much-needed prescription drug coverage for seniors and people with disabilities in Medicare. It added home and community-based care as an alternative to nursing homes. And it helped people with preexisting conditions combat insurance company discrimination.

As we consider the next incremental steps to promote, we should focus on expanding health coverage to the nearly 30 million who remain uninsured, and we should strive to lower health costs while improving quality of care. The following goals meet those criteria.

  • Expanding Medicaid in 19 states: Now that Republicans have at least temporarily lost their fight to repeal the ACA, and since extraordinarily generous federal subsidies remain to expand Medicaid, progressive advocates should renew their efforts to secure added coverage for low-income adults in the 19 states that have not yet approved the expansion. Of the 31 states that already expanded Medicaid, 18 are currently led by Republican governors. Since refusing federal money is unlikely to lead to ACA repeal at the national level, we should now expect other state Republican leaders to be more amenable to expansion, too. Activists and voters should push them in that direction.
  • Providing coverage for immigrants: Because of the ongoing national controversy about immigration, it is unlikely that federal legislation will extend health coverage to immigrants. But there are opportunities to do so at the state level. California, the District of Columbia, Illinois, Massachusetts, New York, and Washington already use state funds to cover undocumented children through Medicaid. In California, approximately 200,000 children have gained coverage through this expansion, and many more are eligible. Now the state is debating extending such coverage to undocumented adults. Progressives elsewhere should push their representatives to make similar efforts.
  • Fixing the so-called “family glitch”: People with access to affordable employer-sponsored health insurance are ineligible to receive ACA premium assistance in the individual marketplace. Unfortunately, due to an ACA drafting error, “affordability” is gauged by examining what it would cost the worker to cover him or herself at work — not the coverage costs for the worker’s family. As a result, many families who ought to be eligible for subsidies are not getting them. This is an acknowledged, unintended mistake, and activists should work to have it fixed. This would help millions.
  • Extending CHIP: Under current law, funding for this popular and effective program, which provides health insurance for low-income children, is only authorized through September 2017. The program was adopted on a bipartisan basis and is very popular among Republican as well as Democratic governors. Progressives should push hard to secure a funding extension as soon as possible.

Aiming to curb costs could create strange political bedfellows

Similarly, progressives should work in concert with the diverse payers of health care to promote moderation of fast-rising health care costs while improving quality of care. Our objectives should include:

  • Paying for quality, rather than quantity, of health care: Our nation’s fee-for-service model — used in private as well as public health coverage — is extraordinarily wasteful and does not beget high-quality outcomes. Much experimental and analytic work still needs to be done to determine how we should most effectively and efficiently pay for quality of care. But progressives should push to hasten the testing and deployment of the most promising new models.
  • Reducing prescription drug prices: One out of every 10 dollars spent on health care now pays for prescription medicines, and the proportion is growing. Drug prices rose by more than 11 percent in 2016 and are projected to rise by almost 12 percent this year. PhRMA’s lobbying clout remains prodigious, but fast-rising drug prices are creating a public and health-sector backlash. The time may be ripe for ending the prohibition that prevents Medicare from bargaining for lower drug prices.
  • Remedying anti-competitive health system market domination: Geographic areas with near-monopolistic concentrations of health systems result in comparatively high health care prices. Public policy should strive to end such concentrations. It’s a goal that both progressives and conservatives can embrace.
  • Promoting a “public option”: In too many locations across the country, the ACA marketplaces only have one insurer. This lack of choice has been roundly criticized by Republicans, deservedly so because the lack of insurer competition tends to result in higher premiums. To correct this problem, progressives should continue their quest to allow a public plan to be established in such low-competition areas.

All of these incremental efforts would require hard and tenacious efforts. But they are potentially achievable in the near future, and they would move our nation considerably closer toward the goal of high-quality, affordable health coverage for all.

Over time, there’s no reason incrementalism can’t get us all the way to 100 percent coverage. Single-payer isn’t the only route to that goal. In the foreseeable future, the step-by-step approach is the strategy progressives should pursue.

Ron Pollack served as the founding executive director of the consumer health organization Families USA for more than three decades, and he is currently the organization’s chair emeritus. He played a leading role promoting the adoption and implementation of the ACA as well as the expansion of Medicaid. The opinions expressed in this article are his own. Find him on Twitter @Ron_Pollack.


The Big Idea is Vox’s home for smart discussion of the most important issues and ideas in politics, science, and culture — typically by outside contributors. If you have an idea for a piece, pitch us at thebigidea@vox.com.

Sign up for the newsletter Today, Explained

Understand the world with a daily explainer plus the most compelling stories of the day.