The Politics of Single Payer Health Care – “Medicare for All”

The Politics of Single Payer Health Care – “Medicare for All”


In the single payer systems, private doctors and hospitals deliver the services and government pays their bills for your services. We have a next-door neighbor, Canada, with a single payer system that works reasonably well. Medicare is a single payer system for the elderly and disabled and works well for them. Some well-run European systems like France and Norway are single payer, and their citizens are reasonably happy with the results.

Single payer is not the only way to universal coverage. The Germans, Dutch and Swiss all have universal coverage using private insurance, whether through employers or individuals.

The British have the only truly socialized medicine system. The government owns and operates the hospitals and the doctors and nurses are government employees. That is not even on the table for discussion and debate in the US.

The case for single payer is pretty simple as follows. It costs less, covers everyone and gets better health outcomes. Right now the US health system costs a lot more per capita or as a percent of GDP than any other system; it gets significantly worse health outcomes, and it does not cover everyone. Moreover there is wide variability among the states, with top performers like Minnesota and Vermont far out performing the bottom ranked states like Mississippi and Oklahoma. California is one of the states that recently showed enormous improvement due to its stellar performance in implementing the Affordable Care Act (ACA).

Who’s against it and why? First and foremost, the insurers are opposed because their roles (and profits) would be eliminated. Second, the hospitals, doctors and drug companies are opposed because their rates would be regulated and they believe their incomes would be less. Third, the employers are opposed because they would have to pay taxes to support the single payer system and they think government will steadily increase their taxes. Lastly, Republican politicians for the most part are opposed because it crosses so many of their red lines: taxes, government control, and regulation of provider rates.

Who’s for it? The Nurses Union is a strong proponent as are many consumer groups. Some doctors and most public hospitals support it, so do many labor unions. The progressive wing of the Democratic Party is strongly supportive.

The public is becoming more supportive, led by enthusiastic young voters. However, the support erodes once it is clear that taxes would have to be increased to pay for it. The California Legislative Analyst’s Office projects the need to roughly double state taxes -- $200 billion in new taxes -- to pay for SB 562 (Lara) and that assumes that federal waivers are forthcoming to fold in all current federal health spending, a risky bet at best with the Trump Administration. When the proposals go to the ballot box via the initiative process, only about 1/4th of the voters support the higher taxes required.

What should single payer proponents do in California with a new Governor who spoke supportively of single payer during the primary? First, try to increase their allies, starting with small employers and then larger employers; find the elements of the provider community that could be supportive such as primary care and emergency room doctors and ob-gyns; can you win over the public health plans or the strong and effective non-profits like Kaiser. Second, develop a persuasive argument that the measure is cost neutral (the taxes are no more than the private costs that patients and employers already pay that would now be eliminated) or costs less than the existing system (other single payer systems and multi payer systems cost much less than the US) and then convince legislators and the voting public. Stop yelling at those who disagree, you’re weakening your case; you need to convince people instead. You need a compelling economic argument and a modernized pro-growth financing mechanism. Third, show the American public the ways in which the poor outcomes and cost inefficiency of the existing systems are hurting them and how it can be improved under what you are proposing – after all the public and many employers and providers are fed up with high costs of care and medicine and insurance premiums, deductibles and co-insurance. People are fearful of losing their coverage at their job and afraid that Medicare will go bankrupt; how does this help your argument. Fourth, make the case to Congress; they control the purse strings, not the state of California. Build working alliances with Republican leaning business communities and independent professionals tired of escalating premiums. Fifth, develop an effective modern reimbursement system that rewards improved patient outcomes and greater cost efficiency and penalizes the outliers in terms of high cost and/or poor outcomes. Sixth, update your bill to incorporate the best lessons from systems around the world that can be adopted here. Lastly, think through the right incremental changes in the existing systems that get you towards where you aim to end up.


Prepared by: Lucien Wulsin

Dated: 11/15/18



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