Single-Payer Health Care: If Not Now, When?
Senate Finance Committee Chairman Max Baucus (D-MT) - Senate Finance Committee Chairman Max Baucus (D-MT) says, "I don't think a single-payer system makes sense in this country." (Alex Wong / Getty Images)
For supporters of a national health insurance plan funded solely by the government, you would think things are looking up.
There's a new Democratic president about to take office, with substantial Democratic majorities in the U.S. House and Senate. So, many people think a "single-payer" health care bill could be on the verge of passage.
"The country needs it and the American people support it, so that makes the prospects pretty good," says David Himmelstein, an associate professor at the Harvard Medical School and co-founder of Physicians for a National Health Program, which has been advocating for a single-payer health plan since the late 1980s.
(Alex Wong / Getty Images)
President-elect Barack Obama said at a town-hall meeting in August that he would "probably go ahead with a single-payer system" if he were designing a system from scratch.
But that's not anywhere close to what he's been advocating.
Instead, the new administration's plan is focused on building onto the existing system, in which most people get insurance through their job.
And on Capitol Hill, the lawmakers who will be charged with overseeing health care overhaul legislation are singing a similar song.
"I don't think a single-payer system makes sense in this country," said Senate Finance Committee Chairman Max Baucus (D-MT). "We are America. We will come up with a uniquely American solution, which will be a combination of public and private coverage."
Even House Ways and Means Health Subcommittee Chairman Pete Stark (D-CA), who has in previous sessions of Congress introduced his own single-payer proposal, says the public is not ready for the huge change that eliminating the health insurance industry would mean.
"I don't think with something as personal and important as medical care, people are ready to give up what they have," Stark said.
That frustrates people like Himmelstein, who says he's seen poll after poll that shows significant public support for a single-payer system. "A majority of American people say they favor a plan like Medicare paid for out of taxes covering all Americans," he says. Medicare is one type of single-payer system.
Robert Blendon, who studies public opinion and health care at the Harvard School of Public Health, says it's true that single-payer enjoys significant public support. But most of the time, the support is highest when it's compared to the status quo.
For example, backers of a single-payer plan frequently cite a December 2007 poll by the Associated Press and Yahoo.
In that poll, 65 percent of respondents said the U.S. "should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers."
But their only other choice in that poll, chosen by 34 percent, was to "continue the current health insurance system in which most people get their health insurance from private employers, but some people have no insurance."
When given more options about ways to expand coverage, single-payer "is the least popular," Blendon says.
For example, a poll conducted by the Kaiser Family Foundation in September offered respondents seven separate proposals.
Of those, the most popular was offering incentives to employers to provide coverage to their workers, supported by 79 percent.
Expanding existing public programs was favored by 72 percent.
The only option that failed to garner a majority was providing universal coverage through a single-payer — 44 percent.
On the other hand, when those same respondents were asked to choose their top most preferred option, single-payer tied for first, demonstrating the depth of feeling of its supporters.
But Blendon says opponents of a government-sponsored health system are equally vehement, which is another reason why no president since Harry Truman has put such a policy on the table.
"It shows the sense of controversy they felt they would face if they did that," Blendon says.
Even Obama demurred when he was asked point-blank about single-payer back in August.
"A lot of people work for insurance companies, a lot of people work for HMOs," Obama said. "You've got a whole system of institutions that have been set up."
What he left unsaid was that that's a fight too big even for him to win.
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ROBERT SIEGEL, host:
From NPR News, this is All Things Considered. I'm Robert Siegel. Reforming the nation's health care system is a priority for President-elect Barack Obama. The elements seem to be in place for change - Mr. Obama's interests, big Democratic majorities in Congress, a crumbling health system, and a public call for action. But as NPR's Julie Rovner reports, one of the biggest changes to a single-payer system still gets a cool reception.
JULIE ROVNER: David Himmelstein is frustrated. A doctor and professor at Harvard Medical School, he co-founded Physicians for a National Health Program more than two decades ago. The group's goal is to promote the adoption of a single-payer health care system in the U.S. The concept is straightforward. Doctors, hospitals and other health-care facilities stay private, but the bills are paid by the government and funded by tax dollars. Himmelstein says it's the only health system fix that makes sense, particularly now.
Dr. DAVID HIMMELSTEIN (Medicine, Harvard Medical School; Co-founder, Physicians for a National Health Program): The economy bottoming out is really making the other alternatives that are on the table not viable options, so they may make political sense, but they're economically nonsensical. So, we think that the country actually is requiring a movement towards single-payer.
ROVNER: But those in charge of health care in Washington don't see it that way. Senate Finance Committee Chairman Max Baucus recently unveiled his own hundred-page white paper for a health overhaul. He says he doesn't see single-payer as a viable option.
Senator MAX BAUCUS (Democrat, Montana; Finance Committee Chairman): I don't think a single-payer system makes sense in this country. And we are America. We will come up our uniquely American solution, which will be a combination of public and private coverage and public and private provisions.
ROVNER: In the House, California Democrat Pete Stark, who chairs the key Health Subcommittee, has proposed his own version of single-payer, but even he says the public is simply not ready for the huge change that eliminating private health insurance would involve.
Representative PETE STARK (Democrat, California; Chairman, Health Subcommittee): We may get there over time, but I don't think, with something as personal and important as medical care, people are ready to give up what they have, or what they think they have, and just walk away from it.
ROVNER: That attitude irritates single-payer backers like David Himmelstein, who says public support for a government funded system is broader than those inside the beltway realize.
Dr. HIMMELSTEIN: If you ask the American people - an ABC News/Washington Post poll has done that and CNN has done that - the majority of American people say they favor a program like Medicare, paid for out of taxes, covering all Americans. That's a description of single-payer.
ROVNER: A lot of people do tell pollsters they would favor a single-payer system to help cover the uninsured and control costs. But that's hardly the whole story, says Bob Blendon. He's an expert in health-care public opinion at the Harvard School of Public Health. The real issue he says is...
Dr. ROBERT BLENDON (Health Policy and Political Analysis, Harvard School of Public Health): What you have is that there are a lot of ways to do this and the others get more support than single-payer.
ROVNER: For example, in September, a poll offered voters seven different options for boosting heath coverage, ranging from giving employers incentives to offer their workers insurance to expanding existing programs like Medicaid for the poor. And while single-payer has won big majorities in many polls, in this one, it came in dead last.
Dr. BLENDON: That really deals with the fact that I have a poll, let's say, that has 52 percent. You're right, but the other plan has 70 percent. And so, when you really rank them, it is the least popular option the president could chose.
ROVNER: Another problem is the fact that while supporters of single-payer are very committed, opponents feel just as strongly that a fully government funded health system would ruin all that's good about U.S. health care. Blendon says that's a key reason why no president since Harry Truman has proposed a single-payer plan.
Dr. BLENDON: That all has to do with the sense of controversy they felt they would face if they did that.
ROVNER: President-elect Barack Obama said at a town hall in August, taped by CNN, that he would support a single-payer system, but only if he was building a new system from scratch.
(Soundbite of President-elect Barack Obama town hall speech, August 2008)
President-elect BARACK OBAMA: A lot of people work for insurance companies, a lot of people work for HMOs. You've got a whole system of institutions that have been set up. Making that transition in a rapid way, I think, would be very difficult.
ROVNER: Making him just the latest president who probably won't be offering up a single-payer national health plan. Julie Rovner, NPR News, Washington. Transcript provided by NPR, Copyright National Public Radio.
