A Liberal’s Case Against Single-Payer

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The late Massachusetts Senator Ted Kennedy was a passionate advocate of universal healthcare and championed a national health insurance plan during his time in office. As Chairman of the Senate Health Subcommittee, Kennedy proposed a compulsory, single-payer program. The program involved the creation of a public insurance program to replace private insurance, and it didn’t include cost-sharing, similar to Bernie Sanders’ recently proposed “Medicare for All” bill. Richard Nixon and Jimmy Carter pushed their own healthcare plans during their respective administrations, both aiming to provide comprehensive healthcare coverage through private insurance, similar to the current Affordable Care Act (ACA). Kennedy flatly rejected them. He considered Nixon’s plan a partnership between the administration and insurance companies, and dismissed Carter’s plan as “piecemeal.” However, Kennedy’s own plan was unsuccessful, and due to his refusal to compromise, so were Nixon’s and Carter’s for decades to come. It was ultimately Kennedy’s good intentions that set healthcare reform back a generation because he prioritized his commitment to ideals over a willingness to compromise. Years later, Kennedy revealed that the greatest regret of his career was his refusal to make a healthcare deal with Nixon. In addition, Carter continues to blame Kennedy for setting back healthcare reform. The Democratic party will have another chance to reform healthcare in the near future, but if it follows in Kennedy’s footsteps and decides to prioritize ideology over pragmatism, it will also have another chance to fail.

For many liberals who are intent on reforming health care, support for a single-payer system often serves as the litmus test to determine if a politician stands for the goal of achieving universal health care, or if they are just another neoliberal shill. Nearly half of adults under 30 support a single-payer system, and many view it as the only way to guarantee universal health care. But before Democrats take back power, the framework for healthcare reform must be unified. Without broad based support from congressional Democrats, the ACA, which is a major achievement of not just the Obama administration, but of the Democratic Party, could not have been implemented. The next step to reform cannot be achieved without similar Democratic consensus to overcome what would likely be united Republican opposition. Yet too many on the left are quick to sacrifice real reform for ideological purity. Despite sharing the same goals and values, many on the left choose to discount centrist policy, due to a level of self-proclaimed righteousness. They believe that staying committed to their progressive ideals is superior to actually making a difference.

Pragmatism shouldn’t be perceived as a threat to ideology, but rather the method through which ideology becomes policy. The ACA is a clear illustration of this. Had Obama attempted to create a single-payer system back in 2009, rather than adopt a healthcare plan proposed by conservative think tank, The Heritage Foundation, and implemented similarly by a Republican Governor, 16 million fewer people would have health insurance. Instead, he chose to pursue his ideals through policy that was both centrist and realistic. He created a landmark piece of legislation that should be celebrated on the left and serve as inspiration to build upon this reform. Considering that Obama couldn’t even get his “public option” through, any pie in the sky proposals would have failed, even with Democrats’ control over Congress.

Strict adherence to ideology prevents the recognition of practical policies that can help achieve the goals of the left and make a real difference in improving the lives of Americans. The commitment idealists have to their means prevents them from achieving their ends. The attention single-payer has received has made it appear the only method of healthcare reform, which is a harmful misconception. There are a plethora of areas for reform. To expand coverage, ACA subsidies can be increased to make purchasing health care on the state insurance exchanges more affordable. The introduction of a public health insurance option would also help to increase coverage. To reduce costs, our options include new policies to improve price transparency, allowing the FDA to use cost-effectiveness when approving new drugs, granting Medicare the ability to negotiate drug prices, reforming the drug patent system, expanding the role of physician assistants, removing red tape on foreign doctors, and reforming medical billing. But the left should recognize that as a center-right nation, with over half the country and strong special interests relying on the current private health insurance system, a universal healthcare system can only be achieved primarily through the private sector, not the public. Scarce political capital needs to be used to make a difference, not a statement.

The problem with such strong advocacy of a single-payer system is that it draws attention away from real reform. It further deepens ideological divides, rather than promote solidarity on achieving similar goals across partisan lines. While most Americans are against a switch to a single-payer system, many also believe that the government is responsible to ensure that all Americans have access to health care. Out of the 58 countries that have guaranteed universal health care for their citizens, only a handful use a single-payer system, meaning there are plenty of methods besides single-payer. Universal health care in the United States would require an optimal combination of the public and private sector, effective healthcare regulation, and conformity to American pragmatism. Countries like Japan, Germany, Singapore, and Switzerland have unique healthcare models that are adaptable to the U.S. system, as they rely on a private-public hybrid insurance framework that the U.S. already uses. We don’t need to throw out our healthcare system and start over, especially when there are so many issues with the newly proposed plan.

Bernie Sanders’ recent bill goes much further than other single-payer nations like Canada, as it aims to provide much more generous benefits at no cost to the consumer. Other single-payer nations use “cost-sharing” like deductibles and copays meant to prevent moral hazard, giving beneficiaries some “skin in the game” when using health care. The government and beneficiaries would literally share the cost of paying for health care, ensuring that it is used by those who need it. Instead, the Medicare for All bill proposes that the government front all of the costs through higher taxes. Without cost sharing, individuals will likely use more health care than they need, raising prices and forcing those who truly need it to wait in line behind those who don’t. Without an incentive to be cost-effective, it would drive up the cost of health care and subsequently the taxes needed to finance them. The bill would also cover health services that many would consider non-essential, services other single-payer nations have left to private insurance (like vision and dental care). More importantly, Sanders’ bill would force 157 million people off of their employer provided healthcare plan and onto the single-payer plan. As Hillary Clinton pointed out in an interview with Ezra Klein, if you tell half the country that they will lose their employer-based health insurance with the single-payer bill, “you’re going to have massive resistance by people, who are gonna say, ‘I’m happy with what I’ve got.’” And most Americans are happy with what they’ve got.

While there are practical benefits to the single-payer system, such as reducing administrative costs and negotiating power, it won’t pay for itself. The single-payer system would move $1.9 trillion in private sector spending (almost 10% of U.S. GDP) onto the government’s bill. Sanders’ plan would require people to be willing to give up their healthcare plans, use less health care, and pay far more in taxes: a mighty sell from a party that already has enough difficulty winning elections. However, despite these obstacles, many remain committed to such a plan and a third of Senate Democrats have already signed onto it, including Senators who may be considering a 2020 presidential run. The costs of the bill, both political and economic, are simply too great. A single-payer system is no silver bullet for reforming our complex healthcare system, despite how simple its proposal might sound. The Democratic Party, which has built a reputation on practicality and realistic promises to its base, risks adopting Republicans’ habit of false claims and impossible promises to win elections, only to divide its own base further once in power.

Liberals have a choice. They can cling to their ideology, fight for a system Americans don’t want or don’t need, and sacrifice their ability to shape public policy in exchange for commitment to ideological purity. Or, they can support practical solutions and participate in policy debates and discussion intent on pragmatic reform, which can have a real difference in making health care more accessible and affordable for all Americans. Lest we repeat the mistake of the late Ted Kennedy, we cannot pursue ideology and ignore practicality. This will only serve to undermine our goals rather than advance them, which we will surely regret down the line. And when the lives of so many are contingent upon their access to health care, there is little room for more regret.

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