The Case for Single-Payer

By Timothy Faust, Jacobin

05 October 17

Winning Medicare for All would allow us to take a giant step toward health justice.

he existing system of insurance in America — a heavily commodified, limited-coverage, multi-payer model — represents the abject failure of market liberalism. At the core of the problem is a basic fact: it’s not profitable to insure people who are sick or likely to get sick. Without massive government subsidization (or, in the case of Medicare or Medicaid, government financing and cost regulation), profit-seeking insurers, with relatively small pools of customers among whom to spread costs, are compelled to restrict coverage, increase premiums, illegally coerce sick people to drop their plans, or abdicate their responsibility entirely and push the costs of care onto their customers.

People end up spending money they don’t have on health care services they can’t afford — but also can’t afford to live without. All the while, health care costs soar, outpacing both inflation and US insurers’ ability to stem their ascent. These forces pervert the notion of “health care” itself, transforming it into a transaction between a customer and an insurance company rather than a relationship between a person, their body, and their doctor. Profit, not human need, is the governing principle.

Single-payer is a very different model. By making the federal government the country’s health insurer, it would make it possible to bring down costs while ensuring everyone gets the high-quality care they need — especially those people the market deems “unprofitable.” It would reshape the relationship between industry, the state, and patients — laying the groundwork for genuine health justice.

Last month, Vermont senator Bernie Sanders introduced his Medicare for All Act — a bill that, if passed, would establish a federal, universal, single-payer health care system in the US. The legislation stands against a cruel summer of “repeal and replace” blood lust, most recently championed by senators Lindsey Graham and Bill Cassidy, and years of mewling, milquetoast non-ideas from mainstream Democrats.

Sanders’s bill is a minor, but significant victory in itself for the movement for health equality. Though even single-payer proponents agree his legislation won’t pass in the next few years, the support it’s attracted is an irreversible mark of progress. Whether out of moral obligation or vulgar opportunism, over one-third of Senate Democrats (including all of the likely 2020 presidential hopefuls in the upper chamber) have cosponsored the bill. And 60 percent of Americans now say it is the federal government’s duty to make sure everyone has health care.

The story of the fight for health justice is just beginning, but after decades of struggle, false promises, and corporate counterattacks, perhaps its prologue is finally coming to a close.

Bernie's Bill

It’s hard not to get excited reading Sanders’s Medicare for All Act. It’s a sweeping document, unequivocal in its ambition.

Over a four-year period — through a combination of automatic and voluntary enrollment — the bill would establish Medicare as the single payer for health care costs in the US. Existing funding for Medicare, Medicaid, and programs like CHIP and TRICARE would be bundled into the larger single payer. And before extending Medicare to everyone, the legislation would improve it: immediate reforms — each notable achievements in themselves — would include removing deductibles and caps on cost-sharing.

Sanders’s bill sets out a robust set of reforms and provisions that would bring about a humane universal health care program.

Under his plan:

• Medical conditions would become a protected class in the provision and payment of health care — allowing neither provider nor payer to discriminate against a person, regardless of any preexisting conditions.


• All American residents would have access to an extensive set of essential health benefits (including abortion, vision, and dental care), with no out-of-pocket costs beyond $250 for prescription drugs.


• Private insurance companies would be barred from offering services already covered by the public payer — farewell to Medicare Advantage and the Medicare privatization movement.


• The Department of Health and Human Services would be tasked with setting standards for data collection and investing in evidence-based care guidelines for providers — joyful news for both the essential yet persistently besieged Agency for Healthcare Research and Quality and people who like the health care they receive to be backed up by research.


• An office of primary health care would be created to measure, analyze, and invest in primary care, particularly for communities neglected or under-served by the existing for-profit model.


• Money would be set aside during the transition to help the (relatively few) displaced workers in the private insurance industry.

Here’s what that would look like in practice. A person could seek treatment — including an abortion or other reproductive services — at virtually any participating doctor’s office near their home. They could not be denied coverage or care for reasons of age, sex, race, disability, or illness — something the insurance industry is still accused of doing today. They would receive care that an independent agency had vetted as likely to help treat their condition. And they would not have to pay a cent for any of the care they were provided.

As radical and compelling as the programs the bill would construct are the ones it would destroy. Most striking is the nixing of cost-sharing. This spits in the face of forty years of “consumer-driven health care,” a euphemism for insurer efforts to shift increasing health care costs onto individuals poorly equipped to weather them. A full 40 percent of insurance plans in 2016 were high-deductible plans (up from 28 percent in 2011). Sanders’s bill would end all of this, making health care free at the point of service, with no deductibles.

One of the most common objections to single-payer — “How will we pay for it?” — is also one of the most inane, considering nearly one-fifth of the economy is devoted to health care spending. The real problem is that in America, health care unit costs are too high, and we rack up those costs in ways that prevent us from allocating our health care spending toward better, more just care for all people.

Conservative claims notwithstanding, the best way to force down health spending is through a single-payer scheme. As the sole purchaser, the federal government is immediately able to set just prices for health care services (for example, by negotiating the cost of drugs). With the weight of the full cost of health care falling squarely on its shoulders, it has an incentive to develop infrastructure and provide accessible primary care for all people, diverting money from low-frequency crisis care to high-frequency primary and preventive medicine.

It can also create evidence-driven guidelines for how to handle episodes of complex care and adjust payments based on adherence to these guidelines. This promotes good care for all patients and respects providers’ agency to provide the best care they can, instead of the current mess, where payment per-service can incentivize unscrupulous providers to bilk payers by either ratcheting up individual unnecessary services (when paid per-service) or providing less care (when paid per-patient).

None of this is to say that the Medicare for All Act would, by itself, deliver health justice in America. Most obviously, it wouldn’t establish a fully socialized system: many hospitals and the like would remain in private hands. But there are other more immediate shortcomings.

First, long-term care, like nursing home, hospice, or home health care would remain the domain of Medicaid. A means-tested program, Medicaid only offers care to people with children, disabled people, or (depending on the state) people with income under the $14,000/year federal poverty line. This creates a high barrier to access, even though long-term care is needed almost universally.

Second, even under Sanders’s bill, there would still be the threat of a creeping two-tiered system. One way health stratification could slip in would be through unregulated contract-making between providers and patients. Massive providers like the Cleveland Clinic could use their regional monopoly (plus the general information asymmetry between patients and providers) to form HMO-type organizations in their own private spheres. This could open the door to a system in which the wealthy essentially had their own private health care market — which would give them leverage to move to reduce their tax obligation to the rest of us. While the state shouldn’t necessarily prohibit private contract-making altogether, incentives like tuition relief for medical training — or free medical training altogether — contingent upon accepting Medicare (or seeking work in under-served counties or disciplines) could assuage this concern.

Third, there’s health infrastructure. Sanders would do well to adopt a centralized approach like the one detailed in Representative John Conyers’s HR 676. Left to their own devices, private providers will expand their hospital wings so they can bill the single payer for more inpatient admissions, regardless of need. They will never choose to build low-margin community clinics or medical-legal partnerships in the neighborhoods they neglect.

Addressing each of these concerns would build on the underlying vision embodied in Sanders’s bill: that health care is something a just nation affords all of its residents.

Toward Health Justice

The United States may be a country where Saudi princes can fly to get a heart transplant, but it remains a place where poor men die fourteen years earlier than rich men. In a land of resplendence, the powerful condemn the marginalized to chronic illness, because it’s not profitable to provide nutritious food or adequate shelter.

Fragmented and commodified, the present model treats health care as something that only happens when people are insured, not a holistic process spanning an entire life. Single-payer could begin to change this. Once the federal actor bears the costs of providing care and not providing care, it could finally be a tool for realizing health justice.

If people are getting sick and dying because they don’t have a place to live, or if the places they live are unsafe, then housing is health care, and you build housing to bring health care costs down. If people don’t have access to healthy food to eat, then food is health care, and you provide them with affordable or free food options to bring health care costs down. If people live in fear of their personal safety — if they are assaulted or beaten at home, at work, by the police, or by their domestic partners — then safety is a form of health care, and you provide safe havens for them to bring health care costs down.

In other words, a single-payer program is not the goal. Single-payer on its own cannot be the goal. Single-payer does not solve the biggest sin of commodified health care: that taking care of sick people isn’t profitable, and any profit-driven insurance system thus disregards the most vulnerable.

Sick people, people with disabilities, poor people, pregnant people, trans people, people of color — all of them are valuable to insurance markets only inasmuch as profit can be extracted from them; afterward, they are drained, discarded, abandoned to charity care, or, absent that, to the carceral state. Corporations have proven themselves unable and unwilling to look these problems in the eye, and people suffer while Democrats use public money to bribe corporations into trying to ameliorate the health care crisis.

Single-payer alone does not solve these problems. But it gives us a fighting chance to square up against them.