Is Something Wrong With Single Payer?


     With all the advocacy efforts expended over the last 20 years, it might be reasonable to expect some results by now for the Single Payer (SP) movement. Of course, SP would be a great way to provide health insurance in America. Instead of thousands of private insurance companies (payers for health care services) competing with each other to see who can fool the most people, there would be one source of payment, the federal government, for doctors, clinics and hospitals. Healthcare would be much more accessible, distributed more fairly, be a whole lot cheaper, and everybody would be covered. What a deal!

     So why does it look like the chances of passing an SP bill in Congress, like the ones proposed by Jim McDermott or John Conyers, are next to nil? It's more than a little perplexing, isn't it?

     We need to look into a couple of sources power and money in our political system, and then it gets a little easier to understand. First, we should keep in mind that the top priority of every member of Congress is to get re-elected. Democrats, Republicans, & Independents—all have to raise millions of dollars for their campaign war chests, or they will lose the next election and be looking for a job. Raising money to spend on the next campaign is priority number one for members of Congress.

     Among the most lavish sources of campaign money, for both Democrats and Republicans, are the pharmaceutical industry (Big Pharma), the private insurance industry, and the healthcare industry. I don't think anybody would expect any of these three to be very friendly to SP. Least of all insurance, which would be obliterated in healthcare by SP. According to the website, these three together contributed over $100 million to members of Congress during the 2009-10 biennium. That's a lot of financial oomph to overcome, no?

     For many years, progressives have accepted the challenge of all that money and power by saying, "Our arguments are sound, and we're going to organize mass support around our ideas in order to overcome the huge financial advantage of our opposition." Makes sense, so far.

     But, SP is complicated and difficult to understand. This is nobody's fault, it's just the nature of the beast. There are many "what if's" involved. Like, "what if they won't let me stay with my doctor?" or "what if my father's illness isn't covered?" We can point to Canada, and say these things won't be problems. But it would take a huge educational effort backed by big-time resources to overcome the hesitations in everyday people's minds. An educational program is needed that is big enough to help a large portion of the American people join a movement capable of swaying members of Congress away from those huge campaign contributions.

     For most progressives, the force in America that would be capable of overcoming the big money, by rallying a mass movement, is the labor movement. This is the nub of the whole business, in my opinion. Should we look to the unions to do all they can to win SP? A little history helps answer that question.

     Right after World War II, most people expected labor to exercise its power and make life fundamentally better for all American workers. This would happen by winning good labor contracts. Also by influencing the political process to win a better social contract for all Americans, both those inside and outside of unions. Instead, the U.S. experienced the McCarthy era. For the most part, communists and socialists were purged from the unions. The Taft-Hartley anti-union law, passed in the late forties, ushered in a period of slow and steady decline for unions that continues to this day. At their peak in the 50's, American unions represented roughly 1/3 of the American workforce. This has dropped to about 12% today, with less than 8% of non-government workers in unions.

     No one knows exactly where this is headed, but it doesn't look good. One thing it seems to have caused is a hardening of big labor's attitude toward fighting for reforms relevant to all workers. When presented with a choice, you can easily imagine a labor official saying, "let's do this so that my members will have an advantage in their contract provisions over people doing the same work who aren't part of a union. Otherwise, why would my members want to keep paying their dues?" For labor officials, that's the main problem. Under SP, everyone would get exactly the same health care, union member or not. Healthcare benefits would no longer be a reason to join a union and pay your dues.

     I can almost hear the chorus of criticism from SP advocates. They will say that many union organizations, perhaps more than half, have taken a position in favor of SP. My answer is that these shrewd, dynamic leaders are well aware of what it would take to build the kind of mass, public movement capable of overcoming the big money against SP. It would take ALL HANDS ON DECK to effect that big a change in America. There would have to be thousands of union members going door to door in all our cities, to explain the complications that the big money guys would keep throwing at people. Demonstrations would have to be mounted across the U.S. on the scale of the anti-Vietnam war and Civil Rights demonstrations of the 1960's. It wouldn't hurt to have a few city-wide general strikes on the scale of the WTO demonstrations in Seattle a few years back.

     Union officials are simply not going to mount a campaign on a scale like that, especially when they feel like they would be cutting their own throats, if successful.

     I realize that there is a lot of support, at least verbal support, coming from the labor movement for SP. Don't be fooled. Posturing, pretending to be in favor of something you're sure will fail, is a long established tradition here in the U.S. For example, take the California Legislature. As long as Arnold Schwarzenegger was the governor and a veto was assured, California Democrats were only too happy to pass SP. But, with Democrat Jerry Brown as governor, SP can't get through the legislature. Most believe this is because there is a chance that Brown might sign it into law!

     Recently, Richard Trumka, the head of the AFL-CIO, attended the national convention of a group called "Labor for Single Payer." This group represents a goodly (thousands?) number of people (probably mostly union staffers) associated with the labor movement. Why, you might ask, would the national leader of the union movement go to this meeting, if he wasn't truly in favor of SP? Well, it looks good, and there is little chance SP will happen. Remember, it would take all hands on deck, and the biggest campaign ever waged by labor in the U.S. In front of some audiences, it looks good to say you're for SP, even if you're really not.

     I'm not saying that labor could have pulled it off, had they really tried. Maybe even all the unions together don't have the strength necessary to win SP. I am saying that they've never really tried, and they aren't likely to.

     Maybe we should try a route that requires a little less of an educational effort. That way, we could proceed without the total and immediate commitment of the labor movement. Here's what we did in Seattle, back in 2005.[1]

     We decided to adopt the slogan of "Healthcare is a Right!" instead of "Single Payer." We reasoned that most people would have no problem understanding and agreeing with our slogan. When we went to the public with our petition, the most frequent reaction was for somebody to read our statement until she/he got to the part about healthcare being a right, then quit reading, smile, and sign. Unlike "Single Payer," people understood and identified with our slogan immediately. "Healthcare is a Right!" was a successful mass slogan.

     From the beginning, my plan was to make Seattle a launching pad for a movement that would mobilize enough mass sentiment to influence the healthcare debate then taking place in Congress. The message would be: No minor adjustments, do whatever is necessary to make equal, high quality healthcare a right in America! We did great in Seattle, 70% yes. Then, a member of the Seattle bunch, who lived in Tacoma, Washington, ran a similar campaign where she lived with the same results; about 70% yes.

     I wish we could have kept the Right to Healthcare campaign going to cities across the country. I really think it would have made quite a difference in 2009, if 30 cities had gone on record that they believe healthcare is a right. It might have helped make the Public Option (PO) part of the final legislation. The PO wouldn't have made healthcare a right in the U.S. right away, but we would have had something to fight for and improve. Maybe make it a little more difficult for private insurance to rip people off, by setting an example of what fair health insurance would look like.

     The key here is that we need a mass slogan that works. That means it has to be both simple and powerful. It has to be easy to grasp by the person-on-the-street, and it's meaning has to be clear. Once organized around the idea of healthcare being a right, the people of the country could exert real pressure on their Congressional representatives to "Make it so."

     Most developed countries that make healthcare a right for their citizens do not have SP health insurance systems. Some do. Many utilize private insurance companies to distribute health insurance. What those countries have in common, according to T.R. Reid,[2] is that they have all eliminated profit on health insurance and heavily regulated how insurance companies provide it. I think a strong public option would result in regulation by competition. Health insurance companies wouldn't dare to charge more or cover less than what the government does, or else people would simply switch.

     But first, we have to organize a mass movement, and we're not going to be able to do that with the slogan "Single Payer." It's too confusing. We can organize people with "Healthcare is a Right!" Then we will be able to really pressure Congress.

     Probably, the next few years will be spent waiting to see how Obamacare works out. If the new health reform law doesn't work any better than it looks like it will, organizing on a mass scale for health reform will again be on the agenda.

     There are some particularly vulnerable sections of the new law to keep an eye on. If Republicans are successful in their court challenge to the individual mandate portion of the law, the whole thing will probably start to collapse. Individual mandate is necessary if the portion outlawing the consideration of pre-existing conditions and guaranteed issue of policies are to hold up.

     The subsidies are pretty generous, limiting the amount people would have to pay for individual coverage to a reasonable amount. But it's hard to imagine Congress, in the current cost cutting climate, coming up with enough funding to cover the subsidies year after year. If that happens, look for uninsurance to be on the rise again.

     Is there something wrong with Single Payer? No, not as a medical insurance system. But it just doesn't work as a way to organize a movement.


1. For more on the Seattle "Right to Healthcare" campaign, please see here at the Monthly Review website, MRZine.

2. The Healing of America by T.R. Reid, Penguin Books, 2010.

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One comment on “Is Something Wrong With Single Payer?
  1. George Fish says:

    This is a very good summary

    This is a very good summary of the SP fight, although perhaps expressing more cynicicism toward organized labor than is really warranted (but not much more). Yet, Brian’s esentially right about the parochialism of the labor movement looking out for its own members first, at the expense, if need be, of the unorganized. Back when he was a real labor leader, Andy Stern noticed this, & called for a more inclusive “justice” unionism instead of a “just us” unionism–something he soon abandoned, as his attacks on United Healthcare Workers West and UNITE-HERE (not to mention the Puerto Rican teachers)soon showed.

    The fight for SP becomes even more complicated when we look at the new slogan advanced by SP advocates, “Medicare for all.” Medicare is semi-privatized, is arranged to give sops to the pharmaceutical and insurance industries. Not just in the Part D “prescription benefit,” but also in the fact that Medicare beneficiaries pay monthly premuims for Medicare coverage, in addition to the taxes charged them as workers to support Medicare; Medicare pays only 80% of the medical costs it covers, thus usually requiring private supplemental coverage in addition to Medicare; and, privatization schemes such as the Medicare Advantage programs, in which HMOs manage Medicare benefits, are also part of the Medicare program.

    So it does indeed get complicated, as Brian notes.

    Something Brian forgot to mention, though, that’s crucial here is the role of organized labor and other “progressives” in forming HCAN, which tailed after Obamacare, tailed after what Obama advocated in terms of healthcare, which specifically abandoned not only any notion of any kind of SP program, but also any sort of “public option” that would compete with private insurance. Brain King’s article makes some very good points indeed.

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