03/31/2008 11:11 am ET Updated May 25, 2011

Why Not Single Payer? Part 5: The Single Payer Health Care Movement and the Plans of the Democratic Presidential Nominee

Following is the text of my speech at the Take Back America Conference panel on "The Single Payer Health Care Movement and the Plans of the Democratic Presidential Nominee." I was honored to be on the panel with Courtney Farr of the California Nurses Association and Congressman John Conyers, Chairman of the House Judiciary Committee and chief sponsor of H.R. 676, the single payer Medicare For All bill.

Most progressives agree that the government has an important role to play in guaranteeing health care for all Americans, in contrast to most Republicans who want to leave people at the mercy of the private market. But the Conference also revealed differences among progressives on strategies for achieving universal health care. For many years, most progressives have supported the principal of Medicare For All -- a system in which all Americans have guaranteed health care from cradle to grave, financed through taxes instead of insurance premiums, and in which medical decisions are made between patients and doctors and not by private insurance bureaucrats. The Campaign For America's Future, which sponsored the Conference, supports a compromise private/public hybrid, in which most people continue to get private insurance through their employers, but in which companies and uninsured individuals can also buy into a public alternative. Most versions of this plan, including that supported by Hillary Clinton, include an individual mandate in which the uninsured are required by the government to buy health insurance, although they are given the "choice" between private insurance and the public plan.

Such difference threaten to divide the progressive movement when it comes to health care reform. This was evident in California recently. A year ago, both houses of the California legislature passed a bill which would have established a single payer system for California's 37 million citizens, which was vetoed by Republican Gov. Schwarzenegger. This year some Democrats, led by California Assembly Speaker Nunez, tried to forge a compromise with Schwarzenegger for a health insurance mandate similar to that enacted in Massachusetts under Mitt Romney. The compromise was supported by some progressives, most notably Andy Stern of the SEIU. It was defeated 8-1 in committee in the State Senate after being opposed by the majority of the progressive health care movement, including the California Nurses Association and the California One Care Coalition.

Progressives will need to take great care not to let these differences undermine the movement for universal health care nationally.

Here's the speech:
Before introducing Chairman John Conyers and Courtney Farr of the California Nurses Association, let me outline a few principals for our discussion this afternoon about how progressives should respond to the health care proposals of the leading Democratic presidential contenders.

First, if we have a Democratic president and an increased Democratic Congressional majority after November, we will have the best opportunity to enact Universal Healthcare in America since the Truman administration. If we blow it, the opportunity could be lost for another generation.

Second, this kind of fundamental social change will never take place only from the top. It requires a mass movement pushing from below. If history proves anything, it's that Washington only enacts major social change if prodded by large scale social movements such as the union movement, the civil rights movement, the women's movement and the anti-war movement. There already is a strong mass movement of unions, doctors, nurses, churches and community organizations building support for Medicare for All as embodied In HR 676 sponsored by Chairman Conyers. It has, I believe, over 80 Congressional co-sponsors--that's nearly 1/3 of the Democrats in the house-- and has been endorsed by over 235 union organizations in 40 states, as well as many citizens, religious and medical organizations.

Third, any healthcare reform plan that's based on private insurance is fatally flawed. A. The incentive of private insurance is upside down. The less care a private insurance company provides for the same premiums, the higher their profits. Most of us saw the cases in "Sicko" of insurance companies paying bonuses to employees who rejected healthcare claims from the sick. B. With hundreds or thousands of different private health insurance plans, it's impossible to negotiate consistently lower costs with health care providers and drug companies. A single payer system has the market clout to reign in costs. C. Most important, private insurance is a colossal waste of money. Administrative costs for Medicare are 2-3%. Approximately 30% of private insurance premiums go to overhead, profits, and executive salaries. Doctors and hospitals have to employ huge staffs just to process insurance claims from a multiplicity of insurance companies. About 20% of the income of private doctors goes to pay for this staff. Overall, the administrative costs of private insurance exceed $400 billion a year. That.s enough to cover all of the uninsured without raising taxes.

Fourth, as Barack Obama has said, "Change is hard." You do not bring about fundamental social change by surrendering on basic principals without firing a shot. Let me say that again: You do not start by surrendering on basic principals without firing a shot. That's the problem with the approach of the leading Democratic presidential contenders and some progressives like those who spoke this morning on the Campaign for American's Future panel led by Jacob Hacker. Before the political battle even begins, they ask the mass movement for universal healthcare to abandon the principal of not-for-profit universal health care for a plan based on employer and individual mandates to buy private health insurance (albeit with a public alternative). George Lakoff's Rockridge Institute calls that approach "Surrender In Advance".

Fifth, Congressman Conyers has kept the issue of universal healthcare alive in Congress for many years when others have given up. John Edwards, Hillary Clinton and Barack Obama deserve credit for placing health care reform at the top of the domestic political agenda for the next president. But their actual plans are deeply flawed. There is no reason that the mass movement for Universal Healthcare has to fall in line behind their specific proposals. We can use the opportunity of a Democraric president and Congress to push beyond the proposals put forth by the presidential candidates.

The argument that some progressives make for surrendering in advance is that a plan based on employer and individual mandates, albeit with a public alternative that the uninsured may buy into with their own money, is more politically practical than Medicare-For-All. I think they're wrong. Their proposals are bad social policy and even worse politics.

Here's what I want to know. Why is it more politically pragmatic to tell middle class voters that if they don't have health insurance, or lose their health insurance, the government will force them to buy it?

The average cost of an individual policy is nearly $5,000 a year and its $12,000 for a family of 4. Hillary and Obama don't specify how poor you have to be to get a government subsidy, but Massachusetts gives full subsidies to those earning up to 150% of the poverty level of about $10,000 for individuals and $14,000 for couples. Premiums are reduced for those earning up to 3 times the poverty level. Individual making more than $30,630 and couples making more than $41,880 have to pay full freight. To quote a column from the Boston Globe by 2 Doctors, "244,000 of Massachusetts uninsured get zero assistance--Just a stiff fine if they don't buy coverage. A couple in their late 50s faces a minimum premium of $8,638 annually, for a policy with no drug coverage at all and a $2,000 deductible per person before insurance even kicks in. Such skimpy yet costly coverage is, in many cases worse than no coverage at all. Illness will still bring crippling medical bills - but the $8,638 annual premium will empty their bank accounts even before the bills start arriving. Little wonder that barely 2% of those required to buy such coverage have thus far signed up."

A government mandate requiring people to pay these kinds of premiums, even if a national plan had somewhat higher subsidies, is effectively a huge hidden tax increase for the middle class and a huge boondogle for the private insurance companies to whom the government delivers large numbers of new customers. Maybe that's why such a plan is more politically "pragmatic". It's a plan private insurance companies could learn to love.

So here's what John McCain will say to a candidate running on a mandate plan: "The Democrats want to punish the middle class with a backdoor tax. If you're an uninsured family and make over $40,000 a year so you aren't poor enough for subsidies but can't afford insurance, the Democrats will fine you or garnishee thousands of dollars of your wages since the average policy for a family of 4 is $12,000." That should be enough to scare off millions of middles class families from voting for a Democrat. Pragmatic politics? I don't think so.

I ask again. Why are these kind of plans more politically pragmatic than Medicare-For-All?

These plans are intricate Rube Goldberg contraptions that are hard to explain to voters. They are complicated mix and match systems which include mandates on employers to provide insurance or pay into a pool, exemptions for small business, tax credits, health market pools for buying insurance, mandates that uninsured individuals purchase insurance, government penalties for people who fail to buy insurance.

To quote Jonathan Cohn, author of "Sick", "If you're going to propose a large-scale change to the health care system and invite the 'socialized medicine' charge anyway, you might be better off endorsing a single payer system, which at least has the virtue of being easy to explain. Unlike, say, a hybrid public-private system, which involves all sorts of convoluted regulations, which then require all sorts of tortured explanations, the essence of single payer can be reduced to three simple words: 'Medicare For All'".

There are progressives who argue that Medicare For All is just too controversial to sell to the American public. A number of polls show that fear is misplaced. A CBS News poll last September asked "Which do you think would be better for the country: having one health insurance program covering all Americans that would be administered by the government and paid for by the taxpayers, or keeping the current system where many people get their insurance from private employers and some have no insurance?" 55% chose "One Program for All" and only 29% chose "The Current system". A January 2007 NBC News/Wall Street Journal Poll found that 53% would be willing to pay higher taxes so that everyone can have health insurance.

And that's while the movement for Medicare for All is still in its relative infancy. With the combination of leadership in Washington by people like Congressman Conyers and a mass movement of citizens groups, unions and churches, we can get the majority of people behind us.

In fact, for those who say that Medicare for All is not practical, I remind you that both houses of the California legislature already passed a single payer health care bill in 2006. Unfortunately, it was vetoed by Governor Schwarzennegger. But we'll be back in 2 years when we will hopefully have a Democratic Governor. Remember, single payer healthcare in Canada started in 1 province, Saskatchewan, and was so successful that it spread to the whole country. That may end up being the path in the US too, whether it's in California, Wisconsin, or Washington state.

Some progressives argue that a plan based around private insurance would also have a Medicare like public alternative that people can buy into. They claim that eventually this program might, by some form of alchemy, evolve into a single payer system. Their logic is flawed. If this plan is modeled on Medicare, it would be a fairly generous plan in which you can choose your own doctor, in which most treatments your doctor recommends are covered, and in which deductibles and co-pays are low. Even with reduced administrative costs, this would be expensive insurance. Private insurance companies would offer lower cost policies with high deductibles and co-pays. This would lead to what's called "adverse selection". The young and healthy would opt for the cheaper plans. Mostly older and sicker people would opt for the public plan. Far from slowly evolving into a single payer system, the Medicare-like plan is likely to become increasingly expensive, making it even less affordable and forcing more and more people back to bare bones private insurance.

So, to sum up, here's what the progressive movement should be saying to our Democratic frontrunners: Run on your Universal Mandate plans if you must. At least you'll keep the issue of health care reform on the political front burner. We'll contribute money and work hard on your campaign. The country cannot afford another 4 years of a Republican in the White House.

But if you're elected president, we're not going to lend the force of our mass movement to supporting your compromised plans. We'll be organizing millions of people behind Medicare For All, the only type of plan than can actually guarantee quality Universal Health Care to all Americans.

ADDITIONAL NOTE: One comment asked for links for activists who want to become involved in the single payer movement. Here are a few good ones:

To read prior installments of this multi-part Huffington Post series, "Why Not Single Payer?", see:
Part 1:
Part 2:
Part 3:
Part 4: