07/24/2008 05:12 am ET Updated May 25, 2011

Why Not Single-Payer?

I want to take a moment and address those of you who have been asking why Health Care for America Now is not focusing on creating a single-payer health insurance system. First of all, here is HCAN's official position:

The goal of Health Care for America Now is to build a national movement to win the implementation of health care reform that meets the principles in our Statement of Common Purpose. We believe that a properly designed single-payer bill is one way of doing that but not the only way. Many of the organizations that belong to HCAN support single-payer reform and have endorsed HR-676. But in joining HCAN, they recognize that the major focus needs to be on winning quality, affordable health care for all rather than advocating for only one approach. Health Care for America Now believes that the big divide in our country on health care is between those of us who believe that there needs to be substantial government involvement in guaranteeing quality, affordable health care for all and those who think that the solution is to rely ever more on an unregulated private market.

I was a leader of the fight for single-payer reform during from 1988 to 1994. I co-wrote with Richard Gottfried -- then and now the Chair of the Health Committee of the New York State Assembly -- the only fully-financed single-payer bill to ever pass a state legislative body in the country. I shared the responsibility with Assemblyman Gottfried for presenting single-payer at twelve debates sponsored by Governor Mario Cuomo in 1991 on healthcare reform proposals. I wrote a training manual and talking points for candidates for Congress to use in running on single-payer in 1992. I could go on, but you get the idea.

So what happened to me? Five years ago, I sat down to write a history of the struggle to win a single-payer system. (Will it be Déjà vu All Over Again? Renewing the Fight for Health Care for All Tales, Hopes and Fears of a Battle-Scarred Organizer [pdf]). Here's what I wrote in the preamble to that article:

I intended to write this piece as a cautionary tale for both the new generation of organizers for universal health care and the veterans of the last fight. To my surprise, the writing led me to a fresh understanding of the paradox of achieving universal health care in the United States: the political debate about health care reform is turned upside down once the debate turns from the problem state to the solution stage. At that point, people become more scared about what they will lose from reform than what they will gain. This conclusion led me to reframe my view of how we go about organizing for universal health care, and -- to my even bigger surprise -- to outlining a new proposal for comprehensive reform.

I wrote at the time: "So here's my proposal, in a nutshell: provide everyone in the country with the option, and the means of paying for, coverage through Medicare or through private insurance."

One point of this approach was not to scare people away from reform or to make it easier for the opponents of reform to panic the public. I realized we could reassure people about change by building on what people are familiar with -- both private insurance and Medicare's public insurance plan.

A lot of what I wrote at the time also had to do with the need to reaffirm the positive role of government in America. To do that, we need to demonstrate that government can better people's lives in real ways. Even though it might make us feel good, stating our ideological position in the hope that people will eventually come around is not effective. We need to win real changes that show government can work in positive ways.

Our goal is to have the United States provide a guarantee of good, affordable health coverage to all its residents. That's the bottom line. A national health insurance plan (single-payer) is one way to accomplish the goal, but it's not the only way. In fact, one of the myths about health care around the world is that "everyone but us has single-payer." In fact, single-payer is the way Canadians provide a government guarantee of good health coverage. Other countries -- including the European countries usually held up as models -- do it differently, with all sorts of variations of public, private, and non-profit insurance and socialized medicine. But what's true in all these countries is that health care is guaranteed and regulated as a public good.

We need to keep our eye on the prize and on the real debate. It would be great -- a progressive dream -- if the political debate were between putting everyone into a government health insurance plan (single-payer) and having a very large public insurance plan along with regulated private insurance (which is what the HCAN principles say). But the real debate is between those of us who believe that health care is a public good where government has to guarantee quality, affordable coverage and those who think that the problem with the health care system is that the market's not working, and if we gave people a voucher to buy unregulated private insurance, it would solve everything.

That's why the focus of our grassroots campaign in 2008 is our Which Side Are You On? statement. It lays out two very different visionsfor reform: "Quality affordable health care for all" or "On your own with private insurance". That's what America has to decide.

Late last year, I wrote an article that lays out in a lot of detail the argument for Health Care for America Now's strategy: Winning Quality Affordable Health Care for All [pdf]. I hope you'll take the time to read it. For now, I want to share with you the last two paragraphs from that piece:

We have to start where the American public is today. After seven years of the George W. Bush administration and 30 years of conservative dominance the American public is fearful about their economic status. Most Americans see the government as being corrupt, ineffective and on the side of wealthy special interests. People do not trust the government and that do not think that the government is on their side. Health care reform contains the promise to turn this around, to demonstrate that government can work for all of us, which the public interest can trump corporate interests and the "you are on your own" ethos of the new gilded age. Health care reform holds the promise to create a generation of Americans that support a government that works for everyone, just as the New Deal's advances led to four decades of activist government for the public good.

Coming off more than a quarter century of conservative domination of American politics, I am reminded that Karl Rove's hero, William McKinley, was followed by Theodore Roosevelt and the Progressive Era. Our job is to build a movement for health care reform that ignites the hopes and aspirations of the American people, the American values of opportunity and fairness. Winning real health care reform will requires a clear vision, a persistent, strategic energy and a belief in the miracle of change.

(Also posted at the NOW! blog)