• A question for single payer advocates: Where do the votes come from?

    Alexander Burns and Jennifer Medina report in The New York Times that

    At rallies and in town hall meetings, and in a collection of blue-state legislatures, liberal Democrats have pressed lawmakers, with growing impatience, to support the creation of a single-payer system, in which the state or federal government would supplant private health insurance with a program of public coverage.

    I support universal health insurance: I voted with my feet to work in Canada. When the office of an outspoken New England legislator asked me for comments on the text of a single-payer bill, I was glad to give them.

    My question is: How do advocates plan to build a coalition that could pass single-payer?

    I’m not talking about the current weakness of the Democratic Party. Let’s assume a future in which the Democrats have recaptured the presidency and the Congress. Let’s assume that Republican health care policies are supported by only about 1 in 5 Americans, as is the case today.

    The problem is that even in these circumstances, I fear that many Americans will judge the risk of a financial loss in a transition to single payer to be greater than the benefit they are likely to receive from single payer.

    Consider that 49% of Americans have health coverage through their employer (7% have non-group coverage, 36% have public insurance, and 9% are uninsured). These employees aren’t getting health insurance for free. They pay for their insurance benefit through foregone wages. But it often looks to them like they are getting insurance for small premiums, if not for free. If they have to pay for their insurance through increased taxes, many will likely perceive that they have suffered a net loss.

    Moreover, some people would suffer an actual loss in a transition from employer-supplied health insurance to single-payer. In theory, we might expect an employee’s compensation would rise enough to cover the tax costs of single-payer, but that won’t happen for everyone. Some people will be net losers.

    In part, this is because a universal care system will, by design, help equalise access to health care. Suppose we tried to do this through a scheme that held total health care spending constant. Then making access more equal would require redistributing some health care resources from the haves to the have-nots. That might be just, but the haves would hate it. And they vote.

    Alternatively, we could bring the care of the underserved up to the standard of the well-served. This will require increased health care spending and an even larger increase in taxes. Most of those taxes would come from the affluent. The affluent already have good insurance, so they gain little from single payer. Again, the haves are net losers.

    As I see it, there won’t be a sustainable US single-payer system unless we can make American health care more efficient. Efficient enough so that you can level the have-nots up to health care standard of the haves without increasing spending. There are theories — or at least stories — about how to do this. Single payer would reduce administrative costs. A single insurer would have great power to knock down the prices charged by manufacturers, hospitals, doctors, and nurses. Either course will involve political warfare against powerful industries.

    There is a counterargument against my pessimism. Other developed countries have single-payer (or other forms of) universal health care. If, Canada did it, why can’t the US make the same transition?

    However, the US may have missed the window when establishing a single-payer system would have been comparatively easy. The Canadian transition began in Saskatchewan in 1947. Saskatchewan farmers were largely uninsured and had nothing to lose in the transition to public insurance.

    So my question for single-payer advocates is, where do the votes come from?

    @Bill_Gardner

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