ACA Vs. Single Payer: Bury the Hatchet?


The Nation, Aug. 28, 2012

PNHP note: The following exchange among PNHP co-founders Dr. Steffie Woolhandler and Dr. David Himmelstein, attorney Oliver Hall, and former health-insurance-executive-turned-whistleblower Wendell Potter was prompted by an article by Potter titled “Healthcare advocates: Time to bury the hatchet” in the July 11 online edition of The Nation. A link to Potter’s original article appears at the end.

By Steffie Woolhandler and David Himmelstein

Wendell Potter’s insightful critique of his former bosses in big health insurance was marred by his reprimand of his newfound friends in Physicians for a National Health Program and the rest of the single-payer movement for failing to adopt the political style of his erstwhile employer.

Potter incorrectly implies that PNHP urged a no vote on President Obama’s health reform by the Supreme Court. Some PNHP members condemned the ACA for boosting private insurers’ financial (and future political) power with a trillion-dollar infusion of public subsidies and mandated premiums. Others welcomed its expansion of Medicaid. All agreed that the reform would leave at least 26 million Americans uninsured and most others underinsured; that it would accelerate the corporate takeover of medicine and increase costs; and that single-payer reform remains an urgent necessity.

Potter derides PNHP as a group of strategy-less “die-hards” too “furious at the president and the Democrats” to vote in November or pursue rational alliances. How odd to see a group of 18,000 doctors — including a number of Republicans, conservatives and libertarians — caricatured as ultra-leftists! His call for diluting the single-payer message in defense of Obama’s reform mistakes the nature of the group and its role in society. Physicians are neither politicians nor corporate lobbyists. On health policy, as in our consultations with patients, we’re ethically bound to tell the truth, not a tale we only wish were true. Aspirin may ease the pain of cancer, but it must not be portrayed as a cure.

In Massachusetts, five years into Obama/Romney reform, access to care has barely budged, medical bankruptcy is common and costs continue to spiral. Having lived with such reform, doctors in the state favor single-payer over it by two to one, according to a recent Massachusetts Medical Society survey.

Love it or not, Obamacare is the new status quo. Private insurers—whose paperwork and profits siphon off nearly one-third of healthcare dollars—are still in charge. We and our PNHP colleagues remain determined to replace them with a humane, publicly controlled single-payer system. We invite others to join us.

Founders,Physicians for a National Health Program
New York City

By Oliver Hall

As the attorney who filed the amicus brief on behalf of Single Payer Action, It’s Our Economy, and Fifty Medical Doctors Who Support Single Payer, all of which opposed the individual mandate but otherwise supported the Affordable Care Act, I agree with Wendell Potter that it’s time for progressives to bury the hatchet [“No Time for Infighting,” July 30/Aug. 6].

I invite Potter and other progressives supporting the ACA to join those who never wavered in supporting what we all know is the only solution to the healthcare crisis — single-payer, aka Medicare for All. I hope Potter will blow the whistle on the individual mandate, which he, more than anyone else, must recognize as a deal with the devil.

If Potter won’t bury the hatchet by embracing single-payer, he should at least rescind his demand that single-payer advocates support a law entrenching the same for-profit health insurers he now renounces after a lucrative career as their PR man. Otherwise, he’s just perpetuating the same old misinformation.


Potter replies:

By Wendell Potter

Our country owes Drs. Woolhandler and Himmelstein an enormous debt of gratitude for their untiring efforts over many years to see our uniquely dysfunctional and inefficient multipayer system of private insurance companies replaced with a more rational single-payer one.

As I thought was evident, I’m on their side now. I agree with them and my other friends at PNHP that we must keep working for a more humane system in which private insurers are no longer in charge and can no longer siphon off our premium dollars to cover unnecessary administrative costs and to reward shareholders and executives.

I hope Drs. Woolhandler and Himmelstein will take another look at my article. They’ll see I was suggesting that all reform advocates, not just PNHP members, might consider taking a more strategic approach to achieving their goals. In fact, I referred to PNHP only once, in the penultimate paragraph. I did not write or imply that the organization urged the Supreme Court to declare the ACA unconstitutional, only that many single-payer advocates (including some PNHP members I know personally) felt that way and expressed themselves very vocally. I also did not characterize PNHP as a group of “strategy-less ‘die-hards,’” and I did not reprimand advocates, single-payer or otherwise, “for failing to adopt the political style of my erstwhile employer.” Developing a comprehensive research-based strategy and forming alliances with other organizations to achieve a goal is not synonymous with adopting the insurance industry’s political style.

Anyone who knows me and what I have written and said about the ACA knows that I always point out that the law falls far short of getting us to universal coverage and controlling costs. But I have indeed written that as flawed as the bill is, it is all we are going to get from the 111th Congress, and that starting over would mean that millions of Americans who now or soon will have better access to care would be out of luck for who knows how long if it hadn’t been enacted. I’ve often cited Drs. Woolhandler and Himmelstein’s 2009 study, which estimates that, as a PNHP news release put it, “nearly 45,000 annual deaths are associated with lack of health insurance.” When the ACA is fully implemented, that number will drop. This means that many friends and family members will not have to die prematurely. That number will not drop to zero, however, which is why we need to “get down to the business of developing a strategy to move forward.” That I did write, and I trust it is something all reform advocates can agree on.

As well-written as Mr. Hall’s amicus brief was, it didn’t persuade Chief Justice Roberts to declare the ACA unconstitutional. And as sincere and hopeful as single-payer advocates were at the beginning of the debate on reform in 2009, they regrettably were not able to persuade Congressional leaders or the president to give single-payer even a hearing. So now that the ACA apparently will move forward, where is the strategy to persuade the public and lawmakers to even consider single-payer as a replacement for what we have now? Is it likely that a President Romney and Senate Majority Leader McConnell would be more receptive than Barack Obama and Harry Reid? Is the best strategy to wait until the special interests are no longer as powerful as they are on Capitol Hill and in statehouses or as able to manipulate public opinion? Is it best to wait for the revolution as millions more Americans fall into the ranks of the uninsured and die? No, thank you. My children and your children might be among those who die waiting for the revolution. Any one of us could be. We absolutely need those who have been unwavering in their support of Medicare for All — including the single-payer advocates I’m preparing to meet with as I write this — to stay unwavering and join us to begin the process of developing a strategy to win. I invite anyone interested in seeing a single-payer healthcare system established in this country to join in.


This article appeared in the September 17, 2012, print edition of The Nation.

Potter’s original article:


  1. Christine Niskanen on September 20, 2012 at 1:36 pm

    After reading the above articles, as well as Wendell Potter’s original article in The Nation, I agree with Mr. Potter that it serves no purpose to continue to lay blame on other health care advocates. That’s just what the insurance industry wants, & continues to work for.
    It appears to me that all single-payer advocates will get now is incremental changes towards Medicare-for-all. Both political parties, including the Democrats, are just too entrenched with the insurance industry for them to help us in any meaningful way.
    So, this means that it would be best for us to work together towards the common goal of getting our country as close as we can to a single-payer model.

  2. Jay Kallio on September 20, 2012 at 1:51 pm

    I want to speak plainly:

    If efficient, excellent policy were all that was needed to achieve political success we would have achieved single payer decades ago. Even ironclad arguments are politically irrelevant in today’s “best government that money can buy”. Until we establish and enforce restrictive public financing of elections we do not have even a remote chance of achieving national single payer. Not a chance. The big money is against it, and public opinion is against it. Campaign finance reform is probably a pre-requisite for all progressive policy, including single payer.

    Note: Please do not quote the NYT poll where a majority [around 65%] of respondents said they approved of the government playing a role in helping the poor receive needed health care. Support for that dropped to around 35% when asked whether they supported a national health insurance run by the government. I will not debate with anyone arguing that a majority support single payer on that poll, I find it disingenuous. No poll has ever shown support for single payer to be greater than around 35% except one poll in California which showed around 45% supported the idea right after CNA had done a tremendous job of publicizing our position there. I encourage anyone who believes that some invisible majority in the US supports single payer to go out across the country and ask voters what they think of the idea and experience first hand the often violently negative response the idea elicits. We have yet to win the hearts and minds of the US public, many of whom revile any Left ideas, based on past experiences in countries they fled, where Left wing governments persecuted them, often confiscating their wealth. Many refuse to listen to any arguments for single payer, saying, “The Left lies” and they have heard all the pie in the sky before, “There’s no free lunch”.

    Many people have pondered why the US culture of individualism steadfastly opposes many social democratic programs that work in other countries to better serve their citizenry, often ascribing that resistance to greed, selfishness, and ruthless competitiveness, or general ignorance and stupidity. In my experience more than anything else it reflects across the board cynicism with all government, and retreat into defensive self reliance as the only reliable haven of security. The US is a country of ambitious, and often traumatized immigrants and refugees.

    I have repeatedly suggested very broad strategy for getting to single payer, or de facto single payer in the form of a highly regulated insurance system that is in most ways a single payer system while it retains private ownership, which might be the best we can accomplish given the capitalist culture and commitment of the US public.

    I suggested that all single payer advocates put money and energy toward establishing a single payer system in one state to serve as a model, suggesting Vermont as the most viable state. We can debate the success of that effort, but it is essential to demonstrate the efficiency and viability of single payer on a small scale before the idea will be entertained on a national level.

    Meanwhile, it is essential to support public insurances, and fight against privatization of those insurances, so that we maintain models for public administration of health care on the national level. Silently allowing privatization of Medicare and Medicaid removes any evidence we could call upon to argue for publicly administered health insurance. Americans reject arguments based on the systems adopted by other countries, which have proved useless as examples of success.

    We must make the argument that government is the answer, in an overwhelming “government is the problem” climate that pervades the US electorate opinion. The Left typically distrusts and derides government at least as much as the Right, which effectively eviscerates any argument one could make for more government involvement in health care. Our single payer message lacks any credibility or integrity when we simultaneously undermine any authority or competence in government to administer a single payer system. We don’t make sense, and sound ridiculous.

    I further suggest that we “bury the hatchet” with ACA supporters. Progressive legislators who would idealistically prefer a single payer system, but supported the ACA do see a path, however risky and rocky, that it could slowly morph into a much more progressive system as costs spiral out of control and the resultant public uproar escalates into broad based demand for cost controls on an industry that has long resisted any such regulation. Only through the mandate forcing people to participate in the system is it possible to mobilize public involvement in this issue. Otherwise public opinion remains a quiescent “I want to keep what I have” preference for the devil they know. Many elected officials believe that only by forcing the public, via the mandate to purchase insurance, to take a stand will they ever muster the political will to enact regulations. The ACA is merely the first step, and is not expected to work as policy, it is expected to fail. There is an underlying political method to the madness.

    They tell us again and again, “You have to build a mass movement”. We have not done that, so the only alternative is to force the mandate on everyone and hope that a victimized public will react with outrage and demand remedy in the form of punitive regulation. That may be a path to de facto single payer. It’s very risky, given the passivity the public has so often demonstrated, which may derail the evolution toward regulation we hope will occur. We have offered no better strategy.

    Lastly, I want to point out that from the introduction of the first incarnation of the ACA I objected very strongly to the mandate on the same basis that Drs. Woolhandler and Himmelstein have presented. On an economic level it is the equivalent of giving arms to the enemy, because they will use the largesse gained by this huge infusion of customers and cash into their coffers to gain ever more political sway over the legislative process. Today I have to moderate my objection. Given there is no alternative strategy, we must take that risk. If we really believe in single payer, and we are willing to accept that we may need to cloak a single payer system under the rubric of a highly regulated “private in name only” administrative entity in order to achieve it, then we should conditionally support the ACA as a first step. Without public outrage and mobilization we will not get there. We need that wind at our backs to make this work.

    There are no guarantees we will see anything acceptable develop within our lifetimes. It may take at least another generation to quell the pervasive distrust of government that disqualifies it as too corrupt and incompetent to administer a single payer program, which alienates even many progressives from supporting single payer. The forces of for profit insurance and medicine may win, but at least we could say we took a chance and made a serious try. Lets give the profiteers a run for their money, at very least. :)

    In short, I suggest:

    1) Support a state single payer system no matter how imperfect, in full view of how inappropriate a comparison it will be to a national program. We need that model to hold up as an example.

    2) Consistently and actively fight the forces of privatization of Medicare and Medicaid. Track the outcomes and keep up the drumbeat for publicly administered health care.

    3) Conditionally support the ACA as a reform that will offer a small advantage to people who will otherwise die without it and will offer an opportunity to expose the unworkability of the for profit health care system that obscenely allows huge numbers of people to die amenable deaths every day. It is designed to fail, and we need to position ourselves to build de facto single payer with regulations to contain the failure.

    Alternately, in my wildest dreams I envision a miraculous nationwide reversal of fortune for unions, where they expand their membership into all occupations and establish their own parallel worker owned and administered health care programs with designs to ultimately unite to achieve economies of scale equivalent to a national single payer system. We leverage that unassailable advantage into legislative adoption by the US as a national health care system. Then I wake up.

    In the absence of any other viable political strategy I believe we should at least refrain from hurting our natural allies who support the ACA. It’s not productive.

    I challenge others more sophisticated than I to offer an alternative, but insist it must be politically realistic. Merely being impeccably researched and perfected policy is not good enough, as experience demonstrates.

    Thank you for your time.

    • Jim on September 29, 2012 at 7:20 pm

      I think Jay makes some very lucid arguments.
      I would like to add a few points. While I think the ACA is a tiny step forward on several fronts, it is not clear to me yet where it will lead. I am not entirely confident that it will or even could “morph into a more progressive system.” My fear is that it could “morph” into a total individual market. Consultants are already crunching the numbers to determine what the breakeven point is for companies to shed their corporate health plans and dump their employees onto the Exchanges.
      In most cases it seems that if average family income is less than 250% to 300% of the Federal Poverty Level, it is less expensive for companies (and possibly even some employees) to gross up income, pay the penalty and dump their employees onto the Exchanges. Couple that with the frequently heard comment by employers that they won’t be the first to abandon their health plans but they will be “fast seconds” and I foresee the possibility of the worst of both worlds – no group insurance and no single payer. Those who want to “de-couple health care from employment will get their wish, but for those single payer advocates who have been making that argument it won’t take the form they envisioned.
      Perhaps this is the catalyst that those optimists think is needed to “morph into a more progressive system”. I am skeptical.
      I would like to see single payer advocates expand their coalition building by emphasizing the economic growth arguments to single payer. Small employers will have access to the entire labor force not just those willing to forego health insurance or who have health insurance through their spouses. Large employers will see their health care outlays stabilize. Workers will have more job opportunities because their choices won’t be circumscribed by their need for health care. Entrepreneurs will not have to add the cost of health care to the already burdensome costs of a start-up.

  3. Bev Alves on September 20, 2012 at 4:26 pm

    Although for the time being we must live with the plan we have now, we must not waiver in our determination to get equitable healthcare for all. ACA may cover more people than before, but under ACA much of healthcare coverage will remain in the hands of private insurers whose main interest is making a profit, not providing good health care for patients. In time many of those who will be covered under ACA, won’t be able to afford to pay for their coverage.

    ACA is a tiered system and will not provide an equal opportunity for access to health care and/or high quality care. Unlike Medicare or the VA, private insurers will still be in control under ACA. Since private insurance companies are in the business of making profits, they will continue to raise their rates to offset increases in their costs. Under ACA, the Med Loss Ratio, the % of money actually spent on providing healthcare, has been raised to 80-85%. (Just think what the term Medical Loss Ratio actually means! Private insurers consider money spent on patient care as a loss to them. This concept is an outrage; healthcare should be about caring for patients, not about profits!) The lower the MLR, the less is spent on healthcare. Even though under ACA the MLR has been raised, private insurers still get to use 15-20% of premiums for non medical purposes, like huge CEO salaries. The overhead for Medicare is only about 3%.

    Because private insurance companies are in business to make a profit, they are and will continue to raise premiums. This will make it very difficult for many people to afford to purchase insurance on their own, or to pay for the insurance provided by their employers. (Many employers are already “cost shifting” the costs of higher premiums onto their employees by increasing the % of premiums employees must pay and/or the amount for deductibles and co pays. Some employers have or are developing a “defined benefit plan” which gives an employee a lump sum to purchase insurance on their own. Of course the sum the employee gets is much less than the cost of their insurance, so the employee will have to make up the difference. In fact, because of the rise in premiums, some employers are already or will in the future, just drop healthcare coverage for their employees, and ACA isn’t even in effect yet.

    These ways of cost shifting will make it harder and harder for people to afford their insurance. Whether an insurance co is allowed to keep 20% of the cost of premiums for a $10,000 policy or 10% of the cost for a $20,000 policy, their profit will continue to rise. (Since ACA was passed into law, the average operating profit margins of private insurance companies have continued to expand. Profits are certain to increase even more, starting in 2014, when the bill actually goes in effect.) As the costs of insurance rises more and more people will not be able to afford coverage at all. More people will be forced onto the exchanges.

    The exchanges under ACA will be marketplaces where often confused and anxious consumers must compare and purchase health insurance. Mandated insurance coverage ranges from bronze, silver, gold, and platinum plans. Each plan offering different cost-sharing features – i.e., different deductibles, co-payments, and coinsurance, which will determine the actuarial value of each plan. The bronze plan is valued at 60 percent, silver at 70 percent, gold at 80 percent, and platinum at 90 percent.

    Under ACA, each state is responsible to develop and implement their own exchanges. (It will probably make it more difficult for people to move from one state to another, especially if they already have a healthcare issue.) Two years ago, while lobbying in Albany for a NY State healthcare bill, I met with a legislative aide to a state senator. In explaining the exchanges to me, this aide said, “People will buy the plan they think they’ll need or can afford.” When I asked him how someone can know in advance what they’ll need before they need it, or what will happen if they can’t afford the plan they need, he became silent!

    Equitable, high quality, humane healthcare is a basic human need! By definition, that makes it a human right! Sadly, when people who now have coverage begin to suffer, when those who have coverage can no longer can afford the coverage they have, when they are forced to give up other life essentials to provide healthcare for themselves and/or their families, they will join with us. They too will demand equality healthcare for all. It will happen; it’s just a matter of time!

  4. - bill on September 21, 2012 at 4:04 am

    The ACA reflects the same ‘lesser evil’ approach that has gotten us where we are today: drifting continually away from government that addresses the needs of its citizens toward government that addresses first the needs of its financiers in its functioning (and approaches addressing all public needs from this perspective).

    To say that the ACA is better than the status quo ante is correct only insofar as the ACA makes insurers do what they might well have done anyway: cover more conditions and raise their premiums sufficiently to sustain their profit margins. Otherwise, by explicitly enshrining private insurers in the provision of publicly-subsidized health-care without curbing their outrageous (by comparison with other industrialized nations) overhead/profit margins or providing any significant incentive for them to curb provider costs it constitutes a major step backward from any sustainable health-care system, and will almost certainly result in major cutbacks on planned subsidies well before even the end of this decade (because public support for that degree of government spending on a new ‘entitlement’ will rapidly fade as those costs become evident).

    So, even at best, the ACA represents a step forward only from an extremely short-term perspective and only for a needy but relatively small subset of the American public whose needs could have been satisfied by far less expansive regulation while the main problem was addressed separately. But its effect will be to delay the implementation of any REAL solution for however long it takes for as many people to come around to the realization that the system is STILL irretrievably screwed up as were coming to that conclusion 2+ years ago (when momentum for real change was in the air, a momentum which has apparently completely evaporated save in a few enclaves like this one).

    That is why the ACA is on balance a step backward and hence a mistake, and why we indeed WOULD have been better off had the Supreme Court ruled it unConstitutional in its entirety and forced us to ‘start over’ (in Potter’s words). Because start over we will have to anyway, far enough down the road that it may be even more difficult than it would be now (and MUCH more difficult than it would have been 2+ years ago when the time was so clearly ripe for real reform).

    The national leaders of the Democratic party (aided and abetted, however reluctantly, by the entire Congressional Progressive Caucus) are responsible for having brought us to this sorry state. To call them our ‘natural allies’ is laughably naive, though suggesting that those rank-and-file ACA supporters who do so out of sincere belief that the ACA represents a step toward something better (rather than out of knee-jerk loyalty to the Democratic party) may be potential allies may be less so (or may not be, since progress toward anything better may require more serious pressure on the Democratic party than many of them may be willing to apply: ‘lesser-evilism’ is truly seductive, especially to those already fearful of where our country is going).

  5. Emes Said on May 12, 2013 at 5:43 pm

    After reading ACA provisions in detail, I concluded the only reasonable intent was to destry current system so much, it would require shift to single payor system with rationing of healthcare.
    This con clusion is inescapable and makes sense from the perspective of the progressives who believe single payor acces for all, albeit only those deemed young and worthy of healthcare, better than expensive care of elderly baby boomers. Expect to see euthanasia implemented under single payor system by 2020.