Single-Payer Health Care Is Coming To America-Are We Ready?

By Rick Ungar for Forbes

Speaking at a recent conference, Mark Bertolli, CEO and Chairman of Aetna Insurance, announced that the end is near for profit driven health insurance companies. “The system doesn’t work, it’s broke today. The end of insurance companies, the way we’ve run the business in the past, is here.”

In highlighting the reasons for his bold statement, Bertolli called out the ban on medical underwriting propounded by the Affordable Care Act, which Bertolli believes has made the traditional health insurance business model untenable in the long term, while also giving an ‘honorable mention’ to the MLR requirements.

Underwriting is the process of separating out the healthy from those more likely to be ill and then offering coverage to the good risks while passing on the bad ones.

And yet Bertolli, who leads one of the nation’s largest health insurance companies and is a man known for his honesty and willingness to do the right thing, was not raging against government interference nor suggesting that the Affordable Care Act has destroyed his business as it leads America down the road to healthcare disaster. Indeed, Mark offers a considerable measure of praise for Obamacare saying, “For most of what has already been implemented, it has been a pretty good thing.”

If you are a single-payer advocate—and it is no secret that I fall within this category—you are likely pumping your fist in the air at this news. After all, when the CEO of one of the nation’s largest health care insurers waves the white flag, it’s got to be a good thing for those who wish to usher in the era of universal coverage.

To you single-payer supporters who are enjoying Bertolli’s perceived capitulation, I would simply say, “chill out.”

While I have long argued that the for-profit health insurance model no longer works, and that some form of a single-payer system is—whether you like it or not— inevitable, the simple fact is that we are no more ready to make single-payer a success in America then we are capable of sustaining the existing for-profit model.


Because our healthcare cost issues are going to be as damaging and deadly to a single-payer approach as they have been to the for-profit business model.

Yes, there is ample reason to believe that the conversion to a single-payer system will go some distance in solving some cost issues. Right now, the for-profit model sucks about $400 billion a year out of our health care dollars to pay for administrative costs —costs that largely disappear in a public system where administrative costs run dramatically lower. That’s a lot of money that could be better spent on providing actual care to those in need.

However, the few state-based experiments in making government-sponsored health care available to everyone have revealed problems—such as over-usage of the medical system when it is made available without co-pay or deductible—that can quickly eat up these savings, putting us right back in the soup when it comes to making this alternate approach to health care work out.

The notion of creating a “Medicare For All” health care system in America has been on the table ever since Medicare first came into being in 1965. And for just as many years, the battle has raged over whether making such a system available to all Americans would be akin to a capitulation to socialism in a nation that prides itself on its free-market principles or, conversely, a humane and moral step forward for our society.

Polls have long shown that when the idea of a “Medicare For All” is suggested, or some other variation of a national health insurance system is put to the public, the results tend to be favorable. However, when the wording of such a poll includes the words ‘socialized medicine’ or suggesting an increase in taxes to pay for the same, the results tend to be very different.

For advocates of a universal care system, the driving factor tends to be the underlying belief that health care should be a basic right for all humanity . For the more pragmatic supporters, the belief is that what we’ve currently got just isn’t working so why not try a different way?

Those who oppose a universal or single-payer approach, appear to believe that the practical matters are the greatest concern while some object based on deep ideological concerns. The practical fear is the perceived inevitability of rationing in medicine, and the wait times to receive medical care that come when the system is opened to all, based on our lack of adequate funds to pay for the increased services or the limited availability of sufficient medical personnel to meet the demand.

Whichever side draws your support, if the war over the Affordable Care Act has taught us anything it is that there is likely to be more than enough legislators to block an effort to extend Medicare to all Americans, or some other variation of a single-payer system, for the foreseeable future. However, if the for-profit insurance companies find it no longer worth their while to stay in the business, which is my own expectation and a notion that appears to be shared by Mr. Bertolli of Aetna, a single-payer system may be thrust upon our politicians when government is the only entity large enough to take on the financial responsibility of our health care system.

However it happens, and I very much believe it will, we had better be prepared—and we are not.

If single-payer is in our future, whether on a state-by-state basis or a system operated by the federal government, it would be best to set it up before we are forced into it by failed private insurance companies. That means that devising a workable program with political support from all sides is far preferable to waking up one day to find that this is the only option available to us.

To do this, supporters of the single-payer model are going to have to offer up something more than their good intentions to both politicians and citizens who oppose this approach. Supporters are going to have to offer the solutions designed to control what are now out-of-control health care costs without putting patients in jeopardy of death due to rationing or causing folks undue waiting times to deal with a medical problem.

And this all has to be done in a way that does not increase the cost of health care to taxpayers and promises to lower costs over time.

That’s a tall order to be sure. But it not only can be done- it is being done.

It also means that single-payer supporters cannot pretend that the experiments in variations of universal care in states like Maine, Minnesota and Tennessee did not fail. They did. By the same token, opponents of universal care cannot just point to these failures as the reason we should not be striving to achieve a far better health care system than the one we’ve got.

Failure does not mean that these efforts could not have succeeded had they been better planned and executed or that what we’ve learned from these failures can’t be used to do a better job in the future. The point of experimentation is not to give up when something doesn’t work—the point is to learn from the failure and devise approaches that will accomplish the goal while avoiding the mistakes that made earlier experiments go wrong.

In the coming days, you’ll find a discussion here on how we can go about reducing these costs in a way that will give opponents of universal care—and the politicians who represent their point of view—permission to support what is an important and noble goal. As a “warm-up”, take a look at a piece I published some weeks ago, relaying the story of Grand Junction, Colorado. This reveals what is possible when cost issues are tackled on the local level—which is precisely where the problem must be solved.

Now, if you are so engrossed in your ideology that you cannot deal with the idea that a government based payer system— or some combination of government and private industry— cannot come forward with a solution to our problem, these articles are not going to be for you. On the other side of the coin, if you are so convinced that there is no room for private industry in a healthcare system where government is the primary payer for care because profit is, somehow, the mortal enemy of quality healthcare for all, then you too will be equally disappointed.

However, if you are interested in bringing forth a new, uniquely American model for our health care system, there may be some ideas that might ring true or, at the least, spark a non-partisan, non-ideologically based discussion.

More to come.


  1. Margalo on March 8, 2012 at 1:22 pm

    If you get published in Forbes, you can only be delusional to get published. There has been a good plan sponsored by Rep. Conyers, H.R.676, Expanded & Improved Medicare For All Act, introduced in every Congress repeatedly for about a decade. It provides coverage for preventive care, which reduces costs in every study and is modeled, if not pioneered, very well by Kaiser Permanente HMO. It also provides coverage of alternative health care providers. Clearly, this short bill has been very well thought through to provide an excellent health care system for all, exempting the VA,which has its own system. I cannot figure out why this bill is not consistently put forward by all single-payer advocates in every article, email, etc. Conyers will keep going with the bill, but he is past the age of retirement, and Kucinich will not be returning to Congress unless by some miracle of concerted effort he is able to win a primary in WA State this spring. He would keep it going until enacted. If Conyers leaves Congress, we must be sure that one of the other 75 co-sponsors will introduce it until passed. I recommend reading the bill to everyone, as we should not settle for less. (Find it on under H.R. 676 & be sure to type it exactly as I did or it won’t come up.)

  2. ter badger on March 8, 2012 at 1:54 pm

    i think that the best way to implement it is to lower the age of people able to receive medicare by one year each year until 65 years from now everyone is covered. As each group is added there should be enough time to asses what is good and what needs to be fixed. A side benefit is that many of the older recipients might retire early which could open more job opportunities to the unemployed.

  3. Hoosierpop on March 8, 2012 at 4:27 pm

    Ter badger’s plan to implement universal medical care gradually is a good one, but I would start at the other end of the age continuum to gather political support. In other words, enroll every newborn citizen in Medicare. How many politicians would seriously object to taking good medical care of newborn babes? Everyone would be covered in a few generations, and probably sooner, because those at the other end of the age continuum would soon mount pressure to include them too. I would call this plan “Babycare.”

  4. Tom Cox on March 8, 2012 at 5:17 pm

    Other than simple mean spiritedness, I can’t figure out why half the country wants to deny healthcare coverage to poor people.

    In the 2008 campaigns, all of the candidates were tripping all over themselves offerring their versions of healthcare reform. They wanted Americans to vote for them to ensure that all Americans would be covered. As soon as the new president took office, the entire rrepublican party did an about face and vowed to block any healthcare reform offerred by the majority.


    Why do they hate healthcare reform?

    Congressman Alan Grayson exposed the truth about the Republican healthplan when he explained that it was really simple, “Don’t get sick and if you do get sick, DIE QUICKLY.”

    • Philip George on March 9, 2012 at 11:14 am

      Tom Cox; The answer is simple . Too many people eating from the filthy trough of slime put there by the Health
      Insurance companies!

      • Brenda on June 28, 2012 at 12:06 pm

        Precisely, I have Medicare-due to cancer and severe arthritis. I have no waits for Doctors, My ER visits are covered. In short NONE of the “horror stories” are true. I have one of the BEST specialists treating my Cancer in my area as well.

  5. Barabajagal on March 9, 2012 at 11:16 am

    Referring to: “Right now, the for-profit model sucks about $400 billion a year out of our health care dollars to pay for administrative costs — costs that largely disappear in a public system where administrative costs run dramatically lower. That’s a lot of money that could be better spent on providing actual care to those in need.” That, Mr. Ungar, is pure, unadulterated poppycock. There isn’t an example, study, human experience on this planet that dictates, suggests or postulates that government administration costs less than private sector administration. You want $400b lopped off the health care bill in this country? Start by eliminating the diversity in State law makes it nearly impossible for an insurance company to navigate. If you cover employees in all 50 states, you effectively have 50 different insurance carriers to work with. That’s a great starting place. A government agency to do the same is not.

    • Richard R Schneider, MD on March 10, 2012 at 12:20 pm

      This is a link to a NEJM article comparing overhead costs in the US compared to the government system in Canada. I suggest you read it before making unsubstantiated claims that there exist no studies comparing overhead costs of government run systems vs private insurance run systems. In addition, the overhead costs for Medicare have been shown to be less than 10% as compared to at least 25% in the private system.

      • Sarah Williams on March 11, 2012 at 9:31 pm

        Just had to say “Amen” to Richard.

      • No Difference on March 13, 2012 at 2:57 pm

        Less than 5%, not less than 10%. Even better!

        • Richard R Schneider, MD on March 14, 2012 at 6:26 pm

          5% is less than 10%. Actually I have heard numbers as low as 2-3%. I said 10% because that is mathematically correct and I didn’t want to take any chances. (I had a minor in math in college.) I have also heard numbers as high as 8%, so I just wanted to make sure I didn’t say something that wasn’t true.

          • Chris Hagel on April 14, 2012 at 3:23 pm

            I inquired about that extra percentage about five years ago.
            Medicare has about a 3% overhead.
            That extra three or four percent that the conservatives rip into Medicare about is the cost of assessing and reviewing it. I’m not using the exact wordage as I don’t have the info at my fingertips, but that’s the general drift.

            Nevertheless, the info was provided by Prof. Len Rodberg, a strong single payer endorser, who is quite knowledgeable in this area.
            He emailed me the info back then.

            The total percentage (that doesn’t actually go towards health care), in any event, is much lower than the 15, 20 or even 30% overhead of this market driven non-system of health care, that most Americans are presently victimized by.

            That extra percentage is what they’re getting all bent out of shape about: “Ooo that evil Medicare, don’t trust their figures, it’s actually an 8% overhead…”

            Blah, blah, blah.

            Mean while, health insurance/big pharma CEOs are out on their yachts with their friends and family and return home to their mansions at days end and so on…
            As millions of people are weighed down by co-pays and huge deductibles AFTER they’ve already paid the huge premiums, most times being under insured anyway.
            Also small and large businesses are saddled with this overhead of this market driven non-system of health care.

            This is some of the sickening waste that these big “I love my country and people…they’re fighting for our freedoms…united we stand…” conservatives ignore; which should actually be eliminated.

            This is some of the real waste to be eliminated as a reassessment of values and morals, with a fair and rational look at our utterly irrational market driven non-system of health care; instead of this “austerity budget” that’s beginning to take hold of our country.

  6. Sarah Williams on March 11, 2012 at 9:28 pm

    It would be easier to add defined groups to the Medicare rolls based on something other than age, for example adding all first responders and their families, thereby taking a great financial burden off states and municipal government. Budget-crunched legislatures might go for this quickly. Then we could move out to other state and local government employees. By the time we had added a couple of large demographics, we would begin to see the path more clearly. With the current improvements in Medicare preventive health under ACA, the financial benefits would kick in more quickly if we added people from all age groups. We are beginning also to see success in prevention of cancer, which costs pennies compared to treatment, as with the HPV vaccine. Removal of the profit motive and fee for service principle from health care will go a long way toward encouraging prevention and lowering costs.

  7. No Difference on March 13, 2012 at 2:53 pm

    The author of this article could have made a much better argument. The first issue has to do with the real intentions of Mr. Bertolli, CEO of Aetna. Maybe he champions PPACA for a completely different reason? For instance, perhaps PPACA might ensure his company — and the entire health insurance industry — healthy profits for as long as PPACA is executed. After all, PPACA WAS drafted as a backstop for insurance company profits, as evidenced by the fingerprints of ALEC and other lobbies found all over that bill.

    Supporting PPACA is a sure win for Bertolli; in fact, it is the only win remaining. Had Single Payer been implemented in 2010 rather than PPACA, the health insurance industry would have been gone by now, having foreseen no future revenue path. PPACA extends the life of this leech industry, which will now attach itself tightly to the teat of government-mandated purchase of insurance policies by “consumers” (nee patients).

    If Bertolli were seriously ingenuous about his position on Single Payer, as portrayed in this article, I’d imagine the Aetna Board of Directors lugging out and dusting off the guillotine in preparation for execution of justice against such a heretic who speaketh such treason which could drive down the price of Aetna stock.

    But that possibility was never explored in this article, was it?