Single-Payer Is Not Dead

By Froma Harrop for Real Clear Politics

The prospects for single-payer health care — adored by many liberals, despised by private health insurers and looking better all the time to others — did not die in the Affordable Care Act. It was thrown a lifeline through a little-known provision tucked in the famously long legislation. Single-payer groups in several states are now lining up to make use of Section 1332.

Vermont is way ahead of the pack, but Hawaii, Oregon, New York, Washington, California, Colorado and Maryland have strong single-payer movements.

First, some definitions. Single-payer is a system where the government pays all medical bills. Canada has a single-payer system. By the way, Canada’s system is not socialized medicine but socialized insurance (like Medicare). In Canada, the doctors work for themselves.

Under Section 1332, states may apply for “innovation waivers” starting in 2017. They would let states try paths to health care reform different from those mapped out by the Affordable Care Act — as long as they meet certain of its goals. States must cover as many people and offer coverage as comprehensive and affordable. And they can’t increase the federal deficit. Qualifying states would receive the same federal funding that would have been available under Obamacare.

My conservative friends complain that the innovation waiver requirements would rule out everything but single-payer. No doubt they are diligently working on a more privatized alternative that would cover less, cost more and raise the federal deficit.

“Vermont is the only state where they’re thinking very concretely about using (the waiver) as part of their plan,” Judy Solomon, health care expert at the Center on Budget and Policy Priorities, told me.

Hawaii got close. Its Legislature passed a single-payer bill in 2009, which was vetoed by then-Gov. Linda Lingle, a Republican. Lawmakers overrode the veto, but Lingle refused to implement the law.

The quest remains rocky, Dr. Stephen Kemble, a single-payer advocate and past president of the Hawaii Medical Association, told me. “If Vermont can get things going, that would make things easier for others.”

In Washington state, “our focus is to work on grass-roots support,” says Dr. David McLanahan, Washington coordinator for Physicians for a National Health Program. “We’re laying the groundwork” for legislation and a request for an innovation waiver.

Problems in the Obamacare rollout have energized fans of single-payer. Computer glitches aside, the troubles stem chiefly from the law’s complexity. Single-payer is all about simplicity.

Under the Vermont plan, employers and individuals would no longer have to buy private health coverage.

They would instead pay a tax. The state-run system would also cover more things, like dental. And oh, yes, Vermonters could choose their hospitals and doctors.

William Hsiao, an economist at the Harvard School of Public Health, has projected that Vermont’s annual health care spending could fall 25 percent. The savings would more than pay for the new benefits.

How? Fewer dollars would go to advertising, executive windfalls and payouts to investors. Doctors dealing with one insurer would save on office staff. Fraud and abuse would shrink as a comprehensive database makes crooks easier to spot.

It’s too bad that some liberals have turned single-payer into a religion and are whacking the Vermont plan for not being pure enough. Vermont is permitting continued private coverage for very practical reasons.

Bear in mind that the most acclaimed health care systems — in Germany, in France and our Medicare — combine single-payer for basics with private coverage for the extras.

Vermont intends to use its state health insurance exchange as the structure on which to build its single-payer system. By 2017, the road to an innovation waiver should be clear.

Go forth, Green Mountain State. Show us what you can do.


  1. SPCentral on January 15, 2014 at 3:05 pm

    Indeed – we fought hard for that tiny little worm hole of light. I personally remember harassing lawmakers on the phone and online every THIRTY MINUTES to make SURE this was not dropped, forgotten, set aside, whatEVER… I want to tell you that a key person who made SURE that section got in there was John Garimendi (sp?) who held – I don’t even remember what office at the time. And even AFTER we got it into the ACA, some singlepayer supporters were not helping by spreading misinformation that in fact this tiny little option was not going to allow for innovation and all kinds of other misinformation. Lessons to be learned: you may be an expert but please, before you go declare something dead or impossible, please please please make SURE you TRULY have done your due diligence. It is great to see this mentioned here but I remember well how many supporters dismissed this when I declared this as a small victory and a pinprick of hope that should not be ignored. Just sayin…

  2. Thomas Cox PhD RN on January 15, 2014 at 5:54 pm

    We do not just need a single payer, we need a single payer, insurance risk retaining, national health insurer. Few countries have that – certainly not Canada or Great Britain, both of who are using a variety of capitation-like payment mechanisms to transfer insurance risks to health care providers.

    If you do not like a third-party health insurer or managed care organization making decisions about your health care that are primarily aimed at increasing their profit margins, why would you want you trusted health care provider to be your health insurers and making decisions about what they will and will not do for you based on how it will affect their profit margin?

    Most voters and almost all politicians simply do not understand how insurance works.

    Yes, a single payer system IS the most mathematically efficient insurer possible (See “Standard Errors: Our Failing Health Care (Finance) Systems And How To Fix Them” at my website) but a single payer isn’t enough.

    The single payer actually has to retain its insurance risks. Medicare does not do that. Medicare, through the Prospective Payment System, transfers its insurance risks to health care providers. The risk assuming health care providers: Physicians, Hospitals, Nursing homes and Home health agencies become their patients’ de facto health insurers.

    For the same reason that more than a thousand health insurers is a terrible idea, that they are inefficient, offer lower benefits per premium dollar, are subject to wide swings in loss ratios and have inordinately high aggregate surplus requirements (Billions of dollars in idled assets if properly protected from insolvency), hundreds of thousands of Physicians, Hospitals, Nursing homes and Home health agencies is an even worse idea because they offer far lower benefits per premium dollar, are far more subject to wide swings in loss ratios and have astronomically high aggregate surplus requirements (Trillions of dollars in idled assets if properly protected from insolvency).

    State managed, insurance risk retaining insurers would be an improvement over our current mess, but they are still far less efficient, especially the smallest states, than a national health insurer.

    There is, unfortunately, a very great danger that we will fall for an insurance risk transferring single payer such as Medicare For All, which will do little to change the situation we are in now.

    Here’s hoping we aren’t duped again…

  3. Tim Albright on January 15, 2014 at 11:36 pm

    A Humane solution to this problem is for the President to declare a National Emergency and give anyone with proof of filing an online or a paper application for Obamacare Temporary Medicare coverage for 6 to 12months. That is the minimum time period needed to straighten out this mess. There are empty desks available in all 1300 Social Security Offices nationwide that could be staffed quickly to process the new Medicare cards. See for details.
    + online software is still not fixed completely, the paper application software is failing, and the back-end software is a bust. Now consider the hundreds of insurance companies and the new software they will be using to interface with the government and you can see that it will be at least a year to get Americans enrolled or re-enrolled in life-saving, pain-killing health insurance. God Help Us.

  4. Ronald on January 24, 2014 at 8:54 pm

    So they may continue to have private insurance in Vermont? Could someone explain why? Is it just another unnecessary concession to the small but uninformed crowd that do not trust “socialized medicine?” And why is it wrong for “Progressives” to oppose this crap? We should have straight-up single-payer and if some rich or Vermont Tea-Partier does not like it let them move to South Africa or someplace where the reactionary ANC government sold out to finance capitalists a long time ago and they do not have universal care.

  5. mike russo on February 10, 2014 at 5:19 pm

    i am still waiting and hopping for a comprehensive national health plan for everyone that gives complete life time coverags from the cradle to the grave. that is not only a good thing to do , it’s the only thing.