Why Obama’s Public Option Is Defective, and Why We Need Single-Payer

By Drs. Steffie Woolhandler and David Himmelstein for the Progressive

Once Congress finishes mandating that we all buy private health insurance, it can move on to requiring Americans to purchase other defective products.

A Ford Pinto in every garage?

Lead-painted toys for every child?

Melamine-laced chow for every puppy?

Private health insurance doesn’t work.

Even middle-class families with supposedly good coverage are just one serious illness away from financial ruin.

Illness and medical bills contribute to 62 percent of personal bankruptcies — a 50 percent increase since 2001. And three-quarters of the medically bankrupt had insurance, at least when they first got sick.

Coverage that families bought in good faith failed to protect them. Some were bankrupted by co-payments, deductibles, and loopholes. Others got too sick to work, leaving them unemployed and uninsured.

Now Congress plans to make it a federal offence not to purchase such faulty insurance.

On top of that, it’s threatening to tax workers’ health benefits to meet the costs of simultaneously covering the poor and keeping private insurers in business.

President Obama’s plan would finance reform by draining funds from hospitals that serve the neediest patients. His other funding plans aren’t harmful, just illusory. He’s gotten unenforceable pledges from hospitals, insurers and the American Medical Association to rein in costs, a replay of promises they made (and broke) to Presidents Nixon and Carter. And Obama trumpets savings from computerized medical records and better care management, savings the Congressional Budget Office has dismissed as wishful thinking.

The president’s health plan can’t make universal, comprehensive coverage affordable.

Only single-payer health reform — Medicare for All — can achieve that goal.

Single-payer national health care could realize about $400 billion in savings annually — enough to cover the uninsured and to upgrade coverage for all Americans. But the vast majority of these savings aren’t available unless we go all the way to single payer.

A public plan option might cut into private insurers’ profits. That’s why they hate it. But their profits — roughly $10 billion annually — are dwarfed by the money they waste in search of profit. They spend vast sums for marketing (to attract the healthy); demarketing (to avoid the sick); billing their ever-shifting roster of enrollees; fighting with providers over bills; and lobbying politicians. And doctors and hospitals spend billions more meeting insurers’ demands for documentation.

A single-payer plan would eliminate most insurance overhead, as well as these other paperwork expenses. Hospitals could be paid like a fire department, receiving a single monthly check for their entire budget. Physicians’ billing could be similarly simplified.

With a public insurance option, by contrast, hospitals and doctors would still need elaborate billing and cost-tracking systems. And overhead for even the most efficient competitive public option would be far higher than for traditional Medicare, which is efficient precisely because it doesn’t compete. It automatically enrolls seniors at 65 and deducts their premiums through the social security system, contracts with any willing provider, and does no marketing.

Health insurers compete by NOT paying for care: by seeking out the healthy and avoiding the sick; by denying payment and shifting costs onto patients; and by lobbying for unfair public subsidies (as under the Medicare HMO program). A kinder, gentler public plan that failed to emulate these behaviors would soon be saddled with the sickest, costliest patients and the highest payouts, driving premiums to uncompetitive levels. To compete successfully, a public plan would have to copy private plans.

Decades of experience teach that private insurers cannot control costs or provide families with the coverage they need. And a government-run clone of private insurers cannot fix these flaws.

Drs. Steffie Woolhandler and David Himmelstein are associate professors at Harvard Medical School. They co-founded Physicians for a National Health Program, a nonprofit research and education organization of 16,000 physicians, medical students, and health professionals who support single-payer national health insurance. For more about the group, go to www.pnhp.org.


  1. Anthony on July 23, 2009 at 1:39 pm

    No doubt and I love the fact Ed Schulz is beating this into the ground, somebody has too. Keith and Rachel are too focuses on the hypocrisy of the Right which is fine, but hardly of importance compared this. They need to be OUT there EXPLAINING what a Strong Public Option is and that we ACTUALLY NEED Single Payer for it to really work.

    I support Single Payer 100%, it works in Europe, it can work here. This whole nonsense about paying for it, ha it will pay for itself….

  2. Gerry Hunt on July 26, 2009 at 8:24 pm

    We all seem to have missed the most important point of this process of negotiation.

    In order to control costs you must collect information about the costs. The health insurance industry has never in the past 100+ years been held accountable for reporting their costs of doing business or their premium income. If they want to have a seat at the table and be a player in this marketplace(?) they must be held accountable for reporting revenues and operating costs.

    The information on National Health Expenditures compiled by the Centers for Medicare & Medicaid Services (CMS) includes a category “Private Health Insurance”, but that data is not collected from the insurers, it is compiled by the CMS actuaries based on reimbursements reported by medical providers. That is the closest any database in this country can come to SWAGging what private health insurance is costing our economy. (A SWAG is a Scientific Wild Ass Guess.) So CMS guestimates that private health insurance is 34.6% of our national health expenditures and 22% of that 34.6% is spent on administrative overhead. I would expect that the CMS SWAG figures on Private Health Insurance are very conservatively understated because the insurers would raise holly hell if they were anywhere close to being overstated.

    So back to my first point. If there is to be any form of cost control and if the private health insurers want to be part of a “Free Market” competion for our National Health Care Dollars, they must be held to account for the premium revenues they are collecting and the operating expenses that they are paying out. They are fiduciary agents taking our money and paying it out and they must be held to account much as the banks are when they enter into a mortgage contract or as investment brokers are when they invest our life savings.

  3. Gerry Hunt on July 26, 2009 at 8:29 pm

    My prior posting had an error in it. 20% of that 34.6% is spent on administrative overhead, not 22%. Sorry for the incorrect posting.