Single-Payer Guide to the 2016 Presidential Elections
The grassroots movement for single-payer healthcare reached a milestone during the 2016 Presidential Election season: by the end of 2015, 58% of adults in the U.S. supported "Medicare for All" healthcare reform, including a staggering 81% of Democrats, 60% of Independents, and 30% of Republicans. This almost universal support for single-payer reform among Democrats allowed Bernie Sanders to run an unprecedented primary campaign advocating for single-payer healthcare, while on the Republican side, front-runner Donald Trump has taken heat from opponents for his long-time support for single-payer reform.
We will keep this page updated with key resources related to the national debate over single-payer reform, including research, opinion polls, media coverage, and fact-checking. Please forward any additional resources for inclusion to firstname.lastname@example.org.
Click on a subject heading below to skip to a topic:
- The Sanders Medicare for All Proposal
- Debate Over the Cost of the Sanders Plan: the Urban Institute and Kenneth Thorpe
- The New Liberal Myth of Single-Payer Rationing
- Myth: Single-Payer Will Cost the Poor More
- Myth: Single-Payer Will Cost the Middle-Class More
- Myth: Healthcare Taxes on the Rich Will Hurt the Economy
- Sanders Plan Turns Healthcare Over to Governors, Dismantles ObamaCare
- Media Blackout on Clinton's Alternative Proposals
- Jill Stein Support for Medicare for All
- Public Opinion Polling on Single-Payer and Healthcare Reform
The Sanders Medicare for All Proposal
On January 17, 2016, the Sanders campaign released a proposal for a national Medicare for All plan, which included projected savings and a financing proposal: press release here, campaign summary of the plan here, and the full plan outline here.
You can read initial coverage of the proposal by Kevin Drum at Mother Jones, Jonathan Cohn at HuffPost, and Yamiche Alcindor and Alan Rappeport at the New York Times.
The plan differs in some respects from the American Health Security Act, a single-payer proposal Sanders had filed previously in the Senate, and is actually most similar to the Expanded & Improved Medicare for All Act, HR676, filed by Rep. John Conyers in the House. These are the key components of the plan:
- Universal coverage. (The outline doesn't discuss whether undocumented people would be covered, but Sanders's earlier legislation uses a residency test.);
- Comprehensive benefits (Covering not only primary care, specialty care, inpatient, emergency, mental health and substance use care, but care not covered by some countries with universal healthcare: vision, hearing, dental, long-term and palliative care, prescription drugs, and medical equipment and supplies.);
- No deductibles, co-insurance, co-payments or any other payments for receiving care, except for some over-the-counter drugs, and procedures not medically necessary;
- No limited networks - full choice of doctors and hospitals;
- Federally administered. (Sanders's earlier legislation was administered by the states.);
- Paid for by replacing all public and private healthcare spending with a progressive tax scheme:
- A 2.2% income tax, with an exemption for low-income earners;
- A 6.2% payroll tax on employers that replaces premium payments, higher for higher-income employees;
- Several new taxes on high-income earners: increasing the income tax for higher tax brackets, increasing the tax on unearned income (from dividends and capital gains), a new "estate tax" on the largest inheritances, and limiting deductions for the rich.
Debate Over the Cost of the Sanders Plan
The Urban Institute’s response to the Sanders Plan
On May 9, 2016 the Urban Institute published an analysis of Sanders’ plan - the first single payer study ever to find that SP would cost more money than it would save.
The projections found that national health spending on acute and long term care would increase by 16.9% under the Sanders plan, and federal government spending would increase by 257.6%.
When pressured by Physicians for a National Health Program on specific numbers that are widely out of step with previous predictions (as well as other countries’ actual balance sheets), UI conceded that they factored in “political realities” – that the insurance companies and drug companies are just too powerful to ever create a true single payer – admitting that they did not actually asses the cost of Bernie Sanders proposal, but a proposal of their own making.
Many of the Urban Institutes' arguments mirror the ones Kenneth Thorpe made earlier in 2016 and are debunked one section down.
Administrative Savings: The Urban Institute article outlines insurance overhead would be reduced from 9.5% to 6% of the total health spending. This 6% is based on the current high cost of Medicare HMOs run by for-profit insurance companies; for comparison, overhead in Canada is only 1.8%. Additionally, the Urban Institute does not take the savings on hospital administrations and doctors’ billing under a single payer system into account, although many analyses, including reports by the Congressional Budget Office and (pre-2016) Kenneth Thorpe, have included these savings in their respective analyses.
In their response to the PNHP article, the Urban Institute implies that any financially significant cuts to administrative cost would inhibit functions such as quality control, payment rates of different providers, and bill payment providers. PNHP counters by citing single payer systems like Canada and even the current Medicare system, that perform all these functions without the heavy administrative costs.
Drug Costs: The Urban Institute claims that the Sander’s plan would result in a 50% increase in the cost of drugs, using the current costs under Medicaid as a baseline. This notion excludes the fact that the U.S government would have significant bargaining power with drug companies which would result in the lowering of drug costs
Utilization of care: The Urban Institute suggests that there will be an increase in the usage of acute care but does not detail how large this increase will be. The UI also argues that the plan would cause a huge disruption of healthcare as physicians would not want to treat a large influx of patients. The current health delivery system – constrained by supply - could not support such a large increase in utilization; this same unfounded argument was used against Medicare and Medicaid in the 1960s. PNHP suggests it is more realistic to assume that rather than increase usage of the system, unnecessary use would be eliminated, as seen in Canada. Essentially, when faced with a higher demand of healthcare, doctors will more likely prioritize treatment and delay seeing healthy patients or eliminate unnecessary procedures.
On January 27, 2016, Emory University health economist Kenneth Thorpe published an analysis of the Sanders Medicare for All plan, claiming that the plan would cost almost $1.1 trillion more per year than Sanders projected, requiring much higher taxes than those proposed by Sanders.
The Thorpe analysis received widespread media coverage; it was accepted uncritically by the press and used to conclude that Sanders's single-payer plan was implausible. See Dylan Matthews at Vox, Jonathan Cohn at HuffPost, Paul Krugman at the New York Times, Jonathan Chait at New York Magazine, Kevin Drum at Mother Jones, and more.
Thorpe did not publish the methodology or data he used to reach his conclusions, which made scrutiny of his claims difficult - most columnists above referred to Thorpe's reputation as a liberal economist who has supported single-payer reform in the past as reason to trust his critique.
Rebuttals by David Himmelstein and Steffie Woolhandler on HuffPost and by UMass economist Gerald Friedman on his blog and in the American Prospect, point out that the Thorpe report low-balls the savings from single-payer reform by:
- Assuming only 4.7% savings from reducing administrative waste. This is lower than virtually every projection, including earlier single-payer studies by Thorpe himself that projected twice this much in administrative savings. Lowballing administrative savings accounts for almost 1/3rd of the gap between the Sanders and Thorpe projections;
- Assuming implausibly massive increases in use of care when universal coverage is implemented - which accounts for most of the gap between the Sanders and Thorpe estimates. Thorpe's assumed utilization increases are far beyond that experienced by countries that have transitioned to single-payer healthcare, and in fact are more than the U.S. delivery system could provide given the current supply of hospitals and physicians;
- Not including any projected savings from reduced pharmaceutical costs, which is a key cost-saving feature of single-payer systems by using the country's collective purchasing power to negotiate lower drug costs.
Thorpe has projected massive savings under single-payer reform in his previous studies of Massachusetts, Missouri, and nationally - more than enough to cover the entire population. However, Thorpe served as the Deputy Assistant Secretary for Health Policy under the Clinton administration, where he was a key consultant for the failed Clinton health reform effort. It is not unreasonable to wonder whether Thorpe's new-found skepticism has something to do with backing Clinton's presidential bid, as opposed to finding the Sanders plan to be dramatically different from the single-payer efforts he's previously found to be economically sound.
Thorpe published a follow-up piece in The American Prospect, explaining the gap between his estimates and Sanders's. Although Thorpe still does not produce all of his underlying data and assumptions, the article confirms the above areas of disagreement.
The New Liberal Myth of Single-Payer Rationing
The debate over Sanders’s Medicare-for-All plan has spawned a new, “liberal" remake of the claim that single-payer leads to rationing. Several Democratic health policy writers are now claiming that single-payer systems control healthcare costs primarily by “saying no” to patients.
Their reasoning, unaccompanied by any actual evidence, is that single-payer plans negotiate lower costs for medical services, drugs, and devices by being willing to cut them out of their national coverage, which necessarily requires being willing to say “no” to patients. Ezra Klein at Vox writes that a single payer system needs to be willing to say no to patients “quite a lot." Paul Krugman at the New York Times agreed, adding some frosting to the inaccuracy cake by claiming that “foreign single-payer systems are actually more like Medicaid than they are like Medicare,” and that to get costs down we’d “have to say no to patients.”
While conservatives have long argued that single-payer creates waiting times for elective procedures and therefore rations care, the notion that such countries offer worse access to procedures, drugs, devices, or providers in order to gain leverage in price negotiations is a brand new mythology.
Countries with single-payer put hospitals on budgets and set uniform payment rates for types of care that fall outside a budgeted institutions, such as physician visits, tests, and procedures. Medical devices are covered (at lower negotiated rates), and drug formularies are generally less restrictive than private insurance plans in the U.S.
The sort of rationing Klein and Krugman describe is exactly what most American residents WITH a health insurance experience regularly::
- Almost 60% of insured Americans are now in narrow, ultra-narrow, or tiered plans, which gives insurers leverage over providers, but leaves patients with massive medical debts from "surprise medical bills" and no continuity of care;
- Private insurers increasingly rely on drug exclusions, closed formularies, and plans with three-tiers of co-payments that serve only to shift costs onto patients and block access to care; and
- More creative forms of rationing every year, such as narrow pharmacy networks.
Never mind the rationing that gets imposed on the 31% of Americans who delay care they can't afford care due to deductibles, co-payments, or lack of health insurance.
In fact, negotiating lower costs allows single-payer systems to avoid rationing access to care, such as for Hepatitis C treatment:
Other countries have negotiated with the drugmakers to get better deals. The United Kingdom, for example, pays $55,000 for the hepatitis C drug Sovaldi; the United States pays $84,000…(The U.K.) doesn't ration this drug like we do. Instead, it recommends Sovaldi for all hepatitis C patients — something it can do in part because it pays less for it.
Myth: Single-Payer Will Cost the Poor More
Washington Post blogger Max Ehrenfreund’s piece “Study: Bernie Sanders’s health plan is actually kind of a train wreck for the poor” concludes that single payer under Sanders would leave millions of poor families “substantially worse off”. The Washington Post Editorial Board concluded the same thing a few days later.
The most recent, and most exhaustive, rebuttal of this claim was made by physicians Steffie Woolhandler and David Himmelstein of PNHP. Their article Cherry-Picking Statistics to Bash Sanders' Medicare for All Plan was published in the Huffington Post.
Thorpe’s finding are not credible:
- 84 million poor or near-poor individuals would benefit from the plan. 50 million are currently uninsured or are insured through the private market, and another 34 million poor and near-poor Medicaid recipients are children, retirees, or others who have no earnings and couldn't be impacted by the payroll tax.
- Only 1.2 million poor/near-poor Medicaid recipients earn more than $15/hour, and would stand to lose out financially under Sanders's plan. But even that overstates how many might be harmed, since some pay out-of-pocket costs that Medicare-for-All would eliminate. Tweaking the plan to better accommodate those earners shouldn't be difficult.
- Thorpe falsely claims that poor families would pay the 2.2% tax. Sanders’s outline clearly indicates that there’s a personal exemption; a family of 4 earning up to 120% of the poverty line ($28,800/year) would not pay the tax.
- Thorpe also seems to assume that in addition to this 2.2% tax, all 6.2% of the employer payroll tax will be shifted onto Medicaid recipients as well. This clearly ignores the fact that minimum wage workers can have exactly 0% of the tax shifted onto them. Even for the poor who are working at a rate above rock bottom, the idea that employers will go so far as to cut wages is historically improbable; it’s more likely that wages would simply continue to stagnate. Ironically, it is the country’s runaway healthcare costs – the kind only serious government intervention can curtail – that have already inured us to decades of stagnating wages.
To summarize, the vast majority of the poor would be financially better off under single payer. They wouldn’t pay the 2.2% income tax, and employers would find it very difficult – at least in the short term – to pass on costs to the employee. Although Thorpe’s numbers are not credible, he raises a valid question about single-payer: who would see the savings from moving to a single-payer system? Would savings go to workers, or would their employers pocket the savings and pass along tax expenses to their employees? It turns out the best way to ensure that these savings go to workers is to couple single-payer reform with an increase in the minimum wage – a policy Sanders has also proposed, but Thorpe ignores.
Check out Healthcare-NOW’s full analysis of this issue for more.
Myth: Single-Payer Will Cost the Middle-Class More
Hillary Clinton claimed that Sanders’s single payer plan would be impose a tax hike on the middle class of about 9%. Her spokesman quipped: “The last thing you should do is cut their take-home pay right off the bat.”
This attack is false on two accounts:
- It disingenuously implies that the increase in taxes will leave middle class families worse off. Because the tax replaces private health insurance premiums, the vast majority of Americans would pay less under the Sanders plan than they are paying right now. The typical middle class family would save over $5,000 under this plan.
- The 9% number is wrong. Those below 120% of the poverty line wouldn't pay any extra in taxes; those above would pay a 2.2% tax on any income earned over 120% of the poverty line. A 6.6% tax would be levied on employers, but much of that tax would replace their current staff healthcare expenses.
This was an unsuccessful line of attack, and Hillary has stopped using it.
Myth: Single-Payer will be bad for the rich
Ezra Klein, among others, has implied that the taxes levied on the wealthy to help pay for Sanders's plan would be harmful to the economy: “tax increases of the scale Sanders proposes here would begin to have real economic drawbacks. European countries tend to pay for their health care systems through more broad-based, economically efficient taxes like VATs; Sanders's effort to fund a universal health care system so heavily on the backs of the wealthy would be unprecedented.”
The Federal tax system remains highly progressive. However, since 1977, the United States has dramatically reduced tax rates at the top, lowering the average tax rate on the top 1% from 35% down to 28% in 2008 before the Obama Administration reversed this pushing rates up to 33%. While contributing to an unprecedented increase in inequality, declining income tax rates on the rich have failed to raise economic growth rates, which have fallen since the 1970s. This is the pattern that we see across countries and even across states within the United States: higher taxes and more progressive taxes are associated with higher productivity growth across countries within the OECD (Organization of Economic Cooperation and Development) and across states within the US.
Myth: Sanders Plan Turns Healthcare Over to Governors, Dismantles ObamaCare
Prior to Bernie Sanders releasing his Medicare for All plan, Hillary Clinton and her daughter Chelsea Clinton leveled a number of public attacks on the single-payer bill Sanders had filed in the Senate in 2013: The American Health Security Act.
Hillary told an Iowa audience on January 11 that Sanders's bill would let Republican Governors undermine their healthcare:
[Sanders's] plan would take Medicare and Medicaid and the Children's Health Insurance Program and the Affordable Care Act health-care insurance and private employer health insurance and... send health insurance to the states, turning over your and my health insurance to governors.
Chelsea doubled down the next day with some truly outlandish fear-mongering in New Hampshire:
Sen. Sanders wants to dismantle ObamaCare. I worry if we give Republicans Democratic permission to do that, we'll go back to an era — before we had the Affordable Care Act — that would strip millions and millions and millions of people of their health insurance.
This first wave of attacks on Sanders's single-payer bill was widely rebuked as inaccurate in the press, by Lori Robertson at FactCheck.org, Pat Garofalo at U.S. News, Ryan Cooper at The Week, and Deidre Fulton at CommonDreams. Even Ezra Klein at Vox called the attacks "dumb" while Paul Krugman at the New York Times referred to them as "cheap shots," both columnists who are more supportive of Clinton's approach to healthcare reform.
The rebuttals were resounding, and focused on the following points:
- Sanders's Senate legislation did not offer Governors discretion over implementing single-payer as Clinton claimed. States failing to fully implement a single-payer system under the law would be federally administered, much like the state exchanges;
- An article by Steffie Woolhandler and David Himmelstein showed that the rollout of Medicare in 1966 was not disruptive to seniors' healthcare and was fully implemented in 11 months, belying the claim that Medicare for All would potentially disrupt access to care for the rest of the population.
Media Blackout on Clinton's Alternative Proposals
While policy analysts, news anchors, and columnists have been engaged in an intense debate over Sanders’s “Medicare for All” proposal, Clinton’s healthcare platform has escaped almost all scrutiny. If you combine the election-season writings of our most prolific, liberal columnists on healthcare reform - Paul Krugman, Jonathan Cohn, Ezra Klein and friends at Vox, Paul Starr, Kenneth Thorpe, Jonathan Chait, etc. - you’ll find more than twenty-five articles scrutinizing Sanders's single-payer plan. None of them have mentioned a single Clinton healthcare proposal as a point of comparison. Take for example this U.S. News column titled "Clinton Gets It on Health Care: Her proposals are realistic and politically pragmatic; Bernie Sanders' aren't," which fails to reference even one Clinton proposal, focusing exclusively on Sanders's single-payer plan.
When Clinton’s plan has been invoked by policy analysts/columnists, the debate hasn’t been between two concrete policies, but between one policy (single payer) and a set of goals (expand access to care, make care more affordable). Even a February 2016 Kaiser opinion poll joined the blackout, asking respondents to choose 1 of 4 possible directions for the future of U.S. healthcare. The survey framed the options as being between “establishing a single government plan” and “improving affordability and access to care” under the current system. The phrasing of the latter fails to mention any incremental policy or package of policies that might raise the additional question of whether they're politically feasible, or will succeed in improving affordability and access if enacted.
Because of the lopsided attention to Sanders’s plan, most voters are unaware of what Clinton’s policies even are. When the media finally lifts the curtain on her platform, they’re in for a bit of a shock: most of Clinton's incremental policies follow in the footsteps of Bernie Sanders's work in the Senate.
- On September 29th, 2015, just days after Sanders and Senate Democrats introduced a bill to repeal the so-called "Cadillac tax" on high-premium health plans, Clinton announced her own proposal to do the same. Clinton's position was correctly seen by reporters as necessary if she didn't want to lose labor union support to Sanders.
- Many of Clinton's healthcare proposals are rolled into a package of prescription drug reforms, which she released on September 22, 2015. They bear a striking resemblance to the Sanders prescription drug plan announced on September 1, filed as legislation on September 10. The most impactful proposal suggested by both candidates would allow Americans to import prescription drugs from Canada, where costs for identical drugs are much lower due to Canada's single-payer healthcare system. Sanders was a pioneer of importation, as early as 1999 organizing busloads of American patients who couldn't afford breast cancer drugs across the Canadian border to purchase cheaper 6-month supplies.
- Both candidates also call for empowering Medicare to negotiate drug prices; even Donald Trump jumped on board in January. This plan, along with importation of drugs, are both Democratic Party staples over the past decade, although they were abandoned by Democratic leadership during Obamacare negotiations.
The incremental healthcare platforms of Clinton and Sanders are not identical, but they're close enough to demolish the ubiquitous narrative that Democrats must choose between immediately trying to throw out the Affordable Care Act and implement a single-payer plan, or to improve the healthcare system we're currently stuck with. You can have incremental reforms while building political momentum for more systemic change. In fact, this is a common road to comprehensive reform, such as we've seen in the movements for civil rights, gay marriage, and almost every other leap forward in our country's protection of basic rights.
To find Clinton's full range of healthcare proposals, you have to visit her health care issue page, her briefing on "Lowering Out-of-Pocket Health Care Costs," and her briefing on "Lowering Prescription Drug Costs." To find an analysis of Clinton's healthcare platform... good luck! You may have to write it yourself.
Jill Stein Support for Medicare for All
Green Party presidential candidate Jill Stein supports an improved "Medicare for All" single-payer public health insurance program as a component of her "Power to the People Plan." In January 2016, Stein co-authored a truthdig article with Margaret Flowers advocating for a national single-payer plan, criticizing both Democratic candidates for failing to publicly acknowledge the failings of the Affordable Care Act, particularly the privatization of the healthcare system at the heart of the ACA model of reform.
Public Opinion Polling on Single-Payer and Healthcare Reform
The presence of a leading Democratic candidate advocate for single-payer healthcare, and a leading Republican candidate with a history of support for single-payer, led to greater-than-usual attention to single-payer in public opinion polls. Here is our roundup, along with a critique of one particular poll.
- 58% of Americans favor "a national health plan in which all Americans would get their insurance through an expanded, universal form of Medicare-for-all," including 81% of Democrats, 60% of Independents, and 30% of Republicans (Kaiser Health Tracking Poll: December 2015).
- A May 2016 poll by Gallup also found that 58% of Americans favor "replacing the ACA with a federally funded healthcare program providing insurance for all Americans", including 73% of Democrats/Democratic leaners and 41% of Republicans/Republican leaners. Among those who support both preserving the Affordable Care Act and a universal, federally funded healthcare system, 64% say they prefer universal healthcare (Gallup U.S. Daily Poll, Affordable Care Act Approval: May 2016).
- 51% of U.S. adults believe that it is "the responsibility of the federal government to make sure all Americans have healthcare coverage," reversing a trend of falling support for this position following enactment of the Affordable Care Act (Gallup Annual Health and Healthcare poll, Nov. 4-8, 2015).
- Respondents' opinion on single-payer healthcare vary dramatically depending on the wording used. 63% had a positive response to "Medicare-for-All," 57% to "Guaranteed universal health care," 44% to "Single payer health insurance system," and 38% to "Socialized medicine." (Kaiser Health Tracking Poll: February 2016).
- Satisfaction with the U.S. healthcare system is highest among those in socialized medicine systems (78% for military or veterans), government insurance plans (77% for Medicare, 75% for Medicaid). Satisfaction is lowest among those with private insurance (71% for those with union plans, 69% for employer-sponsored coverage, 65% for individually purchased insurance) and those with no insurance (41% satisifcation). (Gallup Daily tracking polls, Jan. 1-Oct. 31, 2015)
- 31% of Americans still reported putting off medical care due to costs, unchanged since the implementation of the Affordable Care Act. (Gallup Annual Health and Healthcare poll, Nov. 4-8, 2015)
- Healthcare is a top 4 issue in the 2016 elections for both Democrats and Republicans. (Gallup Jan. 21-25 Election Benchmark survey)
The February 2016 Kaiser Health Tracking Poll included a highly problematic question: given four choices for the "future of the U.S. healthcare system," 54% of Democrats felt that "lawmakers should build on the existing health care law to improve affordability and access to care," while 33% of Democrats preferred that "the U.S. should establish guaranteed universal coverage through a single government plan." Although clearly intended as a stand-in for the positions of Hillary Clinton and Bernie Sanders, the option of building on the existing health care law includes no actual policies advanced by Clinton that respondents might agree or disagree with - just an assumption that whatever policies they are, they will successfully "improve affordability and access to care." The single-payer option on the other hand is a concrete policy, described in language that, as Kaiser found in the same poll, tends to elicit less support than "Medicare for All."