The Pursuit of Single Payer: Toppling, or Tipping Point?

August 26, 2024

Comment by: Jim Kahn

This morning, as I pondered writing a broad update on our quest for single payer, I realized that the movement in California, and my involvement, is fast approaching its 30^th birthday. In November 1994, Proposition 186 was on the California ballot. We won … in San Francisco and Berkeley … but lost statewide, by the lopsided margin of 27% yes, 73% no. We were seriously outgunned by the insurers, abetted by various health care interest groups protecting their profitable interests in the existing system.

A lot has happened and changed in the intervening three decades. It’s not a pretty picture. US health care spending jumped from twice the average of other wealthy nations to three times as high, while our longevity fell from roughly equal to four years behind. The Affordable Care Act passed in 2010, cutting the uninsured rate from about 16% to 8%, while hugely boosting under-insurance by encouraging high deductible plans. Medicare Advantage, accelerated by the ACA, caught up and surpassed traditional Medicare, with annual overcharges in excess of $100 billion, making insurers the largest beneficiary of US government largesse. UnitedHealth, a massive insurer, became a multisector leviathan, adding pharmacy benefit management, pharmacies, and physicians. Private equity now controls broad swaths of the provider world. We spend at least $700 billion per year — $2000 per person – in profits and administrative waste, as nearly half of adults report financial barriers to care each year. Overall, we might say that the corporatization of medicine has triumphed over using health care funds for health care. All while three dozen other wealthy nations demonstrate the efficiency and effectiveness of providing universal standardized not-for-profit health coverage. American exceptionalism at its worst.

Has single payer reform definitively toppled? Amazingly, I’m not despondent with our chances. Instead, many factors favor its success. Public anxiety about access to (including affordability of) health care is higher than ever. Awareness of the structural failings of the system is pervasive. Pushback, e.g., against forced Medicare Advantage for union retirees, is rising. Political leaders in both parties are challenging private insurer abuses. Support for a central government role is inching up, with 2/3 support for Medicare for All, if the question is asked neutrally (“your taxes will rise, but you’ll no longer have premiums or cost-sharing, and you can choose your doctor”). Several states are actively pursuing major reform – single payer, or substantial steps on the path to single payer. There are federal bills. The leading candidate for president understands and has in the past supported single payer. Policy and advocacy experts are engaging with each other, as well as with elected officials and health agencies. I’m thrilled to be connected with these individuals and groups, doing all that I can with technical work like online household cost calculations and paths to slashing administrative waste (and, of course, with HJM).

There is a renewed determination to break the logjam, now that we clearly see the abject failure of “path dependence” – sticking with the approach started in World War II, when health insurance originated as an alternative to prohibited wage increases. We should have recognized long ago that the trajectory was off … since 1972, when the Nobel Prize in Economics went to Kenneth Arrow for showing that health care cannot work as a free market good. It’s not soybeans or mobile phones, it’s literally our lifeblood. Health care must be treated, as it is elsewhere around the globe, as a public good, to be disseminated, protected, and cultivated.

These times are fraught and exciting. The upcoming election is pivotal in US history: democracy, freedom, and community are at stake. Single payer is, likewise, resonant with American ideals of freedom (from worry and in choosing doctors) and, of course, community. The vitality we bring to the election and the vitality of health care reform efforts can, must, and will be reinforcing.

It’s hard to say when, but I see a tipping point ahead. I hope you do too. Stay the course.