Like 2008, health care is now an important issue in the Democratic nomination fight. Back then Clinton and Obama both wanted Affordable Care Act-like policies, although they differed on whether there should be an individual mandate.
This year, Senator Bernie Sanders is promoting a single payer plan and his campaign is criticizing Hillary Clinton for purportedly abandoning a commitment to universal coverage.
The Sanders plan has gotten a lot of criticism from liberal writers because it lacks critical details and the numbers don’t seem to add up. There are no cost-control mechanisms. A health policy wonk I know said the plan shows a lack of seriousness about the issue and so may undermine the future of single payer as a real option.
Even more, there’s a big policy error in how single payer is being characterized and this mischaracterization has political implications. What’s wrong comes down to presenting universal coverage and single payer as equivalent.
Single payer and universal coverage are not the same thing.
It’s very common to see people write as if they are. This mix-up is pervasive. But it’s not true in the least.
Universal coverage comes in many flavors. Single payer is one of them, and it’s not even very common.
About a year ago, Ezra Klein explained:
There are few truly single-payer systems in the developed world. Canada has one, as does Taiwan. Most countries rely on many, many insurers. Germany, for instance, has more than 150 “sickness funds.” The Swiss and Dutch health systems look a lot like Obamacare’s health-insurance exchanges. In France, about 90 percent of citizens have supplementary health insurance. Sweden has moved from a single-payer system to one with private insurers.
T.R. Reid, author of the wonderful book The Healing of America, puts universal health care systems in three main categories, with some countries having a mixture of them. These three can be described as single payer, a national health service and a social insurance system. (See them in comparison to an “out of pocket” system by clicking here.)
At the bottom of this post you can click over to a page showing how a number of different capitalist democracies deliver universal coverage.
The U.S. has a mixture of health care systems. Medicare and Medicaid are single payer. The VA is a national health service model. The ACA is a social insurance model. And then we have lots of private insurance that’s regulated under the ACA but its financing is from employers or individuals or both. Some people pay out of pocket themselves.
In mixing up single payer and universal coverage, Sanders and his supporters are making a misleading political argument.
The politics matters because the chance of Congress passing single payer anytime soon is effectively zero and because it is part of today’s nomination debates.
Democrats strongly support expanding health coverage but many likely believe what the Sanders campaign incorrectly suggests.
In reality, Clinton has not attacked universal coverage and she hasn’t changed from supporting single payer before. She never proposed single payer, not in the 1990s and not in 2008.
Now, the Clinton campaign was wrong in having Chelsea Clinton talk about single payer as taking away people’s coverage, with what looked like an implication that they’d lose insurance. In fact, single payer would replace other sorts of insurance. And Hillary Clinton should go beyond the bare bones health plan she’s proposed this election cycle and present more detail herself.
However, Chelsea Clinton was right that the particular sorts of insurance people now have would disappear. In fact, that’s a key feature of a single payer system.
How many people would prefer single payer over what they have now? It’s hard to say for sure. But there’s no doubt there would be disruption as people who have private insurance move to what single payer insurance would provide.
A robust health policy debate is good.
Moreover, I don’t think anyone thinks the ACA doesn’t need some improvements.
It’s wrong, however, to act as if single payer and universal coverage are equivalent when they are not.
Today’s discussion should be based on a more accurate understanding of health policy options. And that means avoiding myths about single payer and discussing the range of ways universal coverage is achieved around the world and could be in the United States.
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