On October 1, 1996, I was one of three speakers who appeared before fourteen Minnesotans selected to participate in a "citizen forum" on healthcare reform sponsored by the Minneapolis Star Tribune and KTCA-TV, Minnesota's public television station. I made the case for a "single payer" healthcare system; the director of what was then called the HMO Council of Minnesota made the case for "managed competition"; and a third speaker made the case for "medical savings accounts" (MSAs). A single-payer system is one in which one payer (the government) reimburses doctors and hospitals. Managed competition is a theory that assumes that competition among HMOs can reduce healthcare costs without damaging quality of care. MSAs are traditional insurance policies with huge deductibles (typically $2,000 per person). After three and a half hours of discussion, eight of the fourteen citizens voted for single-payer, three voted for managed competition, one voted for a hybrid of single-payer and managed competition, and two abstained.

This vote strongly suggests that a sizable majority of Americans would support a single-payer solution to the healthcare crisis if they were ever exposed to a real debate about it. Other data support this conclusion. For example, a 1991 Harris poll found that 68 percent of Americans preferred Canada's single-payer healthcare system, compared with only 29 percent who favored the US system; a 1999 survey of professors and students at US medical colleges, reported in the New England Journal of Medicine, found 57 percent of students and faculty members of America's medical schools "thought that a single-payer system...was the best health care system," while only 22 percent were willing to say the same about managed care. But despite the public's preference for a single-payer system, and despite solid empirical evidence that single-payer would provide higher-quality care for less money than an HMO-dominated system, managed competition was elevated to de facto US health policy during the early 1990s, while single-payer proposals were kept off the public agenda by big business and its allies in Congress.

In California, the single-payer movement forced a debate--a very lopsided debate, as it turned out--about the single-payer proposal by collecting a million-plus signatures to put the proposal on the November 1994 California ballot. From July until Election Day, the anti-single-payer forces, led by the insurance industry, bought $11 million worth of radio and TV advertisements and financed a direct-mail campaign. Our "good neighbor," State Farm, spent close to a million dollars in October 1994 alone on letters personally signed by State Farm agents urging their customers to vote against the single-payer initiative.

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