If there were a firing squad for political rhetoric, the phrase "single payer" would have to be placed against the wall and blown away. This term–generally used by politicians and policy advocates to describe a universal, government-funded national health insurance system–has all the appeal of an examination-room gown. It has no resonance and probably no meaning for 99 percent of Americans, most of whom are nevertheless concerned about access (for themselves and others) to quality and affordable healthcare. Still, progressives and some Democrats have continued to use the term as they call for healthcare for everyone. During his recent book tour, Al Gore demonstrated his wonkish ways when he said he had "reluctantly come to the conclusion" that the only way to fix the "impending crisis" in healthcare is a "single-payer national health insurance plan."
Why worry about these two words now? Because the healthcare debate is revving up, moving toward the pitch it had in the early 1990s, when Bill Clinton won the White House in part with a promise to bring better healthcare to more Americans. But then Hillarycare–the Clintons' proposal for a convoluted public-private system that was hard to explain and easy to mock–brought to a screeching halt the national conversation about the number-one healthcare problem: the millions of Americans who lack insurance. (It also helped Republicans grab control of Congress in 1994.) In the years since, the public discussion about healthcare has focused mainly on narrower issues, most notably a patients' bill of rights and prescription drug benefits for the elderly. Both are important matters, but they have nothing to do with providing affordable insurance for the many Americans who need it. That topic is now–finally–back on the radar screen.
In November the National Academy of Sciences released a report declaring, "The American health care system is confronting a crisis. The health care delivery system is incapable of meeting the present, let alone the future, needs of the American people." The study noted, "The cost of private health insurance is increasing at an annual rate in excess of 12 percent. Individuals are paying more out of pocket and receiving fewer benefits. One in seven Americans is uninsured, and the number of uninsured is on the rise." In the next three years, the number of uninsured may go up by nearly 25 percent and hit 50 million. In Los Angeles, overcrowded emergency rooms are turning away 40 percent of incoming ambulances. Many private hospitals, looking to maximize profits, try to keep the number of vacant–that is, available–beds low, which means even those with coverage or the money to pay cannot always obtain care. Healthcare is again becoming a chief concern of middle-class Americans. A recent front-page New York Times article chronicled the increasing difficulty middle-income families are having finding affordable health insurance in this weak economy. Pollsters report it to be a top concern of voters. And politicians are taking notice.
As part of the pre-primary scuffling among the Democratic 2004 contenders, the undeclared candidates have been positioning themselves on healthcare. Before he dropped out of the race, Gore, who last time out blasted former Senator Bill Bradley for proposing a plan designed to lead toward universal coverage, shifted to supporting a national insurance system to cover all Americans. Howard Dean, a stockbroker-turned-physician who was elected Vermont governor, cites as a White House qualification his "Dr. Dynasaur" program, which guarantees coverage to every child in families with an income below 300 percent of the poverty rate. Dean says he believes in universal coverage, but since his attempt to achieve it in Vermont failed in 1993, he has advocated a step-by-step approach. A fiscal conservative, he also wants a system with co-payments and deductibles high enough to help contain costs. He is dismissive of the patients' bill of rights: "What a lot of hot air. I'm interested in getting people insured." Massachusetts Senator John Kerry has indicated he will weigh in soon with a healthcare address.
The Bush White House is obviously worried about being caught off-guard on this front, like the old man was. Aides have been telling reporters they're looking to take dramatic steps this coming year. Will they offer something beyond modest nonrefundable tax credits that help mainly those who are close to affording insurance and not those further away? Another reason the Administration is likely to move: Its pals in the business community–who are looking to ease the increasingly burdensome cost employers face in insuring workers–are lobbying the White House for assistance.
What is the right way to take advantage of the political moment? Progressives who yearn for a national system that covers all may be heartened and eager to press ahead with the single-payer notion (without calling it "single payer," I hope). As Physicians for a National Health Program argue, a recent study of healthcare options shows that only a government-run system can extend coverage to all Americans. Yet in November, voters in Oregon rejected such an initiative by a whopping 79 to 21 percent. The measure would have created the first state-run health plan covering 100 percent of necessary medical care, including prescription drugs–without any deductibles or co-payments. It would have been financed in part by a hefty new 8 percent income tax and a new payroll tax. Supporters were outspent about 40 to 1 by the state's healthcare industry, fighting for its life. But no government-managed universal plan is going to escape a well-financed attack from the deep-pockets medical industry. Moreover, the healthcare establishment's assaults are not the only obstacle to establishing this sort of system. According to Democratic pollster and strategist Mark Mellman, even though voters are looking for healthcare relief and favor the principle of universal coverage, they don't want the government to be in charge of the healthcare system. "To them," he says, "that implies government control–which to many means the efficiency of the Post Office and the compassion of the IRS."
This latest political opening may not last long enough to permit the advocates of a single, federally administered, universal system to persuade the public that it will be more trustworthy and offer better care and a better deal than privately run HMOs. In the meantime, other proposals that extend existing government coverage are earning attention. The National Academy of Sciences has proposed that three to five states explore pilot programs that provide health insurance to all citizens and legal residents by offering tax credits or expanding Medicaid and the Children's Health Insurance Program. Henry Aaron, a health policy expert at the Brookings Institution, has been pushing similar expansions.
Progressives surely ought to keep urging universal coverage–healthcare should be a right, not a benefit of employment or a privilege of those who can afford it–but they need to dump the single-payer term and replace it with more straightforward rhetoric. Guaranteed health coverage for all? "We don't yet have the words that work for a big, national program, for wholesale reform," Mellman says. (After the pro-initiative forces in Oregon chose the slogan "Secure Affordable Health Care for All," a poll showed the initiative up 8 points with women, down 4 with men.)
In the meantime, universal healthcare advocates should seriously consider how to exploit the moment. Are there strides–rather than steps–that can be attempted in the coming political season? It's not going to be easy with corporate-friendly Republicans in charge of the White House and Congress. But markers–easy-to-understand and easy-to-pitch proposals–ought to be laid down. And Democrats who champion universal coverage and who believe healthcare offers an advantage for their party should make sure they have learned one important lesson of the early Bush II years: Their initiatives must go far enough so that Bush cannot inoculate himself by offering weaker, me-too versions. There should be an utterly clear fight that will give voters a chance to reward those working for positive change and punish the defenders of the current, and worsening, mess.