We Need Clear Thinking: There Should Be No Clash Between Public Option and Single Payer

There appears to be a deep divide within the progressive movement over how to fix health care -- a sometimes nasty food-fight between advocates of a public insurance option and those who favor a "single-payer" system. 

This split is diverting progressive energy from what is probably the most important domestic policy decision of our time. As Washington Post columnist Harold Meyerson noted, while there is extensive institutional support for a public insurance option, there's little "street heat." Progressives seem to be too busy arguing amongst themselves to apply effective pressure to sold-out lawmakers who are protecting insurance companies' profits. 

But the public insurance/single-payer rift is a false dichotomy, and it is distracting us from the real fight. Most systems that people think of as single-payer really aren’t. Something approaching single-payer exists in Canada, Australia and the U.K. But even in these countries, buying supplemental insurance from private insurers is commonplace. 

Has Any Country Gotten "Profits out of Health Care"? 

The reality is that virtually every advanced, wealthy country features a universal system -- we're the exception -- that is financed through a blend of public and private means. See, for example, this Wikipedia entry about the health care systems in Holland, Germany and Belgium -- all of which are commonly referred to as single-payer systems, but in fact have "multiple payers but with some single-payer features." Those features include: universal coverage regardless of citizens' ability to pay, heavy state regulation and either the ability to bargain for the best prices from providers or have prices set by the government. 

So, if you're a single-payer advocate (like I am) the question arises: Wouldn't you be happy to have something like Germany's system? When I lived in Berlin in the early 1990s, I had an accident, broke a bone and went to the ER without insurance. They X-rayed it, set it and gave me a bunch of happy pills to take home. Total bill: $10. 

Then there is the Cadillac of health care systems -- the French model. Would we be poorly served with something like the system that scores the highest among industrialized countries in most measures of patient satisfaction, access, longevity, child mortality, etc.? Of course not. 

The French enjoy guaranteed, quality health care from cradle to grave that is financed, in large part, through tax revenues. However, it is not a single-payer system.Thirty-five  percent of French hospital beds are in private facilities; over 9 in 10 French citizens have supplemental insurance and, as this backgrounder explains, "About 75 percent of the total health expenditures are covered by the public health insurance system. A part of the balance is paid directly by the patients and the other part by private health insurance companies that are hired individually or in group." 

When we talk about single-payer, what we're really saying is that guaranteeing access to decent health care -- just like sanitation and clean water or electricity -- should be considered a fundamental duty of the state. But from that point, there's no reason I can see to exclude the private sector entirely. We regulate utilities that provide those other vital services, and limit their profit margins, but we don't rely on the government alone to deliver our electricity. 

In France, "The state sees that the whole population has access to care; it dictates the types of care that are reimbursed, and to what degree, and what the role is of the different participating entities. The state is in charge of protecting patients' rights, elaborating policies and enforcing them. It is responsible for public safety." 

That sounds fine to me, even though I identify as a single-payer advocate. 

And the reason this is more than a semantic point is straightforward: The proposal before us today would, if done right -- and the devil is most certainly in the details -- achieve a hybrid public-private system with "some single-payer features," much like what citizens of other liberal democracies enjoy. 

Put another way, the idea of getting "private profit" out of health care, while perhaps appealing on ideological grounds, doesn't reflect what the rest of the world has done. A more practical goal is addressing our shortcomings, in part by shifting the balance between the public and private delivery of health care. Currently, the United States ranks dead last among the wealthiest nations in terms of the portion of our health dollars spent on public health. 

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