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

By Joshua Holland, AlterNet. Posted July 13, 2009.

The advantages of having a greater share of health spending in the public sector go beyond a very large insurance pool and the efficiencies of scale and bargaining power that come with it. Countries with a higher rate of public health spending end up with a different set of incentives.

Unlike a wholly fragmented system relying on only private and largely unregulated insurance -- where an insurer has no incentive to make sure you stay healthy, because when you get sick it's just as likely to be on someone else's dime -- public health providers tend to place greater emphasis on preventing illness rather than waiting until people get sick and seek costly treatment. 

A Debate About Tactics, Not a Fight Over Fundamentals 

Karen Dolan of the Institute for Policy Studies is right in arguing that the fissure between public-option fans and single-payer advocates is shallower than it appears at first blush: 

One problem in progressive circles that contributes to the confusion is the perception, real or not, that single-payer and public-option advocates are fighting each other, weakening support for both. Though some of that is going on, the greater problem is that people think that's what's going on, and thereby try to push each other out of the room.  

There are very few health care advocates who will tell you that a single-payer health care system is not the correct remedy for the U.S. health care crisis. What they instead will say is that single-payer is dead politically, and that Obama and the progressive Democrats' public option is the only politically viable option. 

This is a key point -- the divide that does exist in progressive circles is tactical, not ideological. Most of those pushing the public option would, if they had their druthers, enact a single-payer system. But they recognize that the two commercial enterprises that have spent the most on political lobbying in recent years are the "disease care" and insurance industries. 

Like single-payer advocates, they believe that a large insurance pool with extensive government regulation and some subsidies afford the greatest potential for (near) universality and cost containment.

And they think that given the choice -- given a demonstration that this approach works better than having a fragmented system of private insurers -- most people will eventually opt into the public plan, and we'll end up achieving something approaching a single-payer system -- although an American-style variation -- through the back door.

They just don't think single-payer is a viable proposal given the clout that Big Health wields in Congress, and I'm not idealistic enough to say that they're wrong. 

The reason this is an important distinction is simple: People can differ respectfully and in good faith when it comes to tactical differences, but arguments over fundamental philosophical differences tend to become heated, fast. 

Finally, the divisions over the role of public and private insurers distract from other things that we need to fix the system. We may differ on the role that private insurers might play in a revamped U.S. health care system, but there are other issues all progressives should be able to embrace.

We can agree on the need for payment reforms that would discourage providers from ordering endless and often ineffective procedures; we can agree on the need for tighter regulations that would keep insurers from cherry-picking the patients that they want to cover; and we can agree on the need for investing in a secure electronic records system that would cut down on the cost of shuffling paperwork -- estimated at 20-30 cents of each health care dollar we spend.

Understanding all of this leads, I think, to a lot more agreement among progressives than it appears at first blush. It refocuses the debate toward more productive questions: how much private sector involvement we want, and what structure we might adopt for health care financed through the private sector in order to keep the insurance industry's predations in check. 

It also explains why some single-payer advocates -- like me -- are advocating so fiercely for the legislation working its way through Congress to be done right, with a large public insurance pool that's not restricted from bargaining with providers, or otherwise forced to compete with private insurers on an uneven playing field.

See more stories tagged with: health, health care, health care reform

Joshua Holland is an editor and senior writer at AlterNet.

Liked this story? Get top stories in your inbox each week from Health and Wellness! Sign up now »