Newsletter #2: The Single Payer Debate Continues

For now, I’ll keep posting my (brief) newsletters here.  Apologies for those who come across it twice!  You can signup for the newsletter here if interested:


Dear PP Subscribers,

The Democratic primary race has intensified.  Contests in Nevada and South Carolina are looming.  The debate over single payer remains fierce.

The last few weeks have seen continued arguments from a spectrum of commentators as to why a Medicare-for-all program – like that proposed by the Sanders campaign – is untenable.

A number of overlapping lines of argument can be distinguished.  First, it is frequently argued that the Sanders plan is poorly formulated and/or unrealistic given political conditions in Washington.  Recently, for instance, Paul Starr in the American Prospect (headlined “The False Lure of the Sanders Single-Payer Plan”) argues that the Sanders proposal is “not a practical or carefully thought-out proposal.”  Indeed, he sees the plan as an indictment of his overall campaign: it’s “a symbolic gesture, representative of the kind of socialism he supports.”

I addressed some of the earlier (and similar) liberal criticisms in an article published January 21 in US News & World Report, “Single Payer is Worth Fighting For.”  I conclude:

The expansion of coverage achieved by the Affordable Care Act does not constitute a system of universal health care. Too many are uninsured and underinsured. Too many are squeezed by high deductibles, contend with “narrow networks” of doctors and hospitals, or face crushing medical bills and even bankruptcy. Single-payer is the best way to remedy these injustices while simultaneously controlling overall health spending.


I also chatted about some of these issues on the radio with Arnie Arnesan on WNHN 94.7, available here.

A second line is that single payer is simply not affordable – that the number don’t add up.  For instance, in casting doubt on the seriousness of the Sanders’ single payer proposal, Starr relies on the widely-covered estimates of Kenneth Thorpe, an economist at Emory University. Vox covered Thorpe’s new estimates, which put the price of Sanders’ single payer proposal at nearly twice what his campaign has contended.

However, David Himmelstein and Steffie Woolhandler have clearly demonstrated the flawed assumptions behind these numbers in this detailed post at the Huffington Post, which is well worth reading.  As they put it:

Thorpe’s analysis rests on several incorrect, and occasionally outlandish, assumptions. Moreover, it is at odds with analyses of the costs of single-payer programs that he produced in the past, which projected large savings from such reform […] In the past, Thorpe estimated that single-payer reform would lower health spending while covering all of the uninsured and upgrading coverage for the tens of millions who are currently underinsured. The facts on which those conclusions were based have not changed.


A third line admits the shortcomings of the current state of affairs in American health care, but suggests that the right way forward would be to expand towards universal coverage under the ACA – instead of pursuing the more fundamental change of single payer.  I address this argument in an article published online Thursday in Jacobin, headlined “What Obamacare Can’t Do.” I turn to a country that has attempted to work towards “universal” coverage through a system of competing private insurers – the Netherlands – to demonstrate why this approach falls short, both from the perspective of cost and efficiency as well as that of equity.Regardless of the outcome of the primary, the campaign for single payer debate is far from over.  The incremental reforms have already been accomplished – we now either move backwards or we move ahead.

Until the next sporadically timed newsletter,


Post lightly edited. 

Newsletter #1


Newsletters are retro and trendy.  In an effort to not feel left out I’ve started one too. You can signup here:

Given a paucity of current subscribers, I’ve decided to post the letter on this blog as well.  Here it goes …

This is the first of what I hope to be biweekly newsletters, which will combine what (if anything) I’ve written in the intervening period as well as some of the latest in health news/politics/policy (and other items of interest).

So this past week saw a rather vigorous exchange on everybody’s favorite topic (well, at least mine): single payer health insurance.  Hilary Clinton opened with a salvo about Sanders’ health care plan being a “risky deal,” as reported by the Washington Post, which would devolve responsibility for health insurance to state governors.  Chelsea Clinton one-upped this by describing Bernie Sanders’ single payer proposal as a rather frightening sounding scheme that might effectually “…strip millions and millions and millions of people off their health insurance,” as she was quoted by MSNBC.  Basically everybody agreed that this was nonsense.  Ezra Klein wrote about it here at Vox:

Hillary Clinton’s campaign has spent the past few days indulging its worst instincts. It blundered into a dumb attack on Bernie Sanders, but rather than back down it raised the stakes. The result has been a reminder, to liberals, of what they like about Sanders and mistrust about Clinton.

Well put.  I wrote a post (“Chelsea Clinton Grossly Misrepresents Single Payer“)  about the silliness of the Clintons’ charge, and also noted that Chelsea Clinton has little excuse not to have a handle on the issue given that she is something of a public health person (then again, so is Hillary Clinton).  Zaid Jilani of the Intercept also made the good point that, as the headline of his article puts it, “Hillary Clinton’s Single-Payer Pivot Greased By Millions in Industry Speech Fees.” Perhaps the best response was this tweet from the Bernie Sanders campaign, harkening back to an earlier era when HRC’s opinions on single payer were a bit different:


On the other hand, Matt Yglesias at Vox had a less helpful piece asserting, to some extent, that what really matters about single payer is lowering provider reimbursements, which might be done with or without single payer.  Indeed, implementing single payer without an across the board reduction in provider payments, he contends, would be very costly and not very useful.  I disagreed strongly with him in this post, “What’s wrong with Matt Yglesias’ Single Payer Analysis.” Now admittedly, I might be said to have something of a conflict of interest on the topic as a health care provider myself.  But that’s really beside the point: whether or not providers should be paid less is separate from the question of whether we should have a single payer system.  Single payer would have huge administrative efficiencies over our current fragmented mess of a system: it could save a great deal of money separate from the issue of provider reimbursement.  Fellow PNHPer Don McCanne had a more comprehensive take on his blog here.

In closing, consider having a look at a piece I wrote for The New Republic (online) about Sasha Issenberg’s forthcoming book, Outpatients: The Astonishing New World of Medical Tourism.  It’s a wacky world no doubt, and also a good book.  I more or less contend that medical tourism should be understood in the larger context of the corporatization of health care and a global retreat from a vision of universal public health care.