Hey America. Canada here. Yes, we’re still friends, though we’re going through a bit of a rough patch. (Tariffs? Really?) We wish you the best — even your president, although just 25% of us have confidence in him. Well, not just — that’s a big number. I’m kind of stunned.
Never mind. I’m writing to meddle in your election. Why? Healthcare. It could win it or lose it for the Democrats. I watched the July debates. It’s an impressive field; even the anti-vaxxer had her moments. Every candidate wants every American to have access to care. All agree the system is absurdly expensive, captured by insurers and pharma, and tragically unjust. So do most Americans. But there is no consensus on how to fix it. Many abhor the system as a whole, but like what they have.
That conundrum divides the front-runners into two camps. Transformers (led by Bernie Sanders and Elizabeth Warren) advocate for versions of “Medicare for all,” a single-payer system under which private insurance would disappear. Reformers (led by Joe Biden and Kamala Harris) advocate a public option (exiled from Obamacare) to compete alongside private insurance. The go-big camp believes the revolutionary moment has arrived, and that Democrats can win by seizing it. The Obamacare 2.0 camp considers single-payer too disruptive, radical and expensive to win over an electorate attached to private insurance plans and hostile to government-run programs.
Who’s right? Who knows? It’s easy to demonize single-payer. Choice — gone! Taxes — up! Government takeover! Rationing! Most people have health insurance. It is the devil they know, and single-payer offers them the devil they don’t. It’s hard to persuade them that single-payer is viable, and even harder to persuade them that it’s better.
As I watched the debates, I found myself barking at the TV: “Come on!” “You can do better than that!” “Bring your A game!” The case for incremental improvement rests on hoary myths and bad math. It’s no secret why people are opposed to change or are still on the fence. The Democrats need to deal head-on with concerns like these:
I like my private insurance plan and want to keep it. Really? I doubt you love your insurer, part of the cabal that skims off hundreds of billions of dollars a year from direct care. You may like your doctor, low co-pays and deductibles. All around the world, single-payer covers as much or more than your private insurance, often at half the cost. Administrative costs for single-payer are also a fraction of the costs of healthcare administration in the U.S.
Single-payer will raise my taxes. A tax-funded healthcare system needs tax revenues. The issue here is not what you pay in taxes; it’s what you keep in your pocket after taxes and (in this case) healthcare expenses. Even with so-called good insurance, you fork over for co-pays and deductibles and about $5,500 per family as your share of the average $19,600 total cost of premiums paid by your employer. Your income will be lower because your employer has to spend $14,000 a year on your healthcare insurance. The exorbitant cost of healthcare inflates the cost of goods and services made in the U.S. and the price you pay for them. Single-payer makes most people financially better off.
Employers should have to provide healthcare for workers. Health insurance is a huge burden and threat to business. It makes many businesses internationally uncompetitive. You shouldn’t have to stay in a job you don’t like just to keep your health insurance. Businesses should compete for workers on the basis of pay, working conditions and opportunity, not healthcare.
Under single-payer I won’t be able to choose my doctor or hospital. Big lie. Canadians can go to any family doctor they like, and the family doctor is the gatekeeper to specialists. So can the English, and the Spanish, and the Scots, and residents of most wealthy countries. Most Americans don’t have unrestricted choice without paying a big price for going out of network. Under single-payer, the norm is that people choose their providers. In the U.S., most insurers make the choice for you.
Single-payer is unaffordable. Compared to what? Healthcare in the U.S. is twice as expensive as in other wealthy countries. But that doesn’t mean Americans get more healthcare. Massive amounts of money are siphoned off to the insurance bureaucracy that buries doctors in paperwork and challenged claims, and tells patients where they can and cannot go for care. U.S. consumers pay the highest prices in the world for drugs. Single-payer greatly reduces the administrative burden, and has secured far lower drug prices in many other countries.
Single-payer may not provide everything I get now. That’s right, it may not. No program — private or public — offers everything to everyone in every circumstance. But healthcare in the U.S. is spectacularly abundant, and many patients get tests and procedures they don’t need. Healthcare costs twice as much for seniors in Miami as for seniors in Minneapolis, who are just as healthy and satisfied with their care. You want the right care, not necessarily the most care.
If how the U.S. organizes and pays for healthcare were based on dispassionate analysis on the part of fully informed citizens and uncompromised legislators, the status quo would have been shown the door decades ago. Those that stand to lose the most — pharma and insurers — are widely unloved. The monstrosity persists because of money, fear, inertia and deep suspicion of government as an instrument of good. These are formidable obstacles to overcome.
The anti-single-payer playbook is hardly a mystery. If you can’t win public hearts and minds in a contest with drug company felons and insurance oligarchs, and if you can’t get business behind a plan that liberates it from a crushing burden, it’s either a hopeless cause, or you’ve been outgunned.
If the Democrats can sell single-payer, they will likely win in 2020. The new president will have a mandate and the moral authority to get single-payer in place. (I know, there’s still Congress and the Supreme Court.) Job one is to beat Trump, but soon the catharsis will give way to the hard realities of reconstruction. U.S. healthcare is the symbol of a corrupt and broken polity, nothing remotely of, by or for the people. Single-payer isn’t perfect, but it’s incomparably better than the status quo.
The healthcare stakes are enormous. Choose your words carefully, Democratic candidates, and play your hands well.
Steven Lewis is a Canadian health policy analyst and researcher currently living in Australia.