Posted on November 25, 2002

Al Gore on Single-Payer: New Republic


The Single Guy
by Jonathan Cohn
Only at TNR Online | Post date 11.22.02

It looks like Al Gore wasn't kidding two weeks ago when he let slip his intentions to propose a single-payer health care system for the United States. In a piece about Gore published earlier this week, Ron Brownstein of the Los Angeles Times reports that Gore told him the very same thing--and in considerably more detail. Specifically, Gore told Brownstein that he would unveil his plan early next year, and that the plan would observe three principles: The actual practice of medicine would still be done through the private sector; Americans would have "choices"; and the plan would reduce spending by streamlining bureaucracy. "The system as a whole has reached a point of no return," Gore said. "It is collapsing. It is beyond saving in its current design."

Is Gore nuts? Not on policy grounds. In a single-payer system, the government becomes the nation's health insurance company. Instead of paying premiums to an insurer (either directly or through an employer), each American would pay that money to the government; in turn, the government would pay the providers of medical care--i.e., mostly private doctors and hospitals--in the same way insurance companies now do.

Make no mistake: It's a radical overhaul. But single-payer also has clear virtues: As a general rule, the more people who belong to an insurance pool, the more thinly you spread the financial burden of illness, which can be devastating if you face it alone or within a small group. By definition, single-payer spreads the risk pool across the largest number of people possible--namely, everyone in the country. In addition, while people may associate government with excessive bureaucracy, single-payer systems devote far less money to administrative overhead than private insurance. (Among other things, insurance companies spend a ton of money on advertising.)

Typically, opponents of single-payer insist it's better to have a private insurance system that promotes more "choice." But one of the chief advantages of single-payer is that it gives patients the kind of choice that matters--not choice of insurance plan, but choice of doctor. For example, if you switch plans today, you may discover your favorite physician doesn't take your new insurance. But in a single-payer system, virtually every physician would take government insurance, so that would no longer be an issue.

And, of course, single-payer systems by definition make coverage universal--i.e., they give insurance to every citizen as a birthright, regardless of employment status. This isn't just fair: It may also be more efficient, since it would allow people more freedom to change jobs and pursue better opportunities.

None of this means single-payer is ultimately the best way to go on health care. In fact, there are some pretty valid objections to it, though not necessarily the ones its critics are making today. But its virtues make it a credible alternative, one that deserves a major role in the debate over our health care system's future.

But what about the politics? No sooner had Gore introduced the plan than conservative critics pounced on him, calling him an extreme leftist and noting that this endorsement represented another Gore "flip-flop," given his opposition to Bill Bradley's health care plan in 2000. "This is ... Gore, the radical," Michael Kelly wrote in his Washington Post column. He then defined single-payer as "the idea [Gore] savaged his 2000 Democratic primary opponent, Bill Bradley, for supporting."

But the criticism about Gore's apparent reversal on Bradley actually shows why endorsing single-payer has a certain political logic to it. Bradley didn't propose a single-payer plan in 2000. On the contrary, the essence of Bradley's plan (which, by the way, this author lauded at the time) was to help uninsured Americans buy into the same system that now serves federal employees. In that system, federal employees choose from among a menu of private insurance plans, then pay premiums based on what the plans offer. Yes, lots of people attacked that plan for expanding the role of government. But, if anything, it actually reduced government's role, by getting rid of Medicaid (under which government insures the poor directly) and having those people buy private insurance instead.

The lesson is that even if you don't actually propose a radical overhaul of the health care system, critics from the right will still have an easy time denouncing it as medical socialism. Indeed, critics from the right have been known to level that charge at even piecemeal health reform measures--from the State Children's Health Insurance Program (S-CHIP), which merely allows states to subsidize coverage for kids living at or near the poverty line, to HMO reform, which doesn't expand coverage at all but simply regulates the way insurance companies make treatment decisions.

So if you're going to propose a large-scale change to the health care system and invite the "socialized medicine" charge anyway, you might be better off endorsing a single-payer system, which at least has the virtue of being easy to explain. Unlike, say, a hybrid public-private system, which involves all sorts of convoluted regulations, which then require all sorts of tortured explanations, the essence of single-payer can be reduced to three simple words: "Medicare for all."

After all, Medicare is essentially a single-payer system, only one that operates exclusively for senior citizens. While its lack of prescription drug coverage remains a major flaw--albeit one that both parties have now sworn to fix--it is also incredibly popular with the people who have it. And why not? If you're on Medicare, you never worry about losing your insurance. If you're on Medicare, you can see most any doctor you want--and get most treatments the doctors recommend. Medicare has a large bureaucracy, but most physicians today will tell you it's a more reliable payer--and a less onerous overseer--than private managed care companies. Indeed, far from true "socialism," Medicare allows doctors and hospitals to remain privately employed.

If there's a big problem with Medicare these days, it's the program's lack of long-term financial viability. But that's a flaw of the entire health care system, and will require resolution with or without major health care reforms. Indeed, single-payer advocates argue that their system makes that resolution easier, by introducing a more efficient system and allowing people to make trade-offs democratically. Enacting single-payer wouldn't necessarily mean expanding Medicare per se (although plenty of Democrats have proposed such schemes before). But a would-be reformer could certainly explain it that way.

This isn't to say single-payer is an easy sell. Quite frankly, it may be impossible to sell sweeping health care reform--any sweeping health reform--right now, given the nation's political mood and power of special interests with a stake in the status quo. But among the proposals out there, single-payer has compelling political advantages. Al Gore may turn out be wrong. But he isn't nuts.

Jonathan Cohn is a senior editor at TNR and a 2002-2003 Kaiser Family Foundation media fellow.