Posted on February 28, 2008

"Why Not Single Payer?" Parts 1-4


Part 1: Response to Paul Krugman and the Leading Democratic Presidential Contenders

Miles Mogulescu
The Huffington Post
Posted October 10, 2007 | 03:10 AM (EST)

Faster than you can say the word “Sicko” and turn around 3 times, the Democrats’ promise of health care for all has gone from “Universal Medicare For All” to “Individual Insurance Mandate”. In Monday’s New York Times, Paul Krugman defends that reversal in an article entitled “Why Not Single Payer?”

The possibility, after the 2008 elections, of a Democratic-controlled Congress which could pass Medicare For All (a/k/a Universal Single Payer Health Insurance) and a Democratic President who would sign it, could bring about the best chance to enact Medicare For All since Harry Truman first proposed it in 1948.

Yet without firing a shot and with no debate, the leading Democratic Presidential Contenders—Hillary Clinton, John Edwards and Barack Obama—as well as a good part of the Washington progressive infrastructure of think tanks and lobbying groups—have given up the fight for Medicare For All. Instead they propose variations of an Individual Mandate plan developed over the past 15 years by the “moderate” corporate wing of the Republican Party, a version of which Mitt Romney enacted in Massachusetts and which Arnold Schwarzenegger is proposing in California as an alternative to the single payer plan which the Democratic California legislature passed last year that he vetoed.

The thing is, I can’t quite figure out why the Democrats are in such rapid retreat from Medicare For All before the first battle has even been joined. Is it another example of the political cowardice by which the only Iraq resolutions that can pass the Democratic controlled Senate are a Republican-driven bill condemning MoveOn.Org. and praising Gen. Petraeus and another declaring the Iranian Revolutionary Guards a terrorist organization? Is it because the Democratic candidates are afraid of being accused by Republicans of supporting socialized medicine? (If so, it won’t help because Giuliani, Thompson, and Romney—whose Massachusetts plan Hillary largely imitates—all quickly claimed that Hillarycare 2.0 is socialized medicine, anyway.) Is it because they’ve been bought off by insurance companies and drug companies or fear that too many other Congress and Senate members have?

Or is it because they think that the insurance companies and drug companies are just too politically powerful to take on: Therefore the only way to insure most Americans is to make a deal with the devil that requires profit-making insurance companies to waive pre-existing conditions and charge everyone similar premiums regardless of age or health, in exchange for Congress delivering them 50 million guaranteed new profit-making customers, partly subsidized by the government?

Paul Krugman’s NY Times column is one of the first direct attempts by a liberal former supporter of single payer to try to make the case for adopting the Individual Mandate approach instead. According to Krugman, “basically it looks like something that could actually happen in the next administration, while enacting a single-payer plan…excellent as those plans are, might take a very long time.”

First, Krugman argues than an Individual Mandate would not require a big tax increase, although he admits (thus defeating his own argument) that taxes which most people would pay for single payer would most likely be lower than premiums that an Individual Mandate would require them to pay out of their pockets to buy insurance. Second, he argues than an Individual Mandate won’t make people feel that they’re “being forced into a government plan”. But the essence of an Individual Mandate plan is that the federal government forces the uninsured to buy health insurance. It involves even more government coercion than Medicare For All.

Finally, he argues that the Democrats’ proposals generally include a Medicare-like public insurance alternative which individuals may buy into and which “would evolve into single-payer over time.” Krugman never quite explains how this piece of alchemy will occur. Moreover, he admits that this is the part of the Democrats’ plan that the insurance industry will fight “tooth and nail”. If the Democrats have already surrendered on Medicare For All without firing a shot, isn’t it likely that the public alternative (the “socialized medicine” part) will be the first part of the plan to be compromised away when the legislative battles start in Congress and the insurance lobby starts exercising its muscle with its hundreds of lobbyists and tens of millions of dollars in campaign contributions?

In short, I find Krugman’s notion that an Individual Mandate is somehow more politically pragmatic than Medicare For All unconvincing and I don’t buy his argument that it’s a backdoor way to eventually get there. I even wonder how strongly he believes his own arguments. Only last January, in critiquing Schwarzeneggers’s Individual Mandate plan for California as a complicated “Rube Goldberg” device, Krugman argued that “the plan requires a much more intrusive government role than a single-payer system. Instead of reducing paperwork, the plan adds three new bureaucracies: one to police individuals to make sure they buy insurance, one to determine if they’re poor enough to receive aid, and one to police insurers to make sure they don’t discriminate against the unwell.” If you then add a public Medicare-like alternative that individuals can buy into, you need a fourth bureaucracy to administer that system.

Thus, when Hillary Clinton claims that her plan requires no new government bureaucracy, she’s not being candid with the voters. That lack of candor will quickly be exploited by the Republicans and the insurance and drug lobbies. While Republicans are wrong that her plan amounts to “socialized medicine”, such charges will still ring true since, in fact, her plan will require intrusive government regulation of the private insurance industry and coercive action to be sure that all citizens are obeying the individual mandate to buy health insurance. That’s one of the big reasons why, once the debate really starts, an Individual Mandate will not necessarily be a popular plan with the voters—Using the political pragmatism test, it stands a better chance of being rejected by the public and meeting the same fate as Hillarycare 1.0 than does Medicare For All, for which the political arguments are simple and clean.

Whatever Clinton might claim, Hillarycare 2.0 in fact requires a highly intrusive government presence in the lives of both businesses and individuals. As with Hillarycare 1.0, this is likely to be the biggest club that Republicans and their insurance company allies will use to defeat her or another Democrat as they did in 1994, unless so many compromises are made to water down the plan that insurance and drug companies decide it’s in their interest to accept the 50 million new mandatory government subsidized customers to pad their bottom lines. (Remember that with private insurance, approximately 30% of the healthcare dollar goes to administration, executive salaries and profits, compared to 2%-3% for Medicare; when all the political deals are finally cut, the private insurance and drug industries might find a new government subsidy for their bottom line an attractive deal.) If an Individual Mandate plan is more politically expedient than Medicare For All, it’s not for any of the reasons which Krugman cites and not because it’s likely to be more politically popular with the voters. The real reason is that with a few backroom political compromises, it could become a that plan the insurance and drug industries could learn to love.


Part 2: What’s Wrong With The Clinton / Obama / Edwards Health Care Plans

Miles Mogulescu
The Huffington Post
Posted November 2, 2007 | 04:23 AM (EST)

In Part 1 of this multi-part Huffpost series on the health care debate, I criticized the leading Democratic candidates — Hillary Clinton, Barack Obama, and John Edwards — for surrendering, without firing a shot, to the insurance and drug companies by opposing universal single payer health care.

In this second installment, I elaborate on the difference between universal single payer health care and the Clinton/Obama/Edwards universal insurance mandate plans and argue that universal mandates are bad social policy.

First, let’s define our terms:

“Universal Single Payer Health Care” (aka “Medicare For All”): From the moment that you’re born until the moment that you die, you will be covered by single quasi-public non-profit health insurer that will pay for both preventative care and for all necessary medical procedures and medications. You choose whatever doctor you want to see and you and your doctor decide on the care you need. It won’t matter whether you’re employed or not or whether your employer offers health coverage. You can never be denied insurance.

“Universal Insurance Mandate:” If you like your employer’s health plan, you can keep it. If your employer doesn’t provide health insurance and you don’t qualify for Medicaid, the government will make you pay for your own health insurance out of your own pocket. If you’re too poor to afford the premiums, at tax time every year the government will give you a credit to reimburse you for part of last year’s premiums. If you’re middle class, the government tax credits may be too small to make the insurance really affordable, or you may have to buy a less expensive high deductible policy in which you have to pay for your doctor visits out of your own pocket, unless you get really sick and need major surgery or an extended hospital stay. You and your doctor will still have to fight with your insurance company on whether it will cover procedures your doctor thinks are necessary. If you try to avoid buying your own insurance or think you can’t afford it, the government will penalize you.

To be fair, the Clinton/Obama/Edwards plans have some positive points. By banning “pre-existing conditions”, they would allow people to buy insurance who are simply uninsurable now. By requiring insurance companies to charge the same premiums regardless of age or health, they would make insurance more affordable to middle aged people. (Conversely, they would make insurance more expensive for younger people.) By providing tax credits, they would help lower middle class people afford at least lower priced, high deductible “catastrophic” policies. Most of the plans include a Medicare-like public alternative that individuals may purchase and whch competes with private insurance.

But overall, a universal insurance mandate is bad public policy compared to universal single payer health care. Some of the reasons:

1. It’s a colossal waste of money. While the administrative cost of Medicare is about 2-3 percent, approximately 30 percent of private insurance premiums go to overhead, profits and executive salaries. In 1999, the last year for which I could find numbers, health care administrative costs totaled $294.3 billion or $1,059 per capita, compared to $307 per capita in Canada. With insurance premiums having climbed 87 percent in the past decade, it would be a fair guess that administrative costs now exceed $400 billion per year. That’s more than enough to cover all of the uninsured without raising taxes.

2. Universal mandates punish the middle class who make too much to receive government subsidies, but too little to afford the cost of health insurance that the government will coerce them into buying. Massachusetts passed a state universal mandate program in 2006 which proponents of a universal mandate point to as the model for a national plan. According to recent a study by the Greater Boston Interfaith Organization, the premium for the minimum insurance plan is unaffordable for households earning between 300%-500% of the poverty level. Premiums for the minimum plan are free for those earning up to 150 percent of the federal poverty level of $10,210 for individuals and $13,960 for couples. Premiums are reduced for those earning up to three times the poverty level. Those earning more than that (i.e more than $30,630 for individuals, $41,880 for couples) must pay 100 percent of the premiums themselves. Premiums range from $1464 per year for young adults to $9600 per year for those over 55. So a 55-year-old couple earning $42,000 a year would have to pay $19,200 a year in premiums, nearly 46 percent of their pre-tax income, for a plan with deductibles of $2,000 per individual and $4,000 per family and out-of-pocket expenses of up $5,000 per year for individuals and $7,500 for families. A government mandate requiring people to pay these kinds of premiums, even if a national plan had somewhat higher subsidies, is effectively a huge hidden tax increase for the middle class and a huge boondoggle for the private insurance companies to whom the government delivers large numbers of new customers.

3. The universal mandate plans assume that most people will continue to be covered by their employers and therefore they won’t have to reach into their pockets to pay the full cost of meeting the government mandate. But employer-based health insurance is a dying dinosaur. Each year fewer employers offer insurance. Between 2000 and 2006, the percentage of employers offering some type of health insurance declined from 64.2 percent to 59.7 percent and it continues to decline. Even many people whose employers now provide health insurance are underinsured — according to a Consumer Reports survey, 29 percent of people with health insurance are “under-insured,” with coverage so meager that they often postpone medical care because of cost. Moreover, as insurance premiums escalate at a far greater rate than inflation or wage increases, more and more employers increase their employee’s share of premiums, raise deductibles and co-pays and reduce benefits. If you lose your job, you lose your insurance. In the larger picture, leaving the burden of health insurance on employers makes American companies less competitive in the world economy, compared to other capitalist democracies where the government pays for health care. Recently, Toyota named the savings in health care costs as the main reason for deciding to open a new auto plant in Canada rather than the U.S.

4. Large numbers of people opting for lower-cost, high deductible plans will lead to many middle class people avoiding preventive care and necessary treatment until they are already very sick, leading to worse health outcomes and in the long-run resulting in higher costs from waiting to treat preventable diseases until they become serious. If, after paying thousands of dollars a year in premiums, a middle class family has to pay $2,000-$4,000 in deductibles before their insurance kicks in, many won’t go to the Doctor until it’s an emergency. For example, someone with a chest infection won’t seek care, thus infecting others, and possibly ending up in the hospital with pneumonia. Men won’t get their PSA checked, women won’t get pap smears and breast exams, people won’t get colonoscopies, thus leading to cancers not being found at the early treatable stage.

5. The strongest argument by progressives who support a universal mandate is that the plan would include a Medicare-like public alternative that would compete with private insurance and, because it would so clearly be superior to private insurance, would eventually evolve into a single payer system. If this plan is modeled on Medicare, it would be a fairly generous plan in which you can choose your own doctor, in which most treatments your doctor recommends are covered, and in which deductibles and co-pays are low. This means that, even after greatly reducing the administrative costs associated with private insurance, it will still be expensive compared to high deductible plans. This leads to “adverse selection.” The young and healthy would opt for the cheaper plans. The people who will buy the Medicare-like plan will be those who think their health care costs are likely to exceed their premiums — in other words, the older and sicker. Far from slowly evolving into a single payer system, as its progressive supporters like Paul Krugman argue, the Medicare-like plan is likely to become more and more expensive as time passes, making it less and less affordable and forcing more and more people back to bare bones private insurance.

Part 3: The Clinton/Obama/Edwards Individual Mandates Represent a Losing Political Strategy

Miles Mogulescu
The Huffington Post
Posted December 3, 2007 | 09:59 AM (EST)

Hillary Clinton is busy in Iowa bashing Barack Obama for offering a health care plan that doesn’t punish uninsured people who won’t pony up their own money out of their own pockets to buy their own health insurance. She points out (rightfully) that if, under Obama’s plan, the Federal government doesn’t force everyone to buy health insurance, millions of uninsured people may decide not to pay for their health insurance and remain uninsured—Thus, Hillary charges, Obama’s plan fails to provide for Universal Health Insurance for all Americans.

Meanwhile, John Edwards criticizes Hillary’s plan on the same grounds. Her plan is vague and elusive on the details, calling for a Federal Mandate, but not specifying what the penalty will be on uninsured citizens who ignore the Mandate. If there’s no penalty, or the penalty is small (under Massachusett’s Universal Mandate plan the penalty is currently $295 per year) then Hillary’s plan doesn’t guarantee Universal Health Insurance either. In addition, Hillary’s plan does not cover 12-15 million illegal immigrants who will continue to flood emergency rooms, driving up premiums for everyone else. Even one of Hillary’s principal health care advisers, MIT economic professor Jonathan Gruber, acknowledges that Hillary’s plan will not include everybody, stating that “Any system that does not have a single payer will not have 100 percent coverage.”

At least John Edwards has the political courage to put some teeth into his plan for the federal government to force the uninsured to buy their own health insurance: Citizens will have to provide proof of health insurance when they seek care or file their Federal tax returns. If they don’t have health insurance, the Federal government will sign them up for a minimum basic plan and take the premiums out of their taxes or garnish their wages. However, Edwards, Obama, and Clinton all avoid spelling out what a minimum plan would cover, what the deductibles and co-pays would be, how much the premiums would cost, and how poor you will have to be for your premiums to be subsidized by the government.

The whole dust-up among Clinton, Obama and Edwards makes clear why Individual Mandate plans—far from being more politically pragmatic than Single Payer/”Medicare For All” plans—are likely to end up being as big a political disaster as Hillary’s 1994 health reform fiasco.

When the Republican Presidential candidate starts attacking the Democratic nominee for trying to compel middle class Americans to buy health insurance that they can’t afford, the Democrat’s poll numbers may start to dive. “If you’re a family making over $40,000 a year so you aren’t poor enough for subsidies and you don’t have health insurance, the Democrats will force you to sign up and keep your tax return or garnish your wages for thousands of dollars, since the average policy costs $10,000 for a family of four.” This is what the Washington consultants think is smart, pragmatic politics for Democrats? The health care issue, which should be a big Democratic advantage on the ‘08 elections, could suddenly turn into liability.

Even if a Democrat wins the Presidency, when it comes time to get a specific proposal through Congress, it will become clear to the voters either that their plan only pretends to cover all the uninsured but doesn’t, or it represents a massive backdoor tax on the uninsured middle class who will be forced by the Federal government to pony up thousands of dollars which they can’t afford to buy their own individual insurance policies. The most affordable of these policies, which realistically will still cost thousands of dollars a year, will of necessity have high deductibles and co-pays. This will force policyholders to forego preventive care and delay going to the doctor until they are really sick and may need major and expensive care. It may even lead to their early death from conditions like breast and prostate cancer that could have been treated if diagnosed earlier. (For some of the other serious problems with Universal Mandate plans as social policy, see Part 2 of this series on the Huffington Post.

Getting major health care reform through Congress (particularly the Senate, with 60 votes needed to end a filibuster) will require a massive popular mobilization. If history proves anything, it’s that Washington only enacts major social change if prodded by large scale social movements such as the union movement, the civil rights movement, and the anti-war movement. Without such movements, there would be no social security, no Civil Rights Act, and we might still be fighting in Vietnam. Why should progressives put such an effort into organizing a mass movement around Universal Mandate plans that will prove unpopular, will not really offer Universal Health Care, will put a huge financial burden on the uninsured middle class, and subsidize the private insurance industry? If we’re going to organize the kind of massive mobilization that will be necessary to really change the health care system in America, then let’s do it for a progressive plan that really works.

HR 676, the “Medicare For All” bill introduced in Congress by Rep. John Conyers, already has 78 congressional co-sponsors. It would cover all Americans from birth until death for all medically necessary treatments and drugs, as well as preventive care. As with Medicare, people can chose their own doctor and determine the best course of care in conjunction with him or her. The 30% of the health care dollar—over $400 billion this year—that goes to pay administrative costs of insurance companies, doctors, and hospitals, as well as insurance company marketing cost, executive salaries and profits, would be reduced to less than 5%, which alone would be enough to cover all of the uninsured. Medicare For All would be paid for by taxes, but would cost most Americans less in the aggregate than they are already paying in premiums, deductibles, co-pays, and forgone wages that are used for employer-provided health care. Unlike Clinton’s, Edward’s and Obama’s plans, it would be truly universal.

A mass movement has already begun to organize around Medicare-For-All. HR 676 has been endorsed by over 235 union organizations in 40 states, including 60 Central Labor Councils, as well as many citizens and religious organization. In California, SB 849, which would have provided for a single payer system for the State’s 37 million citizens, passed both houses of the California Legislature, only to be vetoed by Gov. Schwarzennegger. It was backed by over 400 organizations and unions including the League of Women Voters, the Consumers Union, the California Catholic Conference, the California Nurses Association, the California Teachers Association, AFSCME and the SEIU, and numerous cities and counties. Many other states are building large coalitions favoring Medicare For All.

With a mass mobilization still in its infant stages, several polls show that a majority of Americans are ready to support Medicare For All. A CBS News poll on September 14-16, 2007 asked, “Which do you think would be better for the country: having one health insurance program covering all Americans that would be administered by the government and paid for by taxpayers, or keeping the current system where many people get their insurance from private employers and some have no insurance?” 55% chose “One Program For All” (up from 47% in February, 2007) and 29% chose the “Current System” (down from 38% in February). (Back in January, 2007, according to an NBC News/Wall Street Journal Poll, 53% said they would be willing to pay higher taxes so that everyone can have health insurance, while 40% disagreed.)

So why are the leading Democratic candidates afraid to support Medicare For All and are instead offering up inferior, and politically less viable, proposals for Universal Mandates? When it comes to health care, Andrew Sullivan’s recent description of Hillary Clinton, unfortunately seems to apply to Barack Obama and John Edwards as well. “Her liberalism is warped by what you might call a Political Post-Traumatic Stress Syndrome. Reagan spooked people on the left, especially those, like Clinton, who were interested primarily in winning power. She has internalized what most Democrats of her generation have internalized: They suspect that the majority is not with them, and so some quotient of discretion, fear or plain deception is required to advance their objectives”.

As the above polls suggest, the Democratic candidates need not be so fearful when it comes to Health Care. Even if they are, progressives do not need to follow them in their fear and timidity. Only a progressive grassroots movement has the power to help a Democratic President get meaningful health care reform through Congress, given the millions of dollars in campaign contributions and the arm twisting of corporate lobbyists that will be mobilized against real reform by the insurance and drug industries and other corporate special interests.

So here’s the deal for our Democratic frontrunners: Run on your Universal Mandate plans if you must. You’ve probably gotten yourself so locked into them that it’s hard to change course in the middle of a political campaign. At least you’ll keep health care reform on the political front burner. We’ll even give you money and work on your campaign, because the country and the planet cannot afford another 4 years of a Republican in the White House.

But if you’re elected President, we’re not going to lend the force of our progressive movement to supporting your Universal Mandate plans. We’ll be organizing millions of people behind Single Payer Health Care/Medicare-For-All, the only type of plan that can actually guarantee quality, Universal Health Care to all Americans.

Part 4: In Partial Defense of Obama Against Clinton’s Attacks on His Health Care Plan

Miles Mogulescu
The Huffington Post
Posted February 4, 2008 | 01:36 PM (EST)

In this ongoing multipart Huffpo series entitled “Why Not Single Payer?” I’ve written extensively about why Single Payer/Medicare For All represents both better social policy and better political strategy than the healthcare plans advanced by the leading Democratic candidates, including both Hillary Clinton and Barack Obama (whom I enthusiastically support for numerous reasons other than his Healthcare plan. Among these is Obama’s ability to encourage popular movements which could push change beyond his own campaign proposals.).

However, as a single payer advocate, I find Obama’s healthcare plan to be politically superior, and certainly more honest, than Clinton’s.

First, let’s be clear on one thing: Despite the rhetoric, neither Clinton’s nor Obama’s plan guarantees Universal Health Care for all Americans. Hillary is being less than candid when she proclaims “My opponent will not commit to Universal Healthcare. I do not believe we should nominate any Democrat who will not explicitly support universal health insurance.”

Hillary is using a deceptive rhetorical slight of hand. “Universal health insurance,” which is at the heart of Clinton’s plan, is not the same as “Universal Healthcare” which can only be guaranteed by a single payer system under which all Americans are automatically covered for all medical care by a single, taxpayer funded, not for profit health insurer from birth until death. (Even one of Hillary’s top health care advisors, MIT Prof. Jonathan Gruber acknowledges that Clinton’s plan will not include everybody, admitting that “Any system that does not have a single payer will not have 100% coverage”.)

Clinton’s “Universal health insurance” is a plan under which, if your employer doesn’t provide health insurance or you don’t have a job, the government mandates that you must buy health insurance out of your own pocket. If your income is less than a certain level (which level Hillary’s plan glaringly does not specify) you will retroactively receive a tax refund or tax credit, on a sliding scale, after April 15th of the following year to reimburse you for part of the premium which you already laid out in the prior year. If you fail to buy your own health insurance, the federal government will penalize you.

Again, glaringly, Clinton’s plan does not spell out what the penalties will be. It should be noted, however, that if the penalties are small, the plan will not be Universal because many people will take the penalty, rather than pay thousands of dollars in insurance premiums that they cannot afford. That’s what is happening in Massachusetts under the Romney plan on which Hillary is modeling her plan. If the penalties are large — for example, if the government can garnishee your wages, keep your tax refund, or charge you a large fine — many middle class people who make too much to receive subsidies but too little to afford the premiums will see their standard of living go down.

While, notably, Clinton has not specified an enforcement mechanism in her plan, on Sunday she stated that “I think there are a number of mechanisms” [for enforcing a mandate, including] “going after people’s wages”. Clinton plan punishes the uninsured middle class which makes too much money to qualify for a tax subsidy but too little to afford a meaningful insurance policy which averages $5,000 for an individual and $12,000 for a family of four.

Obama responds, “It’s not that people don’t want health care, it’s that can’t they can’t afford it”. Unless and until health insurance costs come down to a level that everyone can afford, Obama would not punish people for not buying insurance.

Obama circulated a mailer last week which criticized Hillary’s plan, showing a photo of a couple sitting at a kitchen table, stating truthfully “Hillary’s health care plan forces everyone to buy insurance, even if you can’t afford it”. In response, the Clinton campaign convened a conference call of health care policy advisors to denounce the mailer. One of the advisors, Len Nichols, denounced the leaflet and photo, stating, “It is as outrageous as having Nazis march through Skokie, Illinois. I just find it disgusting that this kind of imagery is being used to attack the only way to get to universal coverage.”* (The Clinton campaign and Nichols later apologized for the remark.)

In fact, Obama’s mailer demonstrated why Clinton’s individual mandate plan is a political loser for Democrats. If Clinton’s campaign freaks out so badly at relatively mild criticism from Obama, imagine what it will face from Republicans if Hillary is the nominee in the fall. Already, the Republican National Committee put out a press release saying “Hillary Clinton wants to garnishee your wages”. Here’s what the Republicans will be saying in the fall: “If you’re an uninsured family making over $40-$50,000 a year so you aren’t poor enough for subsidies but can’t afford insurance, Hillary will garnishee thousands of dollars of your wages since the average policy for a family of 4 is around $12,000.” That should be enough to scare off millions of middle class families earning less than $100,000, and make them think twice about voting for a Democrat.

The growing failure of Romney’s Massachusetts plan will give ample evidence to back these Republican charges. In Massachusetts, premiums are subsidized for people earning up to 3 times the poverty level (i.e. up to $30,630 for individuals and $41,880). If you make more than that, you have to pay the full cost of insurance, which ranges from $1464 a year for young adults to $9600 a year for those over 55. At those prices, it’s no surprise that only 7% of the 244,000 uninsured Massachusetts citizens who are mandated to buy unsubsidized insurance had signed up by last Dec. 1, although fines for each uninsured individual will be $2,000 in 2008.

So Obama is right to criticize Clinton for putting forward a plan that would penalize the uninsured middle class, unless and until the cost can be brought down to an affordable level. Hillary’s plan is morally wrong, and it’s a political loser.

Obama’s plan is in most other ways similar to Clinton’s. Both plans would prevent insurance companies from denying coverage based on pre-existing conditions, provide community rating under which risk is shared by limiting the premium difference between the healthy and less healthy and the young and old, and provide subsidies for the less well off to buy insurance. They also both provide for a public plan to compete with private insurance. If enacted by Congress (absent the mandate), these plans will help millions of people obtain health insurance who don’t now have it. Obama’s plan has an additional provision that will lower premiums more than Clinton’s plan would. 80% of health care costs cover the care for the sickest 20% of the population. Obama’s plan provides for the Federal government to reimburse insurers for part of the cost of catastrophic care if they use that reimbursement to lower premiums.

Nevertheless, neither Obama’s nor Clinton’s plan will provide truly Universal Healthcare for all Americans. At a cost of a little more than $100 billion a year each, financed largely through letting Bush’s tax cuts for the wealthy lapse, neither plan can make health insurance affordable for all Americans. That can only be done through a single payer/Medicare For All plan which would save approximately $350-$400 billion dollars a year by eliminating the nearly 1/3 of health care costs that go to paying the overhead, advertising, executive salaries, and profits of private health insurers, and the cost of employees in Doctor’s offices and hospitals required to process claims from multiple insurers (as opposed to 3%-4% overhead for Medicare.)

That’s why I still find it disappointing that Obama — who has a sophisticated understanding of the single payer concept — did not have the political courage to join the 78 Congressional co-sponsors of HR 676, the Medicare For All bill introduced in Congress by Rep. John Conyers. But unlike Clinton, at least Obama is not hostile to single payer. In the South Carolina debate, Clinton angrily accused Obama of having once been a supporter of single payer, as though he had once been a Communist. Obama responded that if he were designing a health care system from scratch, he would support single payer, but that since many people are happy with their current health insurance, he thought it was better for the time being to build on the present system. I disagree with Obama. The present system of employer-based health insurance is collapsing under its own weight and an attempt to build on this shaky foundation will also collapse, if not right away, then within a few years.

Despite Obama’s political calculation to the contrary, the combination of a President with Obama’s extraordinary leadership skills and a budding mass movement already supporting HR 676 (which includes over 235 union organizations in 40 states, including 60 Central Labor Councils, as well as many citizens and religious organizations) the American people can be convinced to support Medicare For All. A CBS News poll in September asked “Which do you think would be better for the country: Having one health insurance program covering all Americans that would be administered by the government and paid for by taxpayers, or keeping the current system where many people get their insurance from private employers and some have no insurance?” 55% chose “One Program For All” and 29% chose the “Current System”.

If Obama is elected President, there will be a strong and serious mass movement supporting HR 676. A President Obama is less likely to meet such a movement with hostility than would a President Clinton. Morever, if Obama manages to pass something resembling his plan, when it fails to provide Universal Healthcare, and when increasing numbers of employers drop or reduce their health benefits within a few years, it is conceivable that Obama could support an evolution towards a single payer system in his second term.

Moreover, in California, a similar coalition just defeated an individual mandate plan proposed by Gov. Schwarzenneger and the Democratic Speaker of the California Assembly with only a single State Senator supporting the bill in Committee. In contrast, a year ago both houses of the California Legislator passed SB 840 which would have created a single payer system for the state’s 37 million citizens, had it not been vetoed by Gov. Schwarzenneger. If California gets a Democratic Governor in 2010, it could be the first state to enact single payer healthcare on a state level. To succeed, it will need a series of waivers from the Federal government and the ability to use Federal healthcare funds towards the cost of the State system. Whatever the fate of Obama’s national plan, it is unlikely that a President Obama would try to block a state from experimenting with its own single payer system which, if successful, could provide the model for the rest of the country. (Canada’s single payer system started first in the Province of Saskatchewan under a Conservative government, before expanding to cover the entire country.)

So, as a supporter of single payer/Medicare For All, I find it disappointing that Obama did not have the audacity to support single payer. Nevertheless, his program is better than Hillary’s coercive individual mandate plan. It will certainly be easier to run on against the Republicans in the fall, and to potentially gain enough popular support to get through Congress without too many crippling compromises. Maybe I’m being naïve, but, in the long-run, the fact that Obama understands single payer and is not hostile to it as a concept, gives me hope that we might get there, or close to there, over the course of an 8 year Obama Presidency.

For that to happen, it will take a mass movement in support of single payer health. Obama speaks eloquently of the fact that real social change is hard and starts from the bottom up through organized movements, not from the top down from a government that institutionalizes fundamental social change only when forced to from below. A mass movement for single payer healthcare has already begun to take shape. My hope is that an Obama Presidency will help give it the space to flourish, and to push Universal Healthcare beyond the bounds of Obama’s more modest proposals.

*Nichols is head of the Health Policy Program of the New America Foundation, which helped advise Romney, Schwarzennegger and Clinton on their health plans. His predecessor at NAM was Laurie Rubiner, a former aide to Bob Dole who was assigned by Dole in 2003 to devise a competing plan to Hillary Clinton’s first health reform plan. She developed the idea of individual mandates, which had roots in conservative economist Milton Friedman, Richard Nixon’s attempts to counter Democratic efforts to enact single payer, and the conservative Heritage Foundation. After leaving her Senate posts, she went to NAM where she further developed the individual mandate idea and helped lay the basis for Romney’s Massachusetts plan. In 2005, Rubiner became Hillary Clinton’s legislative director (a post she just left) where she was instrumental in developing Hillary’s individual mandate plan. In the next installment of this “Why Not Single Payer?” Huffpo series, I will trace the history of individual mandates as a conservative Republican idea that has ironically been adopted by leading Democrats, including Hillary Clinton.