Would patients targeted by ACA prefer single payer?

Support for National Health Insurance Seven Years Into Massachusetts Healthcare Reform: Views of Populations Targeted by the Reform

By Sonali Saluja, Leah Zallman, Rachel Nardin, David Bor, Steffie Woolhandler, David U. Himmelstein, and Danny McCormick
International Journal of Health Services, OnlineFirst - November 3, 2015


Before the Affordable Care Act (ACA), many surveys showed majority support for national health insurance (NHI), also known as single payer; however, little is currently known about views of the ACA’s targeted population. Massachusetts residents have had seven years of experience with state health care reform that became the model for the ACA. We surveyed 1,151 adults visiting safety-net emergency departments in Massachusetts in late 2013 on their preference for NHI or the Massachusetts reform and on their experiences with insurance. Most of the patients surveyed were low-income and non-white. The majority of patients (72.0%) preferred NHI to the Massachusetts reform. Support for NHI among those with public insurance, commercial insurance, and no insurance was 68.9%, 70.3%, and 86.3%, respectively (p < .001). Support for NHI was higher among patients dissatisfied with their insurance plan (83.3% vs. 68.9%, p 1⁄4 .014), who delayed medical care (81.2% vs. 69.6%, p<.001) or avoided purchasing medications due to cost (87.3% vs. 71.4%; p1⁄4.01). Majority support for NHI was observed in every demographic subgroup. Given the strong support for NHI among disadvantaged Massachusetts patients seven years after state health reform, a reappraisal of the ACA’s ability to meet the needs of underserved patients is warranted.

From the Methods

The survey included questions about demographics, health status, knowledge about health insurance, and experiences obtaining and using insurance. One question assessed patients’ preferences regarding reform of the health care system. This question, adapted from a prior Washington Post-ABC News poll question, asked patients to choose one of two health care systems: “the current Massachusetts system — which includes a mixture of insurance types, requires that most people pay copays and premiums and mandates that people obtain coverage — or a single national health insurance program — which would be run by the government, paid for by taxes, cover all residents, and not require co-pays or premiums.”

From the Discussion

Our study is the first to directly compare preferences for the MA health reform to NHI. Our findings are not intended to be generalizable to all residents of MA, most of whom are affluent, white, and commercially insured. Our purpose was not to gauge statewide support for NHI, but instead to understand such support in the key policy-relevant populations of patients who were the main target of the health reform — MA residents who are socioeconomically disadvantaged and racial and ethnic minorities.

NHI has been proposed for many years; however, this option is often regarded as unrealistic because it lacks support of key stakeholders, especially the pharmaceutical and insurance industries. Yet, our results suggest a disconnect between the health care financing system that exists in MA (and now nationally) and the system underserved patients prefer.



By Don McCanne, M.D.

Many polls and surveys have shown that the majority of United States residents would prefer a single payer national health program. This survey is an important addition since it shows that individuals specifically targeted by reform in Massachusetts - individuals who theoretically would be satisfied with the system if reform met their needs - would still prefer to have a single national health insurance program.

Since the reform design of the Affordable Care Act (ACA) was based on the reforms in Massachusetts, it would be safe to say that the response nationally to ACA reforms would be quite similar. So reforms were not adequate for the population they were primarily designed to serve, nor were they adequate for the majority of us who believe that health care should be accessible and affordable for all. ACA falls short of those goals, whereas single payer would meet them. We should go for it.