Some say the goal of establishing a single-payer system in the U.S. is “unrealistic” or “politically infeasible.” While it’s true that single-payer health reform faces formidable opposition – especially from the private insurance industry, Big Pharma, and other for-profit interests in health care, along with their allies in government – there is no reason why a well-informed and organized public, including the medical profession, cannot prevail over these vested interests.

We should not sell the American people short. At earlier points in U.S. history, the abolition of slavery and the attainment of women’s suffrage were considered unrealistic, and yet the movements to achieve these goals were ultimately victorious.

On a practical level, our existing Medicare program – one that doctors, hospitals and other providers are very familiar with – provides a readymade framework for building a universal, single-payer system. This existing infrastructure will help smooth the transition.

What is truly “unrealistic” is believing that we can provide universal and affordable health care, and control costs, in a system dominated by private insurers and Big Pharma.

A government-sponsored “public option” in the ACA’s marketplaces will not fix the health care system for two reasons.

First, a public option would leave today’s multiple payers in place, merely adding one more payer to our already fragmented system. It would thereby forgo at least four-fifths of the administrative savings available through a single payer. It would do nothing to streamline the administrative tasks (and costs) of hospitals, physician offices, and nursing homes, which would still contend with multiple payers and hence still need the complex cost-tracking and billing apparatus that drives up administrative costs.

Second, a quarter-century of experience with public/private competition in the Medicare program (traditional Medicare vs. private Medicare Advantage plans) demonstrates that the private insurers will not allow a level playing field. Despite strict regulation, private insurers have successfully cherry-picked healthier seniors and have exploited regional health spending differences to their advantage.

Thus, under the ACA, relying as it does on the participation of large, for-profit insurers, a public option would not lean toward single payer, but toward the segregation of patients, with profitable ones in private plans and the unprofitable ones concentrated in the public plan, dooming the latter to failure.

As for a “Medicare buy-in” that would lower the age of eligibility for Medicare to 55, for example, such a buy-in would only work if enrollment were mandatory. Otherwise it would become the place where all the sickest patients get dumped. That might be OK for the sick enrollees, since Medicare is better and more secure than private coverage, but it would drive total health care costs (and premiums) up, not down.

Our current “system” is structurally flawed; patching it up is not a real solution.

The Affordable Care Act expanded coverage to about 20 million Americans by requiring people to buy private insurance policies (partially subsidizing those policies with government payments to private insurers) and by expanding Medicaid. It roughly halved the number of uninsured and curbed some of the private insurance industry’s worst practices.

Even so, as of 2017, about 28 million people remain uninsured, and an estimated 31 million would still be uninsured in 2027 if the ACA remained in place, according to the Congressional Budget Office. Tens of millions more are underinsured (an estimated 41 million in 2016), with skimpy policies and high deductibles, and would face financial disaster should they fall seriously ill. Even those with “good coverage” are vulnerable to financial stress and medical bankruptcy.

The ACA preserves our fragmented financing system, and has actually increased the administrative bloat in the system, diverting dollars from needed medical care.

Meanwhile, the private insurers continue to strip down policies, maintain restrictive networks, and deny care. They also continue their efforts to privatize and wring profits out of the historically public Medicare and Medicaid programs.

In short, the ACA tinkered around the edges of our existing dysfunctional arrangements, but it hasn’t fundamentally fixed the problem.

The ability of U.S. businesses to accurately budget for their employees’ health care expenses is critical, but nearly impossible in today’s environment. Costs are subject to steep, unpredictable increases, and are unevenly and unfairly distributed. Companies that provide generous benefits, and those with older or sicker workers face crippling costs, while others evade their responsibility to chip in, leaving their employees with no or inadequate coverage.

In contrast, nations that manage health care expenses in a single risk pool provide their businesses with much greater financial predictability, and costs are distributed more fairly. Thanks to a single-payer system’s ability to reduce needless uncertainty and variation in one part of the budget, a company will be able to allocate more resources toward activities that directly enhance its central business mission and its ability to compete in the global marketplace.

The complexity of our nation’s current health insurance arrangements has created a uniquely American industry of consultants and advisers who assist companies in annual renegotiations with insurers and other firms, in redesigning benefits plans, in communicating such plans to employees, and more. These activities amount to a costly diversion of both time and money from a company’s central goals. Warren Buffett has said health care costs hurt businesses more than corporate taxes do, and calls medical costs “the tapeworm of American economic competitiveness.” An improved Medicare for all will eliminate this business distraction and enable human resource departments to refocus on more strategically valuable roles within their companies.

The new system will still need some people to administer claims. Administration will shrink, however, eliminating the need for many insurance workers, as well as administrative staff in hospitals, clinics and nursing homes. More health care providers, especially in the fields of long-term care, home health care, and public health, will be needed, and many insurance clerks can be retrained to enter these fields. Many people now working in the insurance industry are, in fact, already health professionals (e.g. nurses) who will be able to find work in the health care field again. But many insurance and health administrative workers will need a job retraining and placement program. We anticipate that such a program would cost about $20 billion, a small fraction of the administrative savings from the transition to national health insurance.

PNHP has worked with labor unions and others to develop plans for a jobs conversion program with would protect the incomes of displaced clerical workers until they were re-trained and transitioned to other jobs. Both H.R. 1384 and S. 1129 allocate funds for this purpose.

Studies show that the aging of the population is responsible for only a small fraction of our rising health care costs. Moreover, European nations and Japan have much higher percentages of elderly citizens than the U.S. does, yet their health systems remain stable with much lower health spending. The lesson is that national health insurance is a critical component of long-term cost control. In addition to freeing up resources by eliminating private insurance waste, single payer encourages prevention through universal access and supporting less costly home-based long-term care rather than institutionalization.

First, about half of all malpractice awards go to pay present and future medical costs (e.g. for infants born with serious disabilities). Single-payer national health insurance will eliminate the need for these awards. Second, many claims arise from a lack of communication between doctor and patient (e.g. in the Emergency Department). Miscommunication/mistakes are heightened under the present system because physicians don’t have continuity with their patients (to know their prior medical history, establish therapeutic trust, etc.) and patients aren’t allowed to choose and keep the doctors and other caregivers they know and trust (due to insurance arrangements). For these and other reasons, malpractice costs in three nations with single payer are much lower than in the United States, and we would expect them to fall dramatically here.

Most breakthrough research is already publicly financed through the National Institutes of Health (NIH). According to the NIH website, as of 2017 at least 94 NIH-supported researchers in medicine have been sole or shared recipients of 49 Nobel Prizes.

Many of the most important advances in medicine have come from single-payer nations. Often, private firms enter the picture only after the public has paid for the development and clinical trials of new treatments. The HIV drug AZT is one example.

On average, pharmaceutical drug companies spend two and half times as much of their revenue on marketing and administration as they do on research and development. Negotiating lower prices will permit all Americans to have access to needed drugs without hurting research.

No. It will eliminate the rationing going on today. The U.S. already rations care based on ability to pay: if you can afford care, you get it; if you can’t, you don’t.

In 2017, an estimated 30,000 unnecessary, preventable deaths were linked to lack of health insurance. Many more people skipped treatments that their insurance company refused to cover. Those are forms of rationing.

A single-payer system will ensure that everyone has access to a single tier of high-quality care, based on medical need, not ability to pay.

Long wait times for non-urgent procedures in some countries, e.g. hip replacements in Canada, are often cited by opponents of single-payer reform as an inevitable consequence of universal, publicly financed health systems. They are not. Wait times are a function of a health system’s capacity and its ability to monitor and manage patient flow. In recent years Canada has shortened wait times for non-urgent procedures by using better queuing techniques. In the case of urgent care, wait times have never been an issue. Moreover, we spend twice as much per person as Canada does, enough to assure that we wouldn’t have waits in our single payer system.