Single payer requires a single payer. You can't successfully have a public "option"

Dr. Abdul El-Sayed is the Democratic candidate for Senate in Michigan. A public health physician and former director of the Wayne County Department of Health, Human & Veterans Services, he has long been an advocate for a universal health care program with a single payer, such as Medicare for All, for which I too am a strong proponent (see IMPROVED and Expanded Medicare for ALL. Now. The people want it!, Sept 27, 2026). But recently he added what seems like a “little nuance”. In his debate with Republican Mike Rogers, the Michigan Daily coverage says

El-Sayed has long advocated for expanding Medicare. Most Medicare for All proposals would replace or phase out private insurers, but El-Sayed said families would be able to keep private insurance under his plan if they chose to.

It also quotes him as saying “I want to guarantee every single person in this country, cradle to grave, coverage — without premiums, co-pays, deductibles,” which is good, right? That’s what I advocate for right? Why would I make a big deal about him saying people could keep private insurance? It plays well with the voters, right? It’s kind of what Barack Obama said about the ACA, right? And it passed, right? And it helped lots of people, right?

Yes. But that line about people “keeping their private insurance if they choose to” is really important. It is not a “little nuance”. If he, and others, are serious about that, it will make single payer, Improved Medicare for All, fail. I don’t think that is what Dr. El-Sayed wants, but it is the truth. If people can keep their health insurance, then whatever public plan may be created becomes just one option, the “public option”, a concept that has been long the darling of many “mainstream” Democratic leaders and policy wonks from Obama on down. By definition, there will not be a single payer. If you believe in the whole premise of universal, single-payer health insurance, then that is what it has to be, a single payer, not be simply a “public option”. A recent Health Justice Monitor piece quotes from an article by Robert Kuttner in The American Prospect that advocates for such a public option. Then Jim Kahn and Hank Abrons proceed to debunk the arguments Kuttner makes, with 3 key points:

(1) The public option creates a serious risk of adverse selection. Private insurers have strong incentives to make their plans less attractive to very sick, expensive patients, nudging them toward the public option. If the public plan thus attracts a sicker population, its costs — and, if it must be self-financing, its premiums — will rise. That in turn makes private mainly job-based insurance more attractive to healthier people, likely worsening the selection problem. Meanwhile, because the public option remains embedded in a multi-payer system, we get very little of single payer’s administrative savings. This “cost spiral” will be portrayed by opponents of Medicare for All as proof that it can’t work.

(2) Neither providers nor patients will experience what it’s actually like to give or receive care in a single-payer system. The public option would be grafted onto our incredibly cumbersome insurance system. Providers would still deal with multiple payers, rules, networks and billing systems. And patients would still encounter the complexities of today’s Medicare, Traditional Medicare has substantial cost-sharing and often requires supplemental Medigap coverage, while Medicare Advantage puts beneficiaries back in the hands of private insurers.

(3) The public option doesn’t even begin to address other critical failings of our health system, such as gaps in coverage for essential services (e.g., vision, hearing, and dental), high drug prices, and major access inequities (e.g., lack of coverage for non-working families). 

These are all true and important points. While I don’t think that I can say it better, I can say it in different words, emphasizing some aspects while not in any way disagreeing with Kahn and Abrons.

Their point (1) is about adverse selection. This is an essential problem with all public option plans, and is a strong argument against them. The health insurance industry is all about making profit, and this does not require them to cover more people, or to cover them well. They can often make more profit by covering fewer people, a method explained in detail in Wendell Potter’s recent Health Care Uncovered, “Q3 2026: UnitedHealth’s Profits Soar as it Covers Fewer People, Pays Less for Care.” As Kahn and Abrons point out, this is especially true if the people cut off are those who are sick and cost a lot; the wet dream for insurance companies is to have all healthy people who pay premiums (or whose employers pay premiums for them) who never use any health care or cost the company any money. Having the public option as a “safety net” encourages them to divest themselves of the sick, and puts the burden on the public option, which now has lots of high-cost sick people without the low-cost healthy people to balance them out. The key principle of all insurance is that everybody pays in, and their premiums pay the cost of the minority of people who need to collect; for health insurance it is because they are sick that year. Remember this graphic from Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009 and still true today: in any given year, 5% of the people are responsible for 50% of health care spending. If we let a bunch of those “blue” people, the 50% who are responsible for only3% of costs, opt out, the system fails. And also remember: those 5% next year will not be the same people as they were this year.

  

Kahn and Abrons’ point (2) really includes two important concepts. The public option keeps the grab-bag, complex, pay for some things but not others, different kinds of programs for different people (poor, rich, employed, old) and many different plans within each. It continues prior authorization and the right of insurance companies to deny your care, and keeps people completely confused. It will continue to make life miserable for providers. It won’t really be better than the current non-system because it keeps that and then grafts the public option on. The second part is that, without everybody being in the same universal payer system, organized like Medicare but with Improved and Enhanced coverage for all health needs, then most people are not experiencing the benefits of such a system.

The key flaw that all “public option” plans have is that they keep the insurance companies in the game, and allow them to keep making money by denying people the healthcare that they need. For Medicare for All, or any comprehensive universal single-payer system, to be affordable (and, in fact, cost less than the US spends on “healthcare” now) we need to realize the enormous savings on administrative costs, including insurance company profit. That is the enemy. A good, affordable health plan requires the elimination of for-profit insurance companies that are motivated to cover less care for fewer people so they can make more money.* But keeping the enormously expensive, inefficient, and bad-for-the-public’s-health for profit insurance industry is exactly what “public option” advocates are trying to do! Why? You guess. It’s almost as if they get lots of political contributions from that industry…

Kahn and Abrons point (3) is critical, and speaks for itself. Universal single-payer coverage doesn’t solve all the problems of our health care chaos. It is, however, a necessary, if not sufficient, characteristic. With single-payer Medicare for All those other problems have can be addressed; with our current system, or the version of it that includes the public option, they cannot and will not be, not in any kind of comprehensive way.

Finally, I emphasize the most important moral point: Everybody In, Nobody Out. Every single person is in the same health insurance plan. No one gets to buy their way out. This is horrifying to the very wealthy, and to those middle-class people who like to identify with the wealthy (until they face the stark reality of not being wealthy when their health care coverage is denied). But it is central. When those who are poor and disempowered are in the same system as those who are well-to-do and empowered, the former will get better care because the latter will make sure it works.

This is the moral imperative.

*Unless, of course, they are very tightly regulated, as in Switzerland. They all have to deliver the same coverage to everyone, and charge the same amount in premiums, and not be for-profit. I can go with that; it means that the only thing that they can compete on is customer service! Imagine that!

Why is it so hard to get medical care? And what should we do about it?

You may have noticed, should you or a family member or a friend have had a health problem recently, that it is difficult to get care. It is difficult to find a doctor (or a nurse practitioner, or any health care provider) who is available to add you to their panel. If you are lucky enough to have one, especially one who practices primary care (a family physician or general internist or geriatrician for adults), it is still difficult to get an appointment. If you think you just have a simple question, it can be difficult to get through to them to ask it. Sometimes you can get a nurse, or a medical assistant, or perhaps the desk clerk who may be familiar with some things enough to answer, but often they cannot. Many practices now have “patient portals” (e.g., MyChart ®) where you can post a question for your doctor (often in the form of “I have these symptoms but I can’t get an appointment; do you think I need to be seen?”) that, hopefully, they will answer before you are in extremis.

When all these methods fail, and you are still sick, you can visit an Urgent Care Center, sometimes run by local health systems and sometimes by private chains. They can care for many problems and do some tests, but a lot of things will lead to them sending you to the local Emergency Department. That is, of course, what you were trying to avoid, if for no other reason than the long wait (often hours, even if you have a severe problem that, once they diagnose it, can truly be an emergency; I wrote in the past about a close family member who waited 7 hours to be found to have appendicitis). Not all ED waiting rooms look like “The Pitt”, but it is not uncommon, especially in those centers who have the facilities to care for really dire problems needing urgent intervention (heart attacks, strokes, acute abdominal issues needing surgery, etc.) 

A big part of the problem is that there is a shortage of primary care physicians. This is worse in the US than in other countries but is becoming a problem elsewhere as well, as discussed by Dr. Kenny Lin in “Primary Care Supply and Access Challenges Around the World” on his substack CommonSenseMD. There are also shortages of other physicians (thus the line out the door of the cardiologist’s office), exacerbated by distribution problems (specialists tend to group in major cities and wealthier suburbs). But much of the delay in getting into subspecialists would be mitigated by having more family doctors and other primary care physicians. This works in 4 ways:

1.      The primary care doctor can take care of lots of the problems that people otherwise seek out subspecialty care for. Because you have a heart, it doesn’t mean you need a cardiologist.
2. If the primary care doctor identifies a problem that they think does require a subspecialist (say, a cardiologist) they can refer you to one who is less backed up because primary care doctors have done an assessment and identified that there is a problem requiring a subspecialist. This also makes the subspecialist more effective, because the people they see have already been assessed by a physician and they have a clearer issue on which to focus their attention.
3. Once the subspecialist does their assessment, makes their treatment plan, and initiates it, much of the follow-up can be done by the primary care doctor, freeing the subspecialist from needing to see so many follow-ups and having more appointments for new patient assessments.
4.  Many people (especially older people) have more than one health problem. Not only is going to a separate subspecialist for each potentially inefficient and possibly unnecessary, but can result in “communications problems” between them. This can be dangerous for the patient, in part because treatments for one condition sometimes worsen another. Having a primary care doctor who cares for the whole person, not just one organ system or disease, and is in possession of the assessments and plans from all the subspecialists, means the patient receives care that is coordinated and managed appropriately.

This model is understood and often utilized by subspecialty physicians who understand that their time and effort is best spent in the narrow area in which they are expert. The problem is that it requires a sufficient number of primary care doctors (about 40-50% of physicians), and, in the US, we don’t have them, and are not even moving in the right direction. As I have discussed before, a big reason that students do not choose to become primary care doctors is money…that their incomes are far less than subspecialists, and this needs to be addressed (see, for example, Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people, Sept 28, 2023).

Another part of the reason people do not access care is cost; the American Academy of Family Physicians (AAFP) newsletter Family Medicine Today reports on a survey by West Health-Gallup that 1 In 3 Americans Are Making Basic Living Sacrifices, Borrowing Money To Afford Health Care. Of course ‘…the “need to make these trade-offs was far more common among the uninsured, Gallup found, with 62% saying they made at least one sacrifice to afford their care. However, 29% of those with insurance also said they were forced to make a trade-off to cover their health care costs.” So…a big problem.

The cost issue may seem to be one that is more clearly related to my contention, in a recent blog (Feb 26, 2026), that The problem with the US healthcare 'system': THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST., but in fact so is the shortage of primary care physicians and the difficulty getting appointments. On Feb 18, Health Care Un-covered addressed “The Economic Exploitation of Independent Physicians by Insurers”. It is also a result of practices being owned by profit-making private equity companies (or sometimes by insurance companies, such as UnitedHealth owning Optum) that determine the practice parameters and character, including the speed-up (seeing more patients more quickly) and other business approaches that are good for making money but not for people’s health. In addition, this includes the practice of replacing primary care physicians with less-trained non-physicians, such as nurse practitioners and physician’s assistants. I don’t mean to disparage these professionals, and indeed they can be very good and effective in the roles they are put in – seeing acute minor illnesses or checking on the status of chronic illness such as diabetes and hypertension. But being the coordinator, the “quarterback” – of care for the whole person that the primary care physician can fill, as I described above, requires more, not less, training. It makes care better; not the “most profit” or the “most efficient” but the “most likely to maintain and improve the patient’s health”. Even when for-profit companies don’t own the practices, “A wave of coordinated lawsuits is transforming the No Surprises Act’s arbitration system into a battlefield where insurers seek to intimidate physicians, rewrite the law and consolidate control” (How Insurers Are Using the Courts to Rewrite the No Surprises Act, Health Care Un-covered, Mar 11).

The health of the US population has long been worse, using generally accepted health parameters and measures, than in comparable countries. The situation is not improving, as insurers decrease access by increasing premiums and co-pays and deductibles, forcing a significant percentage of Americans to cut back on other necessities, as well as often denying coverage for important care. These practices control not only patients but physicians, along with the control exerted by hospital systems are for-profit ownership of physician practices. It also contributes to a downgraded role and lower pay for primary care physicians, who are key to maintaining health in the US and other countries. It is not a good situation, and it is getting worse, if Americans’ health is the measure.

It is past time for us to ensure that this is the measure, and not maximizing the profit of corporations!

The problem with the US healthcare 'system': THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST.

That the US health system is (to quote the opening of an important book*) “broken”, is obvious to almost everyone. It’s a mess. Even calling a “system” is probably incorrect. It costs a tremendous amount of money, generally 2-4x per capita what any other wealthy country spends, and generates far worse public health outcomes (even before the wackadoodle RFKJr became Secretary of HHS) such as longevity, disability-adjusted-life-expectancy (DALE), infant mortality, cancer survival, and almost all other measures. It also is very difficult to access, just getting to see a doctor, as well as financially. This situation has long been true for the poor and much of the working class. It is getting worse as low-income people lose access to Medicaid because of cuts to ACA subsidies or because they live in a state that never expanded Medicaid, and for rural people who are both, on average, older (and thus more likely to have health problems) and poorer. Over time it has increasingly become something that affects working class people, as insurance companies raise their rates, employers become stingier with paying premiums, and, very importantly, as the power of unions has been dramatically eroded by a society concerned only with corporations making the most possible money. It is critical to remember that the health insurance benefits employed workers gained resulted from the struggles of unions, never from the generosity of corporations.

The days of “Cadillac health plans” for unionized workers are long gone, and they are finding themselves in the same pool of too many people seeking too unavailable health care at too unaffordable costs. The new Trump administration plan for the ACA will make things much worse; it may offer lower-cost plans in terms of premiums but with enormous deductibles (‘New A.C.A. Plans Could Increase Family Deductibles to $31,000’, NY Times, Feb 26, 2026). So if you get sick and need care, you’re really screwed, and if you don’t you’re paying insurance premiums for nothing!

And now even those in privileged economic positions, who have money and sometimes even personal access because they are doctors, are finding themselves struggling to access care. People can’t find doctors, especially primary care doctors like family physicians and general internists who can manage their health and the input from various specialists. When they can find them, it is hard to get an appointment. It is very difficult to talk to them, or get a message to them, or speak to anyone who works for them who has any clinical knowledge or understanding. Some people say “I have a good doctor, they respond to my calls, or I can communicate on a health portal,” but these grow fewer. I know physicians who have real difficulties! They need supplies for their insulin pumps, but the insurance companies require notes from their doctors, and it is almost impossible to reach them. I know health care professionals who have heart problems requiring them to wear machines recording their heart rhythm over time, who must wait in lines stretching out the door to see their cardiologists. This is bad, not because they are better educated, wealthier, or health care professionals, but because it is bad for everyone. These people, at least, be able to afford to get a “concierge” doctor who they pay out of pocket, but clearly this is not a solution for most folks. 

We are in the grips of a perfect storm, with insurance companies raising their rates and finding reasons to deny care, a shortage of doctors in many areas, both geographic and by specialty, especially including primary care, with doctors having such speed-up of their work that they scarcely have time to see their patients not to mention respond to calls or notes. We have federal and state governments cutting back public benefits, including not only Medicaid but also Medicare and the VA. Doctors no longer work for themselves where they can make decisions about how to run their practice, and balance work and income, but for giant hospital “healthcare” systems and private equity investors interested only in profit.

Well, you know, maybe “perfect storm” is the wrong analogy. That phrase implies that the bad situation you find yourself in is the result of several unrelated events that come together coincidentally at the same time. This is not the case in the health care crisis. While a lot of things seem to be happening together, they are all manifestations of one single thing:

THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST.

That's it. That is 100% of the problem. A lot of effort is spent trying to transfer blame between blameworthy players, with insurance companies saying providers are too greedy, providers saying insurers don’t pay enough. And everyone blames the pharmaceutical industry and even components of that industry – drug manufacturers, giant retail pharmacies, and “PBMs”, the middlemen between drug companies and insurers – blaming each other. But this “it’s not me, it’s them” is all a load of crap. Yes, sometimes one part of the “healthcare” industry is doing better financially than another, sometimes one corporate behemoth puts another out of business, but what is never a major consideration – and I put forward it should be the only consideration – is what improves the health of the American people, as individuals and as a whole. You, the “patient”, the sick person who needs care, is the one player in this whole thing whose interests are not getting the consideration they deserve – which should be ALL of it.

The growing trend, which is the proof of all of this, is the “vertical integration” of the components of the system. This means that the same company is the insurance company, the provider, the drug supplier. It feeds itself sucking out your money at every turn while denying you the care that you need. Several recent posts on the “Health Care Un-covered” substack detail aspects of this, including ‘The Economic Exploitation of Independent Physicians by Insurers’, and recently ‘2025: Big Insurance’s $1.7 Trillion Year’ which shows that while they ARE making these outrageous amounts (from YOUR pocket, whether directly in premiums, co-pays, and deductibles or premiums paid by your employer in lieu of higher wages) the bosses THEY answer to, the sharks on Wall St., are harassing them to do more, charge more, deny more care, because it isn’t enough; they aren’t making enough  profit! They need more!

I said at the beginning of this piece that “almost everyone” realizes that our healthcare system is a mess, and I think this is true. Certainly, those profiting from it, all those insurance companies and health systems and private equity companies and drug companies, know it. They love it. They’re making out like bandits, one might be tempted to say, if only bandits could begin to compete with them in cupidity, heartlessness, and immorality.

The truly infuriating thing is that our governments are in the practice of enabling them, of enhancing their power, of increasing their profits (see, for example, the gargantuan efforts to move US seniors out of traditional Medicare, an efficient and cost-effective single-payer plan to Medicare Advantage, which puts them back at the mercy of insurance companies; see for example Medicare re-enrollment: Time to consider being dissatisfied with a new plan!, Oct 25, 2025). Most legislators and their health pundits who are not the out-and-out-on-the-take corporate enablers that characterize the Republican party are the somewhat-less-but-really-still-on-the-take corporate enablers of the Democratic party!

We regularly hear from even somewhat progressive (not to mention the right-wing) think tanks and academics and legislators that it would be impossible to change the system to truly benefit the health of the American people, and not the pockets of big corporations, even though it has been done in every other wealthy (and many less wealthy) countries in the world. The key change here is to take the profit (or most of the profit, or the possibility of generating ever more profit) out of the health system. The problem is simply NOT that people use “too much” health care and cost too much money; the problem IS simply that insurers and big health systems and Wall St. and drug companies MAKE too much money and are taking the money we pay for health care out of health care!

The only people who are going to speak for the health care needs and interests of the vast majority American people are those people themselves. Demand of your politicians that they commit to single-payer improved and expanded Medicare for All, demand that they pursue policies that actually get more primary care doctors out in practice by decreasing the payment prejudice for subspecialists and banning completely the corporate practice of medicine.

And if they don’t, vote them out!

 

*Joshua Freeman, Health, Medicine, and Justice: Designing a fair and equitable healthcare system, Copernicus, 2015.