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!

Healthcare and Public Health: Issues from 2024 will continue into 2025

As we end the year and begin a new one, what can we say was the most important health-related story of 2024, and what will be the biggest in 2025? Certainly, late in 2024 a huge story was the murder of Brian Thompson on the streets of New York. This was not in any way a random killing, but an assassination of someone the killer believed was responsible for hundreds or thousands of deaths in his role as CEO of UnitedHealthCare, the nation’s largest health insurer. As I discussed in my December 8, 2024 post ‘Murder of a Health Insurance CEO: People HATE the companies and the people who run them’, Thompson was guilty of presiding over a company whose role was to make money by collecting premiums and denying care. He also was guilty of having made this problem worse by bring in artificial intelligence algorithms, which had been shown to be wrong up to 90% of the time, to deny health care to his supposed customers – I say “supposed” because the only customers health insurance companies really have is their stockholders; the people they insure could be called “victims”. 

 Although much of the mainstream media tried hard to focus attention elsewhere – on the accused killer and his personality, on self-serving nonsensical essays like the one by Thompson’s boss, UnitedHealth Group’s CEO Andrew Witty run as a NY Times Op-Ed, etc. – the real story is the outpouring of fury at the health insurance industry from the great mass and majority of the American people. While most did not applaud the murder itself, virtually no one outside themselves and their paid punditry had anything good to say about US health insurance. Probably the overall public sentiment reflected that of Chris Rock: “He actually killed a family, a man with kids. I have condolences for the healthcare CEO. This is a real person, but sometimes drug dealers get shot.”

Another huge story, which will become even bigger in 2025, is the planned nomination by President-elect Donald Trump of profound enemies of public health to the positions responsible for ensuring that health. Foremost among these, of course, is Robert Kennedy, Jr. to be Secretary of Health and Human Services. Kennedy is well-known as a vaccine “skeptic”, which essentially means vaccine opponent, and if he is confirmed as Secretary and is able to implement policies reflecting the positions he has long advocated, we will see the resurgence of many diseases long gone from American life with accompanying deaths, as I discussed on November 15, 2024 in ‘Raw milk, vaccines, and RFK, Jr: Some dates worth remembering’. Remember polio? Measles? I do, but most do not. Check out the numbers on this picture. This is an incredible threat to the public’s health.

But, ultimately, the real story of 2024 – and probably 2025, and sadly beyond – is the fact that the American people remain the only ones in the developed, rich or really even middle-income, world that do not have universal health insurance or care. This is what would prevent the crises, delays, denials, and deaths that the private health insurance industry heaps upon our population and that engenders the wrath of so many. Indeed, that wrath continues to grow because the people who are affected, either personally or through someone they love such as a family member, who realize the inexcusable evil that the actions of these companies inflict, grows over time. While only a small percent of the ostensibly insured will have a terrible event each year, with more years more people and families experience such terrible events. Also, of course, the practices of the health insurance companies become more restrictive and more draconian, leading to both more delays and denials and deaths and more out-of-pocket costs for more people. In other countries, this happens, essentially, very little or not at all. The following chart presents the dates when other countries implemented universal health care, and when they got rid of it because it wasn’t working. Look at it carefully and you might discern a trend:

The US has a higher mortality rate than many of these countries. Jim Kahn, in the Health Justice Monitor, makes an effort to quantify the extent to which health insurance (or lack of it) contributes to this. It is an estimate, but as he notes, whether 170,000 or 220,000, it is too much. And, more, we spend much more than all these other countries on what we call “healthcare” despite so much of it going to corporate profit, that the fact that there is any excess mortality due to lack of health insurance is even more intolerable.

This might come as a shock to many Americans, especially those who have yet to personally experience the delays, denials, and deaths that the for-profit health insurance industry heaps upon its victims, because we are regularly and consistently told by politicians and pundits that a universal health insurance system would be a bad idea, that it wouldn’t work for Americans. That it would be too costly. That it would limit our freedom. We need to recognize that this is not true. Few of us want to have the freedom to choose which insurance company takes our money and then tries its best to limit our access to care (although, if we can afford it, we might choose the one that does it least). What we do want is the freedom to choose the doctors and hospitals that we believe will provide us the best care for our health needs and have our insurance pay for it. Of course, this is not the freedom that they are talking about; what they mean is the freedom of insurance companies (and to be fair, many health care providers) to make as much money as possible, which is what would be limited in a universal government-run health insurance system. And, oh, by the way, provide the funds to pay for it. Imagine that our health care dollars, from our pockets and those of our employers and our government (from the taxes we pay; the large corporations and billionaires who own them don’t) could be spent on providing us with health care rather than lining corporate pockets!

There are actual examples of “single payer” health care in the US. Military retirees and families are covered by government-funded health insurance through the VA or TriCare. In the military itself, for active duty service members, health care is not only single-payer, it is government run. The other big example of single-payer available to Americans is traditional Medicare, for those over 65 or disabled. Medicare. The most popular government program since…Social Security. Under traditional Medicare, health care services are approved for people who need them and have them ordered by a doctor, not micromanaged for each individual with people (or AI!) denying them willy-nilly. In an alternative to Medicare, people can opt for enrollment in an HMO/PPO like system run by the same insurance companies that insured (and often screwed) them before they became eligible for Medicare, and have it paid for by Medicare funds. This program, misnamed “Medicare Advantage”, takes away the guarantees of traditional Medicare and puts you back a the mercy of those for-profit health insurance companies that have treated you so well before!

This is exactly what we don’t need – erosion of Medicare. We need Medicare to be improved, to pay for 100% of all needed medical care, and expanded to cover every American, cradle to grave, paid for by the money now going to insurance company and pharmaceutical and device company and health system profits. The reason to do it is because it would benefit people, remove the major cause of heartache, loss and bankruptcy in the US, and make us more secure and happy people. The reason not to do it is that these huge corporations would no longer be making their exorbitant profits by taking premiums and denying health care, and thus would not be able to make such large contributions to the legislators who should be acting, instead, for the American people.

What do you want? Maybe in 2025 it is time to let your legislators know!

 

A final thought from Bernie Sanders: