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!

IMPROVED and Expanded Medicare for ALL. Now. The people want it!

I am in favor of the US having Medicare for All, specifically Improved Medicare for All, as defined in the two bills currently before the Congress: S 1506, sponsored by Sen. Sanders and 18 cosponsors, and HR 3069, sponsored by Rep. Jayapal with 117 co-sponsors. It is important to emphasize the “improved” part, because the deficiencies of current Traditional Medicare (TM), of which there are many, have been used by opponents of Medicare for All, to argue against it and to push various methods of privatizing Medicare, particularly Medicare Advantage and the WiSER program.

The deficiencies in the current TM program involve what is covered and cost. Some things are not covered by TM, including glasses, hearing aids, and nursing homes. This is ridiculous and is due to lobbying pressure by those industries, which want to ensure their profitability. Cost issues include, prominently, 3 things: Part B premiums (which are scaled to income, but start at $203 a month), Part D premiums (thanks to the GW Bush administration, Medicare now requires beneficiaries to have drug coverage, but also requires that it be purchased from a private insurer, and is not available from the federal government), and Medicare Supplement plans, which pay for the portion of covered services that Medicare does not. This is different from the services Medicare does not cover, like hearing aids or glasses, which the Supplement plans also do not. It is, most significantly, the 20% of a hospital’s Medicare-approved charge that Medicare doesn’t pay for. A hospital may normally charge, say, $40,000 for a stay including surgery and post-op care, but Medicare has an approved charge, say $10,000, and that’s all the hospital can bill the Medicare beneficiary. But then Medicare pays only 80%, so the patient is on the hook for $2,000. That’s largely what Medicare supplement plans cover.

So, the Part B and Part D premiums, and the need to buy a Medicare Supplement from an insurance company, can cost a good deal. This can make Medicare Advantage plans, which are basically HMO or PPO insurance products sold by the same companies that issue commercial insurance, and cover drugs as well as 100% of hospitalizations, look financially attractive. Plus, they also cover hearing aids, glasses, and sometimes dental. And even gym memberships! The potential disadvantage is that they are insurance company products and subject to the same limitations as most commercial HMO/PPO products. The most important are:

•          Limited networks. Only some doctors and hospitals are in the network they pay for. Yours may not be. Or your hospital may be, and your doctor may be, but the ER doctors who care for you in the hospital are not. Or the anesthesiology group. Surprise charges! And most are geographically based, like most HMOs and PPOs, so it may be hard to get non-emergency care away from your home area. And some “destination” hospitals, such as Mayo and MD Anderson, do not accept MA. Virtually all doctors and hospitals accept TM.
•  Denials. Most people who have commercial insurance have experienced denials of claims. Often it seems as if denial is the default (perhaps AI generated). These decisions can be appealed, but most people don’t appeal. And then it can be denied again, multiple times, for little or no reason. It is part of the business model of health insurance companies. For TM, a covered service is a covered service. It cannot be denied.

It’s not as if this will always happen with MA; as with other insurance products, the coverage varies. But it happens a lot, and unsurprisingly, happens most often to those with the lowest-cost products as it does with non-Medicare commercial insurance.

So, the Improved part of Medicare for All is crucial. It needs to cover all necessary health services, not just hearing aids and glasses, but nursing homes and rehabilitation and comprehensive mental health and dental health. All the things that have been cut out as sops to powerful lobbies. And it needs to cover 100%, not 80%, of approved charges. And let me not leave out the All part. That means everyone, birth to death, no exceptions, no carve-outs, no people or groups of people who are in a different plan, no Medicaid, no ACA. Just one program that covers all of us for everything. A single-payer, universal health insurance plan. Like every other wealthy, and most middle-income countries, have.

But Americans don’t support this, right? Well, actually, they do. Recent polling from GQR reveals 94% of Democrats support M4All! And yet Rep. Hakeem Jeffries, the House Democratic leader has recently joined other prominent “mainstream” “centrist” Democrats in announcing his opposition to it, instead favoring yet more inadequate piecemeal “reforms”. Rep. Jeffries: Get with the program! 94% is more than a lot. It is almost all! And it is not just Democrats: GQR also reports

 Massive support among base voters:

● 94 percent among Democrats;

● 94 percent among self-ascribed somewhat liberals;

● 73 percent support among Black voters;

● 76 percent support among women under age 50; and,

● 75 percent support among voters under age 30.

 

Impressive support among swing voters and notable support among Republicans:

● 60 percent among Independents;

● 67 percent among moderates;

● 60 percent among non-college women;

● 66 percent among college educated men; and,

● One in five (19 percent) Republicans and Trump voters support MFA.

Hmm. It is almost as if the Democratic leadership is not interested in welfare of the American people. It almost seems as if, rather, they are interested in appeasing their big donors.

Think about it. When you look at your own experiences with the healthcare system and health insurance companies, and those of your friends and family, it is scarcely a surprise that Americans hate the current system and are not particularly interested in partial solutions which cover some people for some things by method A, and others by method B, and still others by insurance so poor it covers little (method C), or others not at all (method D). The Commonwealth Fund reports that one-third of Americans 19-64 (pre-Medicare) are paying off medical debt, 46% of whom owe at least $2,000, and more than 1/3 used part or all of their savings to try to pay it off.

In addition, millions of Americans are experiencing “job lock”, a situation in which people feel that they have to stay in their current job to maintain their health insurance, rather than being able to find a better job or start a business. ValuePenguin reports that this amounts to 40% of US adults! Wendell Potter, in his “Health Care Un-Covered” correctly notes that the ACA does not solve this problem, nor does any hodgepodge approach. This concept is something that is completely absent from people in other countries -- because they have universal health insurance.

The American people are not interested in partial fixes anymore. They want to have freedom to work where they want and not have their lives ruined by medical debt so that health insurance companies can rack up even more profit (why would they?). They want the comprehensive, easy to understand, effective type of universal health insurance that has been proven to work, in many forms, in most other countries.

It is past time for Improved Medicare for All!

Vertical Integration saves money. And CVS and its competitors use that to line their pockets, not provide healthcare

I have several times referred to the concept of “vertical integration” in the health care/health insurance/pharmaceutical industry, most recently on March 28, 2026, Everything is becoming more unaffordable, but health care may lead this list!. These posts often reference the posts of former insurance executive-turned-whistleblower Wendell Potter on his substack “Health Care Un-Covered”, including “With CVS’s Vertical Empire Under Threat in Tennessee, the Company Threatens to Leave”, which discusses the fact that CVS, most widely known as large pharmacy chain, also owns the Pharmaceutical Benefit Manager (PBM) Caremark. PBMs are add-on middlemen that negotiate better rates for insurance companies with pharmacies. CVS owns pharmacies, a lot of them. This may seem like conflict of interest (COI), but that is apparently a quaintly outdated concept in this era of mega-corporations.

Actually, the PBM-pharmacy COI is only a part of the CVS megalopoly. They also own one of the nation’s largest health insurers, Aetna, so they have both ends and the middleman! And, to round it out, they own a large primary care provider group (Oak St. Health) and long-term care company (Signify Health) and urgent care provider (Minute Clinic). Just read the AI summary if you Google “Companies CVS owns”, but if you want it, the comprehensive list by the SEC is here. This is what vertical integration is; you buy from yourself, and sell to yourself, set the prices (usually in a way that minimizes tax liability), and make a lot of money. The structure is not hard to understand, but it maximizes the conflict of interest. (For a discussion of why this is conflict of interest and not “potential” conflict of interest, see this blog post from August 20 2010, The AAFP, Coca-Cola, and Ethics: Serving the public interest? . In brief, COI exists when a decider has interests in both parties, and a decision one way would help their other interest. The conflict exists whatever the decision is actually made. A judge hearing a case in which one party is a company in which they own a great deal of stock has a conflict of interest; it doesn’t require waiting to see how they rule.)

To be clear, CVS is far from the only major player in the “healthcare industry” (quotes on purpose, and emphasis on “industry”) that is vertically integrated. The largest health insurance company in the US, UnitedHealth, also owns a PBM, (OptumRx), a primary care group (Optum) and a whole host of other companies (SEC listing here). So does CIGNA (their PBM is ExpressScripts). So, there is competition within the “healthcare” sector; it is an oligopoly (few companies) not a complete monopoly. But oligopolies don’t really compete in the way classic capitalist theory would have it; rather, they tend to set prices and divide up the market so they all do well (although they would prefer the other companies to go out of business, the existence of a few tends to forestall any governmental intervention that might occur with a true monopoly).

Is vertical integration bad? A major argument in favor of it is that it can, and often does, increase efficiency. If you own everything, from insurer to care delivery system to pharmacy, and all the other players in between, you can minimize the obstruction from a piece that is owned by someone else. Things can move more smoothly. Costs can be reduced significantly. These are the arguments most commonly put forward, to the public, by vertically integrated corporations that control a huge market sector, oligopolies as well as monopolies.

It is also the argument put forward to stockholders, particularly large stockholders like private equity firms. Especially the “reduced costs” part. This is very attractive to stockholders. It could also be attractive to those ostensibly served by the “healthcare” industry, those people needing – healthcare. After all, they are heavily burdened by the cost of their healthcare, which constantly goes up. This includes the portion that they are responsible for in the form of premiums, deductibles, copayments and “cost sharing” (meaning insurance only pays a part of the bill and you’re on the hook for the rest). Another recent Potter piece, The Bill That Never Ends, summarizes the situation and addresses the fact that deductibles reset every year, so people are constantly behind the 8-ball and can never pay it off. It reminds me of the compound interest that keeps former students in debt for decades even though they may have paid off far more than the original loan! It is an example of how our laws are set up to benefit large businesses, not regular people.

Which, of course, brings us to the issue of efficiency, and lower costs. To what use is this efficiency, this lower cost, put? Cui bono? There is an argument that such efficiency could decrease the overall cost of health care to the nation, as well as to the individuals who require care, which has actually been promulgated for decades by academics and others. There are fewer of them these days, as it has been demonstrated repeatedly that such an idea is frightfully naïve. Yes, money is saved, but it is all used for greater salaries and bonuses for management and greater profits for shareholders. If it were being used to lower premiums, decrease deductibles, lower the cost of drugs, or increase the availability and affordability of health care, we would have seen it. We have not. Too bad.

A weak, but possibly useful, analogy is to a family. The adults (usually) generate the income, and certainly choose how to spend it. This can be mainly to provide food and housing, education for children, health care (to the extent that it is available) and other benefits for the family. Or it could be spent on relatively transient pleasure for the adults – alcohol, tobacco and other drugs, gambling, etc. Most of us feel that the first is better, a “good” thing, and the second is not good, is selfish, and even reprehensible. Apparently, such moral judgement is not applied to corporations, certainly not, in this case, those involved in “healthcare”.

I keep putting “healthcare” in quotes when applied to the industry. This is because it is not an industry that is at any significant level dedicated to providing healthcare to our people; when it does, this is a byproduct. It is an industry that is dedicated to extracting the most dollars possible from the rest of the economy and putting them in their own pockets. While this is, of course, the goal of most of our industries, it seems worse that “healthcare”, perhaps because of the veneer that come from ostensibly doing something good, seems to be particularly effective at it.

A single payer health insurance system only addresses coverage. A national health service, such as in Britain, is a more comprehensive manifestation of vertical integration. It doesn’t always work well, mostly because it is starved of funds as a political act to demonstrate that the public sector does not run efficiently or effectively, thus an argument to privatize it, which has to some degree been done in the UK. And, like almost all efforts to privatize formerly public services, the cost goes way up, the service does not improve or gets worse, and the money that could have been used to benefit the people is lining the pockets of ganevem. This does not seem like a good use of benefits of efficiency and decreased cost arising from vertical integration to me.

Maybe we can do something about it! Imagine if the phrase “healthcare” industry didn’t have to be in quotes!

 

For more (or maybe just more terse):

“The health insurance company gets a cut, the pharmacy benefit manager gets a cut, the drug manufacturer gets a cut, and the patient…gets screwed!” Rep Alexandria Ocasio-Cortez, interviewing CVSHealth CEO David Joyner at a congressional hearing.

Also “Federal rules require the insurer to spend a certain percent on care. But, when you own the care, when the insurer owns the pharmacy, owns the PBM, owns the drug manufacturer, you also own the health care cost.”

The whole clip is not that long and makes the point about vertical integration very clear, including 1000% markups on some drugs! Thank you, AOC!  If you have time to do nothing else, watch this video!

https://ocasio-cortez.house.gov/media/press-releases/icymi-ocasio-cortez-calls-out-cvs-healths-corporate-strategy-monopolize