Getting to Single Payer, Part I

July 12, 2017

By Jill Zorn

chess-pawn-social-mobilityWith all the political turmoil surrounding the possible repeal of the Affordable Care Act (ACA) and destruction of Medicaid, support for single payer health care is growing.  This is the first in a series of blogs that will dig into the topic of single payer – what are the hurdles and how can we overcome them.

Almost every day now, there is a new blog, an op-ed or an article touting the advantages of single payer/Medicare for All/Medicaid for All.  And the polls are showing that single payer is becoming more popular.

The most recent Kaiser Health Tracking poll shows that a majority of Americans (53%) now support single payer health care.  Another survey done in April reported that 61% favored, “Creating a federally funded health insurance system that covered every American” (see page 89 of the report).

So why is it so hard for this dream to become a reality?

I think it comes down to two very powerful forces:  individuals FEARING they will be worse off, and health industry players KNOWING they are likely to be worse off.

To move toward single payer, supporters should understand these forces and develop a strategic path forward that consciously addresses them.

Individuals’ fears of being worse off

Most people are satisfied with the health insurance coverage and access to care that they have, which makes them risk-averse to change.

Charles Gaba, a well-known blogger and tweeter on health care policy, devotes a section of his terrific article , A Zero BS Guide to American Healthcare published on (yes, the “humor” website) to this phenomenon.  Part 4 of his article is entitled, “People Don’t Like Having Their Healthcare Messed With.” Here’s the gist: “When half the people like the way things are, it’s incredibly difficult to get them to change, even if the other half are getting screwed.”

Another blogger, Jon Walker, has written a thoughtful four-part series on the road to single payer.  He explains “status quo bias” in one of those blogs, Fighting for Universal Health Care at the Federal Level:

Resistance to change is one of strongest forces in politics. Even if change might improve things for 90 percent of people, many fear uncertainty, and the 10 percent, whose lives will be worse off, find a way to disproportionately make their voices heard.

Many good ideas with broad support have failed because the public feared implementation could go wrong…The failure to address status quo bias has undermined many efforts. Groups often get too focused on selling the long term benefits of their plans when what many people are most concerned about are the short term disruptions.

Don’t forget, health care is personal.  As Richard Kirsch writes in his book about the battle to get the ACA passed, Fighting For Our Health,

…when we care about something so deeply, change can also be terrifying.  Specific solutions prompt people to ask, how will that change affect me?  Will I be worse off than I am now? What will I lose? (p.32)

Opponents know how to prey on these fears.  They raise the specter of a big, uncaring, incompetent government bureaucracy being in charge of your health care.  Never mind that this ignores that Medicare is a government program that everyone likes – this tactic often works.

For example, the same Kaiser poll cited above reports that supporters of single payer can become opponents when a pointed question is asked whether they favor “government control over health care” or whether they support requiring Americans to “pay more in taxes” (See Figure 4).


Not only do people fear having worse health coverage, they definitely dread having to pay more for it in the form of higher taxes.

As Matthew Yglesias wrote in Vox this week, there is a history of single payer plans losing steam, “Once they started to get specific about taxes.”  Employers spend a lot of money on health insurance, but those dollars are in the private sector and are largely hidden from view.  Most employees aren’t aware of how much their employer is paying for their insurance premiums.  These employer expenses are also made with tax exempt dollars, but again, that is a hidden government subsidy.  When these largely concealed dollars are turned into a tax bill and included in a government budget, “you are talking about a big chunk of change becoming an explicit public-sector cost.”

Needless to say, opponents know how to prey on the fear of tax increases, too.  As Jon Walker points out in his most recent blog post, An Easy Way to Solve the Medicare For All Tax Problem, they are good at highlighting “big scary numbers”, both tax increases and government budget increases, to scare people away from single payer solutions.

The next blog post will be about industry fears.  After that, the series will discuss the pros and cons of implementing single payer at the state versus federal level.

To read the rest of the blogs in this series, click here.

For previous Foundation blogs on this topic see:

How We Can Eventually Get to Medicare for All

Improved Medicare for All

Article tags: