Bernie Sanders and the single-payer dream: Why we must take it seriously


After being out of the news for a few weeks, health care reform came back with a bang this week when Senator Bernie Sanders unleashed his Medicare for all, single-payer reform plan, now backed by sixteen Democratic senators. More than anything, to make progress on reform of our dying health care system, the nation needs to get to a place where it can engage in serious conversations about such proposals.

I will reveal my personal position on single payer right off the bat. I am a fan, but not a disciple. I think, done well, single payer offers the best path forward. But I don’t think it is the only path possible. Nor do I think that single payer is guaranteed to work in this country. With all such things, the devil is in the details.

But that is the problem. In this country, we can’t get to the details.

We devolve immediately into superficial, silly labels and pointless posturing. We toss out concepts like “socialism,” “big government (or “government-run health care”),” and “free market” to support or detract from our positions, and the conversation ends. But that is not adequate. We need to give Berniecare (and all serious attempts to fix the American health care mess) far more serious consideration than that.

We need to take this single-payer plan seriously because it is the first proposal in recent memory that actually addresses, and possibly could even fix, some of the bigger problems in American health care. The American health care “system” is defined by three main problems. Too many people lack access to care. Health care costs too much, both for individuals, and for the nation as a whole. And American health care is low-quality care. It should be added that American health care is a bureaucratic and administrative nightmare for both patients and providers alike.

Obamacare was primarily an attempt to increase access to care. Results in that area have been mixed at best. It did not seriously address cost of care or quality of care issues. And administrative overkill and overload is a hallmark of the Obamacare era.

The more recent Republican health care reform proposals are not even in the ballpark. Millions of people would lose access to care, and many would pay more for their care. The Trump-Ryan-McConnell-Care proposals died a quick, well-deserved death.

Berniecare is a far more serious, and far-reaching, attempt to fix what is wrong with American health care than either Obamacare or the failed Republican plan. First of all, it solves the access issue. Under Berniecare, everyone is in the system. And from the patient’s perspective, the cost issue is solved, as well. One fee, a tax, pays for everything. So right off the bat, the two biggest issues in American health care, and two of the biggest stains on our nation’s moral character, are fixed. That should be enough to get everyone to give this proposal serious consideration.

But criticisms of a single-payer system, especially this version of single payer, which focus primarily on issues of cost and control of health care decision-making, and are more than just relevant. Successfully addressing these concerns is crucial to the success of the plan.

The cost issue is a thorny one. The traditional answer provided by single-payer advocates is that the administrative cost savings generated by going from our current for-profit multi-payer system to a single non-profit payer make universal coverage viable. If nothing else, at least a single-payer system has this specific mechanism to bring current costs (unnecessary ones) down. But there are many who say this would not be adequate.

Inextricably tied to that discussion are issues regarding what services get covered, who decides such things, how those decisions are made, and how the costs of those services will be controlled? Critics of a single-payer approach point to these issues more than anything else, fearing the heavy, inefficient hand of government. Single-payer advocates tend to brush these fears aside, but the fact is this is a legitimate and highly important issue (maybe the most important issue in this entire discussion). Excessive government bureaucracy has contributed as much as any other single factor to the ruination of American health care. Without profound reform, it will do the same thing to a single-payer system. Further, without a wholescale change in how we regulate health care, any approach to fix the system will be doomed to failure.

The answers are in the details, many of which we have yet to hear, but also many of which we may not have conceived of yet. Any plan, this one or any other approach that is going to successfully solve the issues of access, cost, and quality in health care will depend on such details. But we must get past the rhetoric, our incredible enmity, and simplistic labels to discuss such things.

I admit to being a fan of Senator Sanders. He is not compromised by huge insurance and pharmaceutical industry campaign donations, unlike essentially every one of his colleagues. He aspires, as anyone in his position should, to actually fix what is wrong, and he has the guts to risk his neck to get it done.

But I am not here to persuade you to like Senator Sanders (or single payer, for that matter). He has proposed a health care solution that, with the right details, I believe could be the fix that we need. But more importantly, if we hope to fix American health care, and we must do that, we need to get to a point where we can exchange ideas and debate the hard details that will make or break any legitimate approach.

Matthew Hahn is a family physician who blogs at his self-titled site, Matthew Hahn, MD.  He is the author of Distracted: How Regulations Are Destroying the Practice of Medicine and Preventing True Health-Care Reform.

Image credit:


View 52 Comments >

Most Popular

✓ Join 150,000+ subscribers
✓ Get KevinMD's most popular stories