Single-Minded

If you are one of those people who believes the government, rather than for-profit corporations, should provide all Americans with health insurance, then you haven't had much trouble finding evidence to support your view. "Single-payer" systems, as these schemes are known, don't fritter money away on marketing, profits, and the constant efforts insurers make to enroll only healthy, cheap-to-insure customers. Single-payer systems also offer free choice of doctor and hospital, a privilege your typical managed-care enrollee covets. Most important of all, the people who get insurance from single-payer systems seem to be rather happy. Just go ask the citizens of France, who enjoy a system that combines legendary convenience with cutting-edge cancer care. Or, closer to home, ask a senior citizen: Medicare, which covers virtually every American 65 and over, is a single-payer system of sorts; it is also, according to surveys, far more popular with its enrollees than private insurers are with theirs.

But, if you were hoping that Washington would take your views seriously, then you've probably been pretty disappointed. The votes for creating a single-payer system just don't exist on Capitol Hill. So, when Washington gets serious about reforming the nation's health care system, as it is right now, the single-payer crowd inevitably ends up on the margins. You can see it in the press coverage, as reporters, myself included, hype the work of lawmakers like Senator Ron Wyden, who has been pushing a bipartisan bill that would give everybody private insurance. Meanwhile, almost nobody bothers to interview Representative John Conyers, even though his single-payer bill has 90 co-sponsors--not enough to earn it passage, perhaps, but surely enough to earn it a place in the conversation.

For you, then, July 8 should have been a day to celebrate. That's when a coalition of heavyweight liberal organizations, from the Service Employees International Union (SEIU) to MoveOn.org, launched a campaign on behalf of universal coverage called "Health Care for America Now" (HCAN). With its $40 million budget, HCAN has embraced an agenda that goes well beyond the vague, mealy-mouthed principles typical of such efforts. According to HCAN, simply giving everybody a choice of health insurance plans, as Wyden's and many other mainstream reform proposals would do, isn't enough. It's critical that the choices include a public option--that is, an insurance program run by the federal government.

HCAN's agenda--which isn't a plan per se but a set of principles--doesn't go as far as traditional single-payer advocates would like. Instead of Medicare for All, as single-payer advocates describe their vision, it's Medicare for Anybody Who Wants It. But a scheme like the one HCAN envisions might someday become a true single-payer plan, if the public plan proves more attractive than private alternatives and everybody ends up enrolling in it on their own. And that probably wouldn't bother the scheme's proponents. The most well known is intellectual architect Jacob Hacker, a University of California-Berkeley political scientist (and occasional TNR contributor) who has argued passionately on behalf of universal, government-run programs like Medicare and Social Security. Along with the Campaign for America's Future, a liberal advocacy group that is also the driving force behind HCAN, Hacker talked up his idea to all three of the leading Democratic presidential contenders. Barack Obama not only included an optional public plan in his eventual blueprint for universal coverage; more recently, he also tapped Hacker to be on his campaign's health care advisory committee.

But the best-known advocates for single-payer coverage haven't shown much enthusiasm for this approach. And, when HCAN made its splashy debut, these groups made clear their ambivalence. As part of a daily dispatch from Physicians for a National Health Plan, a group that reports 15,000 members, Don McCanne sent out a statement bemoaning the inclusion of private plans. "Why did the coalition insist on including private plans when the industry's track record is so miserable?" McCanne asked. Another prominent member of the organization, Cambridge physician David Himmelstein, made an even blunter criticism. HCAN, he said, "is pushing a superficially attractive health reform that has a long record of failure--akin to prescribing a placebo for a serious illness when effective treatment is available." Meanwhile, the California Nurses Association, arguably the largest and most effective single-payer lobby out there, registered a similar line of complaint: Writing at The Huffington Post, the group's executive director, Rose Ann DeMoro, asked: "Why is Health Care for America Now giving up on real reform?"

Alas, this reaction wasn't surprising--except, perhaps, for its relatively respectful tone. A few months ago, during the Democratic primaries, the California Nurses' national arm launched a high-profile and caustic independent expenditure campaign targeting Hillary Clinton, making similar complaints about her health care plan--even though it, too, had a public insurance option. This time around, the California Nurses offered politic praise of HCAN's nod toward a public program (in part, perhaps, because the Nurses have since endorsed Obama). But it insisted the scheme still wouldn't work. "The insurance companies will always be able to lower their prices with cut rate plans with lower standards that they can aggressively market," Charles Idelson, the communications director, told me. "The upshot is that the private plans will likely be able to cherry-pick the younger and healthier patients while the sicker and older patients end up in the public plan, wrecking the whole idea of a risk pool and driving up the costs for the public plan to operate. The competition won't starve the private plans and cause them to wither away; they'll starve the public plans."

It's a reasonable worry. In the United States, the federal government has managed to maintain Medicare as a relatively vibrant and popular program, despite private competition promoted by conservatives who would just as soon see Medicare vanish. But it's been a constant struggle, one the government has waged only by funding the program adequately and by keeping very close watch over the private competitors, to make sure they don't destabilize Medicare by playing precisely the sorts of games that Idelson describes. For a program like the one HCAN is backing to work, the same thing must happen: Government will need enough money and regulatory power to keep the private plans in line, an idea that is virtually anathema to many conservatives and corporate lobbies, who grasp that a robust public plan might someday cripple the insurance industry.

Countering that free-market faith will require an extraordinary political effort. And the effort must begin now, because a broad, if highly fragile, consensus over how a universal coverage program might work is already emerging. You can see it in Wyden's bill, which has a bona fide conservative champion in Utah Senator Bob Bennett and counts six other Republicans among its co-sponsors. But the Wyden-Bennett bill wouldn't offer Americans the option to enroll in a public plan. SEIU president Andy Stern, whose voice on health care carries considerable weight in Washington, thinks the only way to move the consensus and win creation of a public plan option is through a large grassroots effort. And, since single-payer advocates include some of health care's most dedicated activists--the kind willing to spend days knocking on doors, churning out e-mails, and organizing rallies--they could make a real difference. "Their unique role, if they're inclined to do it, is to guarantee the public option that Obama has in his plan, which will be an incredibly hard fight," says Stern.

Even if that crusade ultimately fails, it might tip the political balance enough to make the difference between a strong version of something resembling the Wyden-Bennett bill--say, one with rich benefits and real protections for consumers--and a weak one. But first single-payer advocates would have to embrace impure and, yes, imperfect versions of their ideal health reform. And that's not something for which they've traditionally shown much interest.

During the last great debate over universal coverage, in 1993 and 1994, single-payer advocates wanted nothing to do with a system that dropped so many into private insurance. That lack of enthusiasm was not the only or even the primary reason that the Clinton health care plan failed. But it certainly didn't help that, once critics of the plan went on the attack, the most heartfelt advocates for universal coverage were content to watch the fight from afar.

In this latest debate over universal health insurance, single-payer advocates don't have the same monopoly on passion and commitment they did last time around. But they could still be a significant and most welcome part of this campaign, if only they would enlist.

Jonathan Cohn is a senior editor of The New Republic.