In short, the evidence is clear that single-payer delivers quality care at significantly lower cost than the current American hybrid system. It thus makes no sense to reject single-payer on the grounds that it would require higher tax revenues. That’s true, of course, but it’s an irrelevant objection.
In addition to being far cheaper, single-payer would also defuse the powerful political objections to the Affordable Care Act’s participation mandate. Polls consistently show that large majorities want people with pre-existing conditions to be able to obtain health coverage at affordable rates. But that goal cannot be achieved unless healthy people are required to join the insured pool. Officials in the Obama administration tried, largely in vain, to explain why the program’s insurance exchanges would collapse in the absence of the participation mandate.
But the logic of the underlying argument is actually very simple. Most people seem able to grasp it if you ask them what would happen if the government required companies to sell fire insurance at affordable rates to people whose houses had already burned down.
No home insurer could remain in business if each policy it sold required it to replace a house costing several hundred thousand dollars. Similarly, no health insurer could remain in business if each of its policy holders generated many thousands of dollars in health care reimbursements each month.
That’s why the lack of a mandate in the alternative plans under consideration means that millions of people with pre-existing conditions will become uninsurable if repeal efforts are successful. An underappreciated advantage of the single-payer approach is that it sidesteps the mandate objection by paying to cover everyone out of tax revenue.
Of course, having to pay taxes is itself a mandate of a sort, but it’s one the electorate has largely come to terms with. Apart from fringe groups that denounce all taxation as theft, most people understand that our entire system would collapse if tax payments were purely voluntary.
The Affordable Care Act is an inefficient system that was adopted only because its architects believed, plausibly, that the more efficient single-payer approach would not be politically achievable in 2009. But single-payer now enjoys significantly higher support than it did then, and is actually strongly favored by voters in some states.
Solid majorities nationwide now favor expansion of the existing single-payer elements of our current system, such as Medicare and Medicaid. Medicaid cuts proposed in Congress have been roundly criticized. Perhaps it’s time to go further: Individual states and, eventually, the entire country, can save money and improve services by embracing single-payer health care.
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