In an instant viral moment, the American public finally began to sense the audacity, and scope, of liberals’ ambitions for our health care. In a town hall broadcast on CNN, presidential candidate Sen. Kamala Harris (D-CA) discussed her co-sponsorship of legislation introduced by Sen. Bernie Sanders to create a single-payer health system. Moderator Jake Tapper asked about provisions in Sanders’s bill that would prohibit people from keeping their private insurance coverage. She responded:
Well listen, the idea is that everyone gets access to medical care. And you don’t have to go through the process of going through an insurance company, having them give you approval, going through the paperwork—all of the delay that may require. Who of us has not had that situation, where you’ve got to wait for approval, and the doctor says, “Well, I don’t know if your insurance company is going to cover this.” Let’s eliminate all of that. Let’s move on.1
In other words, if you like your plan, go jump in a lake.2
Harris’s comments did not surprise analysts who closely follow single-payer legislation. But it shocked plenty of Americans, who may wrongly believe they could keep their coverage under such a system. A January 2019 survey found that 55% of Americans considered participation in such a system “optional.”3 Those numbers echoed an earlier study, conducted in October 2017, which found 47% of Americans—and a majority (52%) of Democrats—believed they could “keep their current health insurance” as part of a “national health plan.”4
Other polling indicates that support for a single-payer system drops substantially when individuals realize the dramatic implications. A Kaiser Family Foundation poll from January 2019 found that support for single payer fell by 21 percentage points when Americans realized it would “eliminate private health insurance companies.” Approval numbers fell even more when interviewers suggested that the plan would require sizable tax increases (23%), jeopardize the current Medicare program (28%), or lead to delays in accessing treatment (44%).5
The organization that conducted the survey, the Kaiser Family Foundation, has a decidedly liberal bent. For instance, Kaiser surveys have touted Obamacare’s benefits while minimizing the law’s costs and drawbacks.6 That even a liberal organization found such a dramatic change in public opinion on single payer speaks to the disquiet among Americans when they discover the true implications of such a scheme.
Not so long ago, Democrats felt the need to reassure Americans that they would not lose their current coverage. When selling his health plan on the presidential campaign trail in 2008, and while trying to convince Congress to pass Obamacare in 2009 and 2010, Barack Obama repeatedly promised Americans that “If you like your plan, you can keep it.” One video shows Obama making that pledge on 36 separate occasions.7
Obama made his “like your plan” promise in large part because similar concerns had helped sink “Hillarycare”—the health-care proposal put forward by Bill and Hillary Clinton in 1993-94. The famous “Harry and Louise” ad campaign at the time warned that “the government may force us to pick from a few health care plans designed by government bureaucrats”; one ad ended with the refrain, “They choose—we lose.”8 Mindful of the implosion of the Clinton plan under a Democratic Congress, Obama felt the need to provide constant reassurance that his legislation would not upset Americans’ current arrangements.
Of course, Obama’s promise ended up proving untrue, as few Americans can forget. At least 4.7 million Americans received cancellation notices in 2013, when insurers started ripping up old policies before Obamacare’s major provisions took effect in January 2014.9 But with healthcare.gov in an online meltdown—Kathleen Sebelius, Obama’s own secretary of Health and Human Services, called the website a “debacle”—these individuals lost their existing plans with no ability to buy a replacement.10
Eventually, Obama offered an apology for the “like your plan” fiasco. In a November 2013 interview, he said, “I am sorry that [people] are finding themselves in this situation based on assurances they got from me.”11 He issued his apology in the face of unstinting criticism. PolitiFact called the “If you like your plan” pledge its “Lie of the Year” for 2013.12 The administration attempted to save face, and help Americans struggling to find replacement coverage, by allowing states to keep certain plans intact, even though some legal experts believe Obama (and President Trump after him) violated their constitutional duties to uphold the law by keeping these plans in place.13
But as the saying goes, that was then, and this is now. While just a few years ago, President Obama went to great—what some have called unconstitutional—lengths to avoid cancelling the insurance policies of a few million individuals as Obamacare went into effect, the single-payer legislation that many Democratic presidential candidates now support would cancel the insurance coverage of a few hundred million Americans.
Section 107 of the House and Senate bills makes clear that under a single-payer system, the government health plan will serve as the only option for Americans’ health coverage:
(a) IN GENERAL.—Beginning on the effective date described in section 106(a), it shall be unlawful for—
(1) a private health insurer to sell health insurance coverage that duplicates the benefits provided under this Act; or
(2) an employer to provide benefits for an employee, former employee, or the dependents of an employee or former employee that duplicate the benefits provided under this Act.14
The legislation prescribes a health coverage “Big Bang”—an effective date, two years after enactment in the House bill, and four years after enactment in the Senate bill, after which all existing health coverage “shall be unlawful.” Yet, ironically enough, Sanders claims that his bill offers “freedom of choice.”15 If making coverage “unlawful” constitutes “freedom of choice,” just imagine what coercion might look like.
When calculating who would lose their current coverage under single payer, it makes more sense to delineate the few people allowed to keep their existing arrangements. Section 901(d) provides that nothing in the House and Senate bills “shall affect the eligibility of veterans for the medical benefits and services” provided by the Department of Veterans Affairs, “or of Indians for the medical benefits and services provided by or through the Indian Health Service.”16 According to the most recent data, approximately 9.3 million enrolled veterans receive care through the VA, and 2.3 million Native Americans receive coverage through the Indian Health Service.17 Only these individuals could keep their existing health coverage under current single-payer proposals.
As to who would lose their health coverage, those totals include the following:
Some of the above numbers overlap—because Tricare and the Federal Employee Health Benefits Program also qualify as employer coverage, and because individuals may hold multiple forms of coverage (e.g., Medicare and Medicaid, or Medicare and coverage from a former employer). But of 323 million Americans, only about 11 million in the VA or Indian Health Service systems would retain their current health arrangements.24
In addition, because the newest version of the House legislation also includes benefits for long-term care, the 7.2 million individuals who purchased long-term care insurance will also see their coverage cancelled.25 For instance, my mother purchased a long-term care insurance policy some years ago, to provide both me and her financial protection should she ever need nursing home care. Although she has paid tens of thousands of dollars in premiums on the policy over several decades, passage of the House single-payer bill would render her policy worthless and “unlawful.”
While Americans have concerns about U.S. health care markets, most like their existing insurance plans and have for quite some time. In November 2018, a Gallup poll found that nearly seven in ten Americans considered their health coverage either excellent (27%) or good (42%).26 Over the 18 years Gallup has conducted the survey, the number of Americans considering their health coverage either good or excellent has never slipped below 63%.27
Would patients still have an opportunity to opt out of the single-payer system, notwithstanding the prohibition on private insurance coverage for any benefit provided by the government system? With single payer, the exception may prove the power of the rule.
The single-payer bills do allow providers to opt out of the government system, but at a very high cost. While the specifics vary in the House and Senate bills, both pieces of legislation would prohibit providers who participate in the government system from entering into any private contract with any eligible individual for any covered item or service.28 Providers wishing to contract privately must obtain written consent in which patients must agree to accept full financial responsibility for those services—and providers must agree not to participate in the government system at all.29
To put it another way, patients who want private care must find a doctor who treats private patients only, because physicians who operate in the government system cannot treat patients privately, period, except for non-covered services like cosmetic surgery. This restriction far exceeds those in place in Britain’s single-payer health system, where doctors who work for the National Health Service (NHS) during the day can and do moonlight as private practitioners, without giving up their right to participate in the government system.30
Given the onerous restrictions on private contracting included in the House and Senate single-payer legislation, several likely scenarios follow should either bill get enacted into law:
These restrictions, and the implications of them, raise obvious questions. If single payer will produce the socialist paradise Sanders and his supporters claim, why do they impose so many restrictions on people who wish to opt out of the system? Does Sanders want to compel millionaires to use the government-run health program as a form of punishment?
An obscure tidbit of history provides a useful analogy to the restrictions on private contracting in the single-payer bills. The barrier around the German capital that Western democracies called the Berlin Wall had a far different name in Communist-run East Germany: The Anti-Fascist Protection Rampart. Despite all the obvious evidence to the contrary, the East German government claimed that the wall they built functioned not to imprison their citizens, but to keep others from entering the country to enjoy the Communist “paradise.” Perhaps Sanders, who has a rhapsodic history with the Communist Eastern Bloc, borrowed this idea from the East Germans—to prevent few Americans from missing the “joy” of his socialist “paradise.”32
Regardless of the motivation behind these restrictions on private contracting, it seems clear that even millionaires, and some multi-millionaires, will likely have to use the single-payer system for at least some of their health needs. Billionaires such as Mark Zuckerberg can afford to pay out-of-pocket for all their health care, no matter its cost. (Zuckerberg could build a hospital just to treat himself, if he wished.) But individuals with a net worth of $1 million, or even $5 million or $10 million, could not afford to fund all their care themselves if they got leukemia or their family was involved in a horrible car crash.
Liberals see this characteristic of single payer as a feature: All, or nearly all, individuals would receive the same care, under the same system. But common sense would view this movement for universality as a bug. After all, creating a single-payer system would require more than doubling current federal income tax rates.33 Why should individuals of modest means, who almost certainly will have to pay some of the costs associated with this massive new government scheme, face higher taxes so the federal government can fund the health care of millionaires and other people in the “one percent”?
In banning private insurance outright, Democrats’ single-payer bill would far exceed practices in other countries, even countries with single-payer systems. Great Britain, for instance, permits private health insurance, which has fairly widespread take-up. As of 2015, just more than 10% of the population held private health insurance, 3.94 million policies in all.34 Some employers provide private insurance as a benefit to their workers, while other individuals purchase coverage themselves.35 Either way, private insurance provides supplemental benefits, whether paying for drugs that the NHS will not cover, or funding care—such as specialist consultations or non-emergency surgery—subject to long waits within the government-run system.36
Likewise, Canada’s single-payer system, also called Medicare, relies heavily on private health insurance. All told, about 25 million Canadians, or roughly two-thirds of Canada’s population, hold some form of private health coverage.37 Because Canada’s federal government does not require provincial health systems to cover outpatient prescription drugs, most individuals obtain some form of health insurance to fund these and other supplemental benefits.38
Unlike the health plans funded by the Canadian and British governments, the single-payer system proposed by Sanders and Rep. Pramila Jayapal presumes to provide every possible service to every American, and at no out-of-pocket cost to them, giving the sponsors their justification to ban private health insurance. But over and above the philosophical issues associated with banning private health insurance—Why shouldn’t individuals be able to buy supplemental or private coverage if they want it?—comes an important logistical question: Can a government-run system cope on its own?
The examples of countries like Canada and Britain suggest that a system that banned private health insurance entirely would face two complementary problems. Would the government system have the money, and the capacity, to fund all medical procedures for all individuals? One American health care expert wrote that he didn’t understand the need for private insurance in Britain, until an NHS manager explained that private care provides a pressure-relief valve for the government-run system:
All the people using the private system have already paid their taxes, so they are siphoning volume out of the NHS that the system otherwise would have to manage….The NHS would come to a grinding halt if private practice went away.39 [Emphasis added.]
By banning private insurance outright, the single-payer bills would not just infringe on American citizens’ freedom to buy the health coverage they desire. That prohibition would also place tremendous financial and capacity pressures on the government-run system, which it likely could not handle.
In 2000, the late-night show Saturday Night Live broadcast a famous sketch, entitled “More Cowbell,” in which a record producer played by Christopher Walken asks the band Blue Oyster Cult to “crank up” the cowbell sound in the recording studio. Walken’s character says: “I got a fever—and the only prescription is more cowbell.”40
That “more cowbell” attitude describes liberals’ attitude about government size to a T. To them, liberals’ belief in “progress” means an ever-expanding role for government. As Ronald Reagan famously quipped about the Left’s view of the economy: “If it moves, tax it. If it keeps moving, regulate it. And if it stops moving, subsidize it.”
Having passed Obamacare with 60 votes in the Senate, Democrats could have put whatever they wanted into the legislation to control health-care costs. Yet premiums continue to rise inexorably higher: More than 2.5 million individuals dropped Obamacare plans in one year alone, most because they could not afford their premiums.41
In view of this clear failure, what do Obamacare supporters propose? More spending on subsidies and more regulation of insurers and prices, or proposals for an entirely government-run system. Government caused the problem, so obviously more government will lead to a solution!
Therein lies the left’s siren call: Just give us more power, and we’ll solve all your problems for you. Yet somehow, the power the Left receives always proves insufficient to accomplish its stated goals.42
The single-payer plan amounts to liberals’ most audacious power grab yet: taking away the health coverage of nearly 300 million Americans. One-fifth of them—the seniors and individuals with disabilities covered by the current Medicare program—may especially find “Medicare for All” much less alluring than its proponents want them to believe.
1 CNN Town Hall with Sen. Kamala Harris, January 28, 2019, http://www.cnn.com/TRANSCRIPTS/1901/28/se.01.html.
2 Chris Jacobs, “Kamala Harris Reveals That Medicare for All Involves Ending All Private Insurance,” The Federalist, January 31, 2019, http://thefederalist.com/2019/01/31/kamala-harris-reveals-medicare-means-ending-private-insurance/.
3 NORC, “NORC AmeriSpeak Omnibus Survey: Knowledge about Medicare for All Remains Low and People’s Views Differ on What the Policy Would Do,” January 24, 2019, http://www.norc.org/PDFs/ASonHealth/20190123_MedicareforAll_Topline.pdf, p. 5.
4 Ashley Kirzinger, et al., “Data Note: Public’s Views of a National Health Plan,” Kaiser Family Foundation, October 25, 2017, https://www.kff.org/health-reform/poll-finding/data-note-publics-views-of-a-national-health-plan/.
5 Ashley Kirzinger, Cailey Munana, and Mollyanne Brodie, “KFF Health Tracking Poll—January 2019: The Public on Next Steps for the ACA and Proposals to Expand Coverage,” Kaiser Family Foundation, January 23, 2019, https://www.kff.org/health-reform/poll-finding/kff-health-tracking-poll-january-2019/.
6 Chris Jacobs, “Politico Reporter’s ‘Fact Check’ on President Trump on Health Care Is Riddled with Omissions,” The Federalist, September 24, 2018, http://thefederalist.com/2018/09/24/politico-reporters-fact-check-president-trump-health-care-riddled-errors/; Chris Jacobs, “What Liberals Won’t Tell You about Pre-Existing Conditions,” The Federalist, June 28, 2018, http://thefederalist.com/2018/06/28/liberals-wont-tell-pre-existing-conditions/.
7 “36 Times Obama Said You Could Keep Your Health Care Plan,” Washington Free Beacon, November 5, 2013, https://www.youtube.com/watch?v=qpa-5JdCnmo.
8 “Harry and Louise on Clinton’s Health Plan,” https://www.youtube.com/watch?v=Dt31nhleeCg.
9 Associated Press, “Policy Notifications and Current Status, by State,” December 26, 2013, https://finance.yahoo.com/news/policy-notifications-current-status-state-204701399.html.
10 David Nather, “Sebelius Struggles to Clean Up,” Politico, October 30, 2013, https://www.politico.com/story/2013/10/kathleen-sebelius-obamacare-099115.
11 Chuck Todd, “Exclusive: Obama Personally Apologizes for Americans Losing Health Coverage,” NBC News, November 7, 2013, https://www.nbcnews.com/news/us-news/exclusive-obama-personally-apologizes-americans-losing-health-coverage-flna8C11555216.
12 Angie Drobnic Holan, “Lie of the Year: ‘If You Like Your Health Care Plan, You Can Keep It,’” PolitiFact, December 12, 2013, https://www.politifact.com/truth-o-meter/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/.
13 Centers for Medicare and Medicaid Services, Letter to State Insurance Commissioners regarding transitional plan arrangements, November 14, 2013, https://www.cms.gov/CCIIO/Resources/Letters/Downloads/commissioner-letter-11-14-2013.PDF; Nicholas Bagley, “Legal Limits and the Implementation of the Affordable Care Act,” University of Pennsylvania Law Review, December 1, 2016, https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2721391, pp. 1722-23.
14 Section 107(a) of H.R. 1384 and S. 1129, the Medicare for All Act of 2019.
15 Holly Otterbein, “Sanders Takes on Fox—And Emerges Triumphant,” Politico, April 15, 2019, https://www.politico.com/story/2019/04/15/bernie-sanders-millionaire-no-apology-1277009.
16 Section 901(d) of H.R. 1384 and S. 1129.
17 Department of Veterans Affairs, “Fiscal Year 2020 Budget in Brief,” March 2019, https://www.va.gov/budget/docs/summary/fy2020VAbudgetInBrief.pdf; Indian Health Service, “IHS Profile,” Departmental fact sheet, July 2018, https://www.ihs.gov/newsroom/factsheets/ihsprofile/.
18 Edward Berchick, Emily Hood, and Jessica Barnett, “Health Insurance Coverage in the United States: 2017,” Census Bureau Report P60-264, September 2018, https://www.census.gov/content/dam/Census/library/publications/2018/demo/p60-264.pdf, Table 1, Coverage Numbers and Rates by Type of Health Insurance: 2013, 2016, and 2017, p. 4.
19 Ashley Semanskee, Larry Levitt, and Cynthia Cox, “Data Note: Changes in Enrollment in the Individual Health Insurance Market,” Kaiser Family Foundation, July 31, 2018, https://www.kff.org/health-reform/issue-brief/data-note-changes-in-enrollment-in-the-individual-health-insurance-market/.
20 Centers for Medicare and Medicaid Services, “December 2018 Medicaid and CHIP Enrollment Data Highlights,” https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html. Unlike the House bill, Section 204 of S. 1129 would keep a limited role for state Medicaid programs in providing institutional long-term care (i.e., nursing home) services. However, in both the House and Senate bills, the federal single-payer program would assume delivery of all health care services for Medicaid beneficiaries.
21 Defense Health Agency, “Tricare: Number of Beneficiaries,” January 4, 2019, https://www.tricare.mil/About/Facts/BeneNumbers.aspx.
22 Alan Spielman, “Federal Benefits Open Season Begins,” Office of Personnel Management Director’s blog, November 16, 2017, https://www.opm.gov/blogs/Director/2017/11/16/Federal-Benefits-Open-Season-Begins/.
23 Centers for Medicare and Medicaid Services, “Medicare Enrollment Dashboard,” December 2018, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Dashboard/Medicare-Enrollment/Enrollment%20Dashboard.html.
24 Berchick, “Health Insurance Coverage,” Table 1, p. 4.
25 Section 204 of H.R. 1384; Marc Cohen, “The State of the Long-Term Care Insurance Market,” in National Association of Insurance Commissioners, The State of Long-Term Care Insurance: The Market, Challenges, and Future Innovations, May 2016, https://naic.org/documents/cipr_current_study_160519_ltc_insurance.pdf, Table 1, Key Industry Parameters, p. 8. The Senate bill would subsume home and community-based services—but NOT institutional long-term care services—into the single-payer program, making the status of privately purchased long-term care policies under that regime unclear.
26 Gallup, “Health Care System,” https://news.gallup.com/poll/4708/healthcare-system.aspx.
27 Ibid.
28 Section 303 of H.R. 1384 and S. 1129.
29 Ibid. Section 303(b) of the House bill contains provisions allowing participating providers to provide non-covered services to patients via private contracts, provided appropriate disclosure occurs. However, because the government system prescribes a very generous benefit package, it appears that providers would have few opportunities to provide non-covered services, cosmetic surgery being the sole likely scenario.
30 David Oliver, “Private Practice by NHS Doctors—Still Controversial?” BMJ, August 14, 2018, https://www.bmj.com/content/362/bmj.k3480.
31 Shefali Luthra, “Fueled by Health Law, ‘Concierge Medicine’ Reaches New Markets,” Kaiser Health News, January 14, 2016, https://khn.org/news/fueled-by-health-lawconcierge-medicine-reaches-new-markets/.
32 Michael Kranish, “Inside Bernie Sanders’ 1988 10-day ‘Honeymoon’ in the Soviet Union,” Washington Post, May 3, 2019, https://www.washingtonpost.com/politics/inside-bernie-sanderss-1988-10-day-honeymoon-in-the-soviet-union/2019/05/02/db543e18-6a9c-11e9-a66d-a82d3f3d96d5_story.html?utm_term=.220bf92174da.
33 Charles Blahous, “The Costs of a National Single Payer Health Care System,” Mercatus Center, July 30, 2018, https://www.mercatus.org/system/files/blahous-costs-medicare-mercatus-working-paper-v1_1.pdf.
34 Quoted in Ruth Thorlby and Sandeepa Arora, “The English Health Care System,” in Elias Mossialos, et al., eds., International Profiles of Health Care Systems, Commonwealth Fund, May 2017, https://www.commonwealthfund.org/sites/default/files/documents/___media_files_
publications_fund_report_2017_may_mossialos_intl_profiles_v5.pdf, p. 49.
35 Robert Wachter, “The Awkward World of Private Insurance in the U.K.,” The Health Care Blog, January 16, 2012, https://thehealthcareblog.com/blog/2012/01/16/the-awkward-world-of-private-insurance-in-the-uk/.
36 King’s Fund, “The UK Private Health Care Market: Appendix to the Commission on the Future of Health and Social Care in England,” 2014, https://www.kingsfund.org.uk/sites/default/files/media/commission-appendix-uk-private-health-market.pdf.
37 Canadian Life and Health Insurance Association, “Canadian Life and Health Insurance Facts: 2018 Edition,” https://www.clhia.ca/web/clhia_lp4w_lnd_webstation.nsf/resources/Factbook_2/$file/2018+FB+EN.pdf, p. 14.
38 Sara Allin and David Rudoler, “The Canadian Health Care System,” in Mossialos, et al., International Profiles, pp. 21-22.
39 Wachter, “The Awkward World.”
40 Video available at https://www.youtube.com/watch?v=cVsQLlk-T0s.
41 Semanskee, Levitt, and Cox, “Changes in Enrollment.”
42 Chris Jacobs, “Obama-Supporting Think Tank Admits Obamacare Has Failed, Recommends Doubling Down,” The Federalist, July 20, 2018, http://thefederalist.com/2018/07/20/obama-supporting-think-tank-admits-obamacare-failed-recommends-doubling/.