“Single-payer healthcare” is the standard name for one of the contestants in the perennial dispute in the U.S. about how medical care may best be financed.  The idea is that a system financed by taxes (and administered either at the federal or the state level, or some mixture of the two) should pay the costs of essential care for all residents (or perhaps all lawful residents), essentially eliminating most of the private health insurance market.

The term ”single payer” does not imply that the health care providers themselves are to become employees of the government at either level, or even of quasi-public entities such as the various entities that together comprise the National Health Service in the United Kingdom.

The presumption, rather, is the other way. The provision of health care will remain a private market under most proposals, but the financing thereof will become a public responsibility.

Right Wing View

One standard objection to government involvement in health care, either in its provision or its financing, was well stated recently by Per Bylund on twitter. “The problem with government is there’s no market valuation of output, so focus must be on cost. Thus, higher cost = more, ‘better’ output?”

The latest twist in the debate over single payer arose due to the Republican Party’s difficulties (despite its majority in both halves of the legislature, and of course despite the fair-weather support of the occupant of the White House) in coming together behind any single plan to replace Obamacare should they manage to repeal it. This inability has meant that Obamacare has not been repealed and it remains the law of the land.

The now-customary use of “continuing resolutions” in lieu of old-fashioned budgets effectively makes the end of September the deadline for any action on the subject this year. As the days ticked down, it became clear that the last hope of Republican unity was the  Cassidy-Graham bill, which seeks to replace Obamacare with a system of federal block grants to the states, allowing the states to choose the more specific health care financing arrangements the want.

But, while the leadership was busy trying to cast this bill in the way most appealing to the various factions in their party, it seems to have occurred to some that a state could use its grant money to finance its own single payer system. In the words of Sen. John Kennedy (R-La.), “I think if you give a big chunk of money to California they’re going to go set up a single-payer system run by the state and then come back and say, ‘We don’t have enough money. We need more.’”

The Cassidy-Graham bill, were it outfitted with an amendment prohibiting states from attempting a single-payer program, would be an odd hybrid beast.  After all, Senators Lindsey Graham (R – SC), Bill Cassidy (R-La), and others have been trying to sell this bill precisely on the ground that it respects federalism, the prerogative of states to go their own way within their own domain.

Left Wing View

Senator Bernie Sanders (I- VT), who was of course Secretary Hillary Clinton’s opponent in the Democratic Party’s primary season in 2016, has put forward a specific single payer plan in recent days. The plan would extend Medicare to the whole population, and it would make Medicare much more generous in the process, eliminating co-pays and deductible and adding benefits.

In terms of the immediate fight over Obamacare on the one hand and various Republican ideas on the other, Sanders stands with Obamacare. Any of the proposals under serious consideration by Republican leadership would from his point of view be a serious step back.

A self-described “neoliberal shill” on twitter, Shannon, put the connection of ideas here well:


There are Democrats, though, who believe the recent hype over Sanders’ proposal may have done some harm to the cause of saving Obamacare.

Elana Schor, in Politico, quoted in this connection Sen. Tom Carper (D-Del.) who himself was quoting an unnamed Methodist minister who once told him, “The main thing is to keep the main thing the main thing.”

So while Republicans argue over whether federalism requires that they allow single payer in blue states, Democrats argue over whether defending Obamacare, rather than single payer, is still their “main thing”.