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The Case for Single-Payer in a Pandemic

Free, universal health care would not have stopped the coronavirus, but it would have protected the poor and vulnerable.

Mark Wilson/Getty Images

Single-payer supporters, myself included, have argued that the coronavirus pandemic demonstrates the flaws of America’s private insurance system, and that this system is hampering the nation’s ability to fight the virus. Conversely, single-payer opponents like Joe Biden have repeatedly argued that single-payer will not “solve” the coronavirus pandemic. On Twitter, the president of the Center for American Progress, Neera Tanden, recently admonished a pro-Medicare for All commenter: “You might want to check out the death rate in France before you think the form of health system is the answer here.” In another tweet, Tanden said she doesn’t “think the health care payment system and the ways a country fight [sic] the virus is correlated.”

This is exactly the sort of hand-waving deflection you would expect from people whose campaigns or careers depend on defeating single-payer and the politicians who support dramatically reforming our own broken system. It’s true that it’s hard to see direct correlations between a country’s health care payment system and its success in fighting a virus, in part because the United States’ health care system is so uniquely insane and unequal among developed nations. You can certainly say that single-payer wouldn’t by itself ensure that the United States’ coronavirus response was adequate, since there are other factors that are just as important. Social distancing measures have proven to be a vital part of the coronavirus mitigation strategy, as have testing regimes and broader questions of pandemic preparedness. Perhaps having Donald Trump as your head of state renders any best practice moot.

Nevertheless, it is hard to argue that ensuring universal coverage, something that Biden’s plan explicitly does not ensure, would not improve our ability to respond to this crisis, if for no other reason than the fact that it would provide the means by which a gravely sick person could go to a doctor or a hospital emergency room to get treatment without going into bankruptcy. The same could be said of a health care system that would have broadly assured that people could receive comprehensive treatment for any of the number of pre-existing medical conditions that exacerbate Covid-19 without encountering roadblocks, like the high deductibles that perversely incentivize consumers to not seek medical advice. It would have improved our response to the pandemic, as well as society more broadly, if these barriers—which are for all intents and purposes additional taxes on the working and middle classes—did not exist.

Single-payer advocates would indeed be hard-pressed to argue that such a reform would be some sort of silver bullet against the coronavirus. Similarly, paid sick leave would be similarly unable to “fix” the coronavirus pandemic on its own—yet you don’t see liberals offering the same resistance. The two policies share this in common, however: There is no reason to think things would not have been vastly better had they been in place before all this happened.

Part of the problem of comparing America’s experience to other countries, like France, is that it’s quite difficult to find a developed country that does health care as poorly as the United States, including both countries that have handled coronavirus well and those that have handled it poorly. Germany, a country with a multi-payer system but where only 11 percent of the populace has private insurance, has one of the lowest fatality rates. Italy has a health system where most are covered by government insurance, but the crisis has been particularly dire as hospitals in its wealthier northern regions have been absolutely crippled by the virus. South Korea, meanwhile, has a single-payer system and swiftly implemented some of the most aggressive and successful testing measures anywhere in the world, limiting the virus’ spread and yielding low fatality rates. Overall, Western Europe is a couple weeks ahead of the U.S. in its outbreak, but we appear to be faring worse than they were at this stage.

Assuming undeserved good faith on the parts of single-payer critics, let’s address the idea that the existence of private players in other countries’ health systems means that the U.S. could or should replicate this. The fact that Germany handles health care far better than we do does not mean that its small private insurance market is the reason for that success. A German study this year found that there were more doctors’ practices established in areas with higher rates of private insurance—which is largely for the wealthy—because private insurers pay doctors more, just like in the United States, and that bringing healthier privately insured people into the public system would reduce premiums for everybody. (Even the Medicare for All bill proposed by Bernie Sanders would not ban private insurance outright; it would simply ban private insurers from covering anything that the government plan offered, from doctor’s visits to MRIs; private insurers would be free to cover extra things like private hospital rooms or gym memberships.)

These arguments about how the United States could maintain a multi-payer system because other countries do it fail to grapple with the fact that other countries don’t have anything like our private insurance industry: Gigantic, multi-billion dollar corporations that cover more than half the country and have an iron grip on our politicians, in addition to hospitals that are used to charging hundreds or thousands more than other countries charge for their procedures. (The maximum co-payment for a procedure in Italy is $48, which is less than some American hospitals charge for a single ibuprofen.)

You cannot turn United Healthcare into a German-style nonprofit sickness fund (and none of the presidential candidates who opposed Medicare for All proposed anything like this anyway, most likely because the same health care industry interests would have opposed it just as vociferously). Even if you’re a cheerleader for the German system, at some point you face the same obstacle as single-payer advocates: If you want to fix health care in America, you have to beat down the private insurance companies to a fraction of their former selves. You can either do that through single-payer and cover everybody, or you can try to trick them into strangling themselves through trying to compete with a public option—and hope that it’s not the public option that dies first.

More savvy proponents of the public option method at least pretend to think that the latter is possible, that everyone agrees single-payer is the goal but a public option is the smartest way to “get there.” This is what Elizabeth Warren argued when she proposed passing a strong public option first, then trying again to pass Medicare for All in her third year as president. It’s even what Pete Buttigieg claimed to believe, at least initially, describing his public option as a “glide path” to Medicare for All. Others state flatly that single-payer is not attainable, even if it would be preferable, and a public option is the best America can reasonably expect. It is not often that leftists put more faith in America’s ability to achieve things than liberals.

Biden and his allies don’t make these arguments; they simply criticize single-payer on the merits, whether that’s by saying it would cost too much or by reiterating that it would not by itself have prevented coronavirus. (Meanwhile, the Republican president mused about how “unfair” it is that 30 million people are uninsured during the pandemic, and added expanding Medicaid or Medicare to his list of things he was Looking At Very Strongly, along with birthright citizenship and low-flow toilets.) But it is plainly true that addressing the virus would have been easier if everyone had high-quality health insurance that they could actually use. It is equally obvious that if you want to address a pandemic, a system in which there are no cracks for people to fall through is better than one in which we ensure that such mile-wide cracks persist solely for the sake of keeping private health insurers profitable.

A few idiots, including Madonna, Politico, and New York Governor Andrew Cuomo, have referred to the virus as the “great equalizer.” This is very stupid, and the more data we obtain, the stupider we realize it is: New York City’s low-income areas are being hit harder, for example, and there are shocking racial disparities in Covid-19 cases so far. In Chicago, 72 percent of those who have died from the virus were black, despite black people making up less than a third of the population there. Health problems like diabetes and heart disease that make patients more vulnerable to complications from the virus are more prevalent among black people.

Black people are a little more likely to be uninsured than white people, and Hispanic people are almost twice as likely to be uninsured; the Medicare for All bill proposed by Bernie Sanders would go so far as to cover undocumented immigrants. According to a Brookings Institution report from this February, around half of the country’s 30 million uninsured (a figure that could double over the next few months as millions lose their employer-provided insurance) are people of color. But the benefits of single-payer would not only be limited to the uninsured: It would also greatly improve upon existing public plans like Medicaid, eliminating the possibility that recipients could lose their insurance through administrative errors or earning too much. Currently, 62 percent of white people have private coverage, compared with under 50 percent for black people; 25 percent of black people have Medicaid or CHIP, compared with just 9 percent for white people.

The pandemic has rather neatly exposed the durability and perniciousness of the racial gaps in our health care system. Single-payer would not fix these gaps entirely, since they also result from minorities receiving worse treatment; a biotech data firm looked at billing data and found that black patients presenting with Covid-19 symptoms like a cough were less likely to be referred for a test. Single-payer might not have ensured more of them were, but it would do a tremendous amount to ensure that people of all races can actually go to the doctor at all, which is not nothing. One lesson that single-payer advocates would be well-served to take away from this crisis is how important it is to lower the financial barriers to medical school, or making it entirely debt-free, to ensure greater representation of minorities and people from lower income backgrounds in the health care profession.

Perhaps the pandemic is a better argument for a full-blown government health care system like the United Kingdom’s National Health Service (NHS), as opposed to a single-payer system. The too-little-too-late coordination of resources among hospitals in the United States, with New York state essentially merging their hospitals to fight the virus, is something that countries like Britain, where hospitals are already run by the government, don’t have to worry about. They similarly do not have to fret over hospitals trying to bid against the government for medical equipment, increasing prices. If there’s an argument against this approach it’s that Britons, sadly, do have to worry about austerity-hungry conservatives starving the NHS of resources. Then again, America starves its rural and safety net hospitals of resources through its worship of market forces—and you can’t just vote the market out of office if it kills your family.

The American health care structure—it would be wrong to call it a “system”—is clearly deeply unsuited to anything that requires large-scale, coordinated action. It is also unsuited to producing a happy and healthy population, or any kind of just and equitable outcomes, shared broadly by all its citizens. It is inarguable that a system in which everyone had worry-free and debt-free health care would be more adept at meeting the challenges of a public health crisis in which it’s not just likely that every individual might need care, but that the needs would fall the heaviest on the poorest and most vulnerable members of society. You should not have to treat anyone who argues the opposite as a serious person. Unfortunately, one of those people is the Democratic nominee for president.