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Study Finds Many Favor a Single-Payer System

Public Citizen Health Letter


July 2007

What do People Want? Aspiring to a Better Health Care System, a Large Proportion Favor A Single-Payer System

Health services in the United States aren’t good enough, cost too much and leave too many people out: that is the consensus emerging from a two-year long process that has not yet concluded. The interim results are in a Federally-funded document, The Health Report to the American People,[1] worth reading not only for what is included but also for what was left unsaid.

Best known for Part D, which provided drug coverage, Public Law 108-173 – the Medicare Prescription Drug Improvement and Modernization Act of 2003 – also included a provision to allow the American public to “engage in an informed national public debate to make choices about the services they want covered, what health coverage they want, and how they are willing to pay for coverage.”[2] The vehicle for this was the creation of a Citizens’ Health Care Working Group, consisting of 14 individuals appointed by the Comptroller General of the United States.

The Working Group held 31 community meetings across the country, conducted an Internet poll and received close to 5,000 commentaries on health care issues submitted by residents throughout the nation. These have been compiled and analyzed in a report that is being disseminated in an effort to get the public to “tell America’s leaders what works and what doesn’t”[3] and what should be done about it. 

Once more, with feeling

The politics of health care are traditionally contentious, both because the stakes are high and because every citizen is a stakeholder. Many attempts at reform have therefore fizzled in acrimonious battles that have pitted providers against each other, providers against patients, practitioners against payers, politicians against advocates and narrow self-interest against public objectives.  

The most recent attempt at providing universal health coverage in this country was the Clinton Health Care Plan. Initially, the combination of the propitious moment and the right leadership appeared to augur success. U.S. businesses were feeling the pinch of rising health care costs, the number of uninsured was rising, the country as a whole was losing its comparative advantage in world markets, hospitals were eager to shed the burden of their “bad debt and charity” pools and even physicians were complaining about the costs and complexities of billing multiple third parties. In 1993, President Clinton announced the promise of “health care that is always there, health care that cannot be taken away” amidst great fanfare. What ensued was a formidable, year-long national debate and the predictable mobilization of an opposition that derailed the discussion and ultimately the plan itself. The insurance industry and its allies exploited the proposals’ complexity in a campaign to portray the plan as excessively bureaucratic and restrictive of patient choice. In print and non-print media alike, “Harry and Louise,” a middle-class couple discussing their concerns about the plan, became the fictional spokespersons for the insurers’ fears. In an attempt to seize the moment, salvage the original plan or confuse the issue, a number of legislators introduced separate reform plans; before long, 27 different legislative proposals were vying for public attention and support. In the end, the Clinton plan had more opponents than supporters, the public became increasingly confused and the issue of universal coverage was laid to rest and has been largely dormant since then.

Given this history, it is surprising that the most recent effort at obtaining input from the population at large has yielded a number of areas on which there is significant agreement. The factors that propelled the 1993 health care debate are still present; indeed, the situation has been compounded by the increased recognition that the United States has the highest health care costs in the world while having worse health status and a substantial fraction of its population without health coverage. 

Those attending the community meetings are not a representative sample of the population as a whole: they tended to be older, whiter and more educated than the population at large. With this caveat, they revealed an unusual level of agreement on key issues, including: appraisal of the present situation, universal coverage, uniform comprehensive benefits, consumer input, financing and desire for a system that is easier to maneuver and is more administratively efficient.

Appraisal of the current situation

An overwhelming majority (96.8%) of the persons attending the community meetings feel that the health care system is in crisis or constitutes a major problem. This opinion is particularly strong in larger cities including New York and Los Angeles, where 100% of participants so indicated. Similarly, over 94% feel that affordable health care should be part of national public policy.

Universal coverage

While a small minority (8.9%) believes that health care should cover only certain groups (presumably defined by age, income or health status), the rest agree that there should be a uniform level of benefits for all.

A majority of those expressing an opinion feel that “everyone should be required to enroll in basic health coverage, either private or public.” However, some feel that this should be an individual mandate requiring individual enrollment; others favor everyone having automatic coverage and access to care under a new national system. The former are in turn divided on coverage for undocumented persons and non-citizens, an issue that is likely to become more salient given the current sentiments on immigration. 

Comprehensive benefits package

The Working Group adopted as a basic principle the need to guarantee “a defined set of benefits…, for all, across their lifespan, in a simple and seamless manner.” These benefits are to be portable, unrelated to health or working status, age, income or other categorical status.”

While the specific content of the benefits package was left undefined, the Working Group’s point of departure was that it should include wellness and preventive services, as well as treatment and management of health problems. The majority of participants in the process feel that coverage should be wide-ranging, including medical, mental, dental and vision care. Participants also agree that both consumers and medical professionals should have a “major role” in defining services covered, with other players (government, employers, insurers) playing minor roles in the decision-making process.

Financing the system

The issue of how health coverage is paid tends to elicit more controversy than other aspects of reform. Nevertheless, a majority of those expressing an opinion (between 55 and 88% of those attending community meetings) felt that “everyone should be required to enroll in basic health care coverage, either private or public.”  

At the same time, there is support for some persons paying more than others, their contribution usually being pegged to income, to a lesser extent, to health behavior.

According to the report, in the course of the town meetings, “many individuals advocated a single payer system to eliminate the middleman, possibly one structured like Medicare or similar to the public school system.” This would require everyone to pay taxes to support the system, whether or not they use it. This would not only be more equitable; it would also simplify the current multiplicity of payers and result in lower administrative costs.

Because resources are not unlimited, the matter of trade-offs was addressed through several questions. When asked how much more they would be willing to pay per year in order to support a system in which every American would have access to “affordable, high quality health care coverage and services,” a majority of participants expressed a willingness to pay more for this goal: about one-third said they are willing to pay $300 or more/year more than they are paying now, with one in seven willing to pay an additional $1000/year.

When confronted with different priorities competing for public spending, respondents ranked “Guaranteeing that all Americans have health coverage/insurance” as the highest. Similarly, when asked to evaluate different proposals for expanding access to care, respondents ranked “Create a national health insurance program, financed by taxpayers, in which all Americans would get their insurance” as the highest.

Open-ended comments submitted to the Working Group also emphasized a desire for a “single health care system.” Among the 1,814 respondents who favored this alternative, fully 46% recommended a single-payer system.

[1] Citizens’ Health Care Working Group. Health Care That Works for All Americans. October 2005.

[2] Ibid.: i.

[3] Ibid.: i.