Scenarios for the Adoption of Single-Payer in the US

Some have dismissed the idea of Medicare-for-all or a single-payer healthcare system in the United States as implausible (or even impossible). They see it as a bridge too far (or as one Brookings Institute reprint put it (Brookings: 26 January 2016: “The impossible (pipe) dream—single-payer health reform”), “‘You can’t get there from here.'”). I’m going to look, briefly, at six scenario-types that could (eventually) deliver single payer to our shores.

  1. Disaster
  2. Via Pharmaceutical regulation
  3. Via state experimentation
  4. Via cultural maturity
  5. Incrementally
  6. Technological

Disaster

Manmade or natural, it doesn’t matter. World War II played a role in socialized medicine coming up in Europe. A major pandemic or other breakdown of the US healthcare system could largely do the same here. We continue to have tens of millions of uninsured persons, and during a big enough health crisis that would probably require a legislative remedy.

Pharmaceutical regulation

Drug prices are too high, and between insurance companies and the lack of price negotiation by Medicare, they aren’t going down anytime soon. If a combination of legislative inaction and increasing demand (in the economic sense) makes the problem bad enough, legislators may be forced (by public outcry) to come down hard on pharmaceutical companies. Were that to happen, once people saw a major regulatory success (in the form of single-payer for drugs), they might just decide they want it for the rest of the system, too.

State experimentation

In 2016 Colorado will vote on Amendment 69, ColoradoCare. Now if Colorado didn’t have some recent history to back up the idea of it going against the grain, we might just dismiss this push for a state-based single-payer system. But they do have that history, and who knows? It might work.

Vermont passed a law in 2011 for a single-payer system, but that plan proved unworkable and was scrapped in 2014.

But if any state succeeds with single-payer, others will follow. If they can actually save their state money and improve outcomes, their neighbors will want to get in on it.

Cultural maturity

With the rise of the Internet, with social media allowing people to see Europeans boggling over the state of US healthcare, people will sooner or later realize that overpaying for our healthcare is just plain dumb. Take drug prices, which the pharma companies claim sustain drug development. Either the rest of the world are freeloaders, or the US are chumps. The same goes for the rest of the healthcare system. It might take another 20 years, but at some point the culture will reach the point where it demands a single payer system. (This is, of course, the Bernie Sanders approach; whether the issue is ripe enough now remains to be seen.)

Incrementally

We already have Medicare, which is mostly single-payer (I’m not old enough to have the alphabet soup of parts B-D memorized, but I know that somewhere in there is some private insurance, too). Medicaid, too (disregarding the federal-state split). One of the ACA’s population-coverage improvements was via Medicaid expansion. That could just happen a couple more times, and before you know it: a single payer system.

There are other opportunities for incrementalism here. If unionizing comes back in vogue, for example, and many of the unions join up to build some gigantic insurance cooperative over time, it could be transitioned to a single-payer system.

Technological

Technology is going to be an ever-greater part of medicine going forward, just as it has been since its modern advent. The need for automation to offset labor requirements will be a huge driver in the coming decades. Depending on how fast and how far technology can go in medicine, single-payer may just come down to a sort of use tax (like that on gasoline) at some point. In this scenario the health care infrastructure may be so expensive and integrated (think the Interstate Highway System) that it requires single-payer. Or maybe it’s just mostly so cheap that the only remaining need for insurance is de-facto single-payer.


Just to be clear, I don’t think single-payer will happen short of the 2020s. But to say it’s impossible? Just use a little imagination.

This is not to say single-payer is inevitable. It may become moot. But if the US continues to overpay for healthcare, sooner or later it will become inevitable. If the interests in this field can’t or won’t work to keep prices in check until they’re on par with the rest of the world, single-payer will become inevitable.