by Don McCanne, M.D.

Considering the difficulty that President Obama has experienced in passing and then implementing the Affordable Care Act (ACA), it is clear that he is in no position to advocate for single payer reform before he leaves office. Thus it seems reasonable to consider the prospects of enacting single payer reform during the term of our next president. What are the prospects?

As people gain more experience with the ACA reforms, it is likely that many will be disappointed. The marketplace (exchange) plans that most people are selecting have relatively low actuarial values with high deductibles, thus many will experience financial hardship should they have significant health care needs. Also many will be disappointed with the narrow provider networks that will often prevent patients from having their choice of physicians and hospitals. Since employers are now adopting some of these same insurance innovations, many who previously were satisfied with their employer-sponsored coverage may also become much less content with their coverage.

It is thought that, by 2017, enough people will have become dissatisfied with our high-cost, administratively inefficient, dysfunctional system that many of them will be ready for an improved Medicare for all. That happens to be the year that our next president will take office. Will we have a president who is willing to support a vastly superior alternative—a single payer national health program?

Obviously we cannot predict the results of a presidential election this far in advance, but we can take a look at the political climate—a climate that is unlikely to change dramatically in the next few years.

A Fox News Poll taken last month revealed that 69 percent of those polled would prefer to see Hillary Clinton as the Democratic nominee for president (1). The preference for the Republican nominee was much more scattered, with the top three—Chris Christie, Jeb Bush and Rand Paul—each receiving about 14 to 15 percent. Other polls have shown Clinton to lead each of the potential Republican candidates.

Suppose Hillary Clinton were elected president, what could single payer advocates expect?

In her recent speeches she has given no hint of support for single payer,  or Medicare for all. She does mention refinements that would build on the Affordable Care Act (ACA). In a televised speech before a large meeting of California physicians, she called for moving away from fee-for-service payment for medical care, expanding payment for “wellness things,” and she called California’s implementation of ACA a “model for the nation.” (2). Considering her prior miserable failure in her attempt at comprehensive reform during her husband’s presidency, it is highly unlikely that she would repeat such an effort. Besides, ACA is the model that she campaigned on during her last effort to become the Democratic presidential nominee. Were she to be elected president, it is safe to say that she would have her hands full with efforts to refine ACA in the face of Republican obstructionism. There would be no single payer under her watch.

Should a Republican be elected, it is likely that efforts would be directed to replacing some elements of ACA with policies supporting less regulation of insurance products, limitation of mandates, and ability of individuals to purchase insurance products in less regulated states. No serious potential Republican candidate supports single payer.

So, no single payer will be coming from the top. Then what can we do? We should intensify our efforts to educate the public at large so they understand why ACA does not seem to be working well for them, while showing them how single payer is precisely the model we need. We need to create a critical threshold of support coming from the general public. If the demand is intense enough, the politicians will follow.

But a caveat. The single payer message must be loud and clear (3). People must understand that the ACA model is fundamentally flawed and must be superseded by a single payer system. Many single payer supporters abandoned the cause and chose to support the “progressive” alternative—ACA. They continue to be involved in the implementation of this highly flawed model (better than nothing but still highly flawed). Fortunately, there are still organizations, such as Physicians for a National Health Program (PNHP), which are not willing to compromise and dilute the single payer message. Doing so would merely continue us down the incremental path of reform, when there are no incremental steps that bridge the gap between a fragmented system of private and public payers and a single payer system.


1.  Fox News Poll, Anderson Robbins Research (D)/Shaw & Company Research (R), April 13-15, 2014

2.  California Medical Association. Clinton urges move away from fee-for-service payment model; says current system is not serving physicians or patients well, April 21, 2014

3.  Burdick, James F., Getting serious about a single payer system. The Baltimore Sun, May 1, 2014

893 words

One-liner:  Single-payer in 2017? Not without the public leading the politicians.

Abstract:  None of the leading Democrat or Republican presidential candidates now on the horizon are likely to promote single-payer reform of U.S. health care. The Democrats’ message is weakened by their support of a flawed Affordable Care Act. Both parties have an opportunity to reform health care if they can see beyond ideology, myths, and disinformation in the present political debate.