A simple visualization of how complex our healthcare system is.

Back on December 20, after the previous Democratic Presidential Primary debate, I said:

I'm actually kind of...disappointed by both of them, for different reasons (which is particularly stunning given that healthcare reform is such a major part of both of their platforms).

My problem with Sec. Clinton was that she had criticized Sen. Sanders healthcare plan on two fronts: First, by noting that the only formal plan he had presented at the time (from 2013) ceded too much authority over to the individual states (thus opening up the possibility of GOP-controlled states screwing around with everyone's coverage even more than they do under the ACA (ie, Medicaid expansion, state exchanges, etc). This may have been a valid attack. The part I had a problem with was when she went after his plan for "costing" $1.5 trillion per year without acknowledging that it would subtract the cost of all private insurance expenses (premiums, deductibles, etc.) from everyone (both employers and individuals):

CLINTON: But I want to quickly say, one of the areas that Senator Sanders touched on in talking about education and certainly talking about health care is his commitment to really changing the systems. Free college, a single payer system for health, and it's been estimated were looking at 18 to $20 trillion, about a 40 percent in the federal budget.

This was a pretty low blow on Clinton's part, because she was basing that "$18 - $20 trillion" figure on an utterly absurd story in the Wall St. Journal which Paul Waldman already tore to shreds back in September:

While Sanders does want to spend significant amounts of money, almost all of it is on things we’re already paying for; he just wants to change how we pay for them. In some ways it’s by spreading out a cost currently borne by a limited number of people to all taxpayers. His plan for free public college would do this: right now, it’s paid for by students and their families, while under Sanders’ plan we’d all pay for it in the same way we all pay for parks or the military or food safety.

But the bulk of what Sanders wants to do is in the first category: to have us pay through taxes for things we’re already paying for in other ways. Depending on your perspective on government, you may think that’s a bad idea. But we shouldn’t treat his proposals as though they’re going to cost us $18 trillion on top of what we’re already paying.

As for Sen. Sanders, my problem with him at the time is that, frankly, he hadn't actually presented a plan; his campaign just kept saying that his plan wasn't the 2013 version...which is fine, but you can't complain about your opponent using your most-recent plan (from less than 3 years ago) if you haven't presented a new one.

...This was followed up by Bernie Sanders being asked about Single Payer, of course. Unfortunately, while he made a strong case for SP, he didn't answer the question, which was actually a reasonable one to ask...and this time, Raddatz actually framed the question properly:

RADDATZ: You note people won't have to pay deductibles or premiums but they will have to pay new taxes. Can you tell us specifically how much people will be expected to pay?

SANDERS: (goes on and on about how SP is much less expensive than the current healthcare system, making many valid points)

RADDATZ: Senator Sanders, you didn't really tell us specifically how much people will be expected to pay...

SANDERS: But they will not be paying, Martha, any private insurance. So it's unfair to say in total...

RADDATZ: But you can't tell us this specifically, even if you were...

Just as Clinton's responses were kind of disappointing, so was Sanders...because I actually would like to see a solid SP plan from him, as opposed to generalities. In fact, as much as he supports Single Payer Healthcare, if you visit his website, there's no actual plan posted. In fact, healthcare isn't even listed as a major issue; it's listed as just one of 13 sub-topics under his favorite issue, "Income Inequality" (although oddly, he does list "Prescription Drug Prices" as one of his major issues):

#9. Guaranteeing healthcare as a right of citizenship by enacting a Medicare for all single-payer healthcare system. It’s time for the U.S. to join every major industrialized country on earth and provide universal healthcare to all.

Gimme a plan, Bernie.

OK, so cut to last night. Literally hours before the latest Democratic debate, Sen. Sanders did indeed finally release his new Single Payer Healthcare Plan...such as it is:

Here's what Sanders actually released; note that the whole thing is only 8 pages, the first three of which are the cover page and two pages of introduction/background:

Bernie’s plan would create a federally administered single-payer health care program. Universal single-payer health care means comprehensive coverage for all Americans. Bernie’s plan will cover the entire continuum of health care, from inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing and oral health care; mental health and substance abuse services; as well as prescription medications, medical equipment, supplies, diagnostics and treatments. Patients will be able to choose a health care provider without worrying about whether that provider is in-network and will be able to get the care they need without having to read any fine print or trying to figure out how they can afford the out-of-pocket costs.

Wow, that's pretty comprehensive alright. OK, so it basically promises to cover everything under the sun. Awesomesauce. It also purports to wipe out the whole "in network" issue (ie, PPOs vs. HMOs vs. EPOs, "suprise billing" where the surgeon is in network but the anesthesiologist turns out not to be, etc.).

As a patient, all you need to do is go to the doctor and show your insurance card. Bernie’s plan means no more copays, no more deductibles and no more fighting with insurance companies when they fail to pay for charges.

Zero co-pays or deductibles of any sort? Not even a nominal $5 co-pay or whatever? Hmmmm...that's...unexpected, to put it mildly.

The United States currently spends $3 trillion on health care each year—nearly $10,000 per person. Reforming our health care system, simplifying our payment structure and incentivizing new ways to make sure patients are actually getting better health care will generate massive savings. This plan has been estimated to save the American people and businesses over $6 trillion over the next decade.

OK, that's a supposed $600 billion saved per year off of $3 trillion, or a 20% savings overall. If so, great.

The typical middle class family would save over $5,000 under this plan.

Last year, the average working family paid $4,955 in premiums and $1,318 in deductibles to private health insurance companies. Under this plan, a family of four earning $50,000 would pay just $466 per year to the single-payer program, amounting to a savings of over $5,800 for that family each year.

Businesses would save over $9,400 a year in health care costs for the average employee.

The average annual cost to the employer for a worker with a family who makes $50,000 a year would go from $12,591 to just $3,100.

OK, I realize this is a broad outline, but President Obama got into a lot of trouble with his "avg. family will save $2,500" line years back. I realize this is just a broad overview, but I still really wish Sanders had added "...versus what they'd otherwise be paying at the current rate of cost increases" or something along those lines.

How Much Will It Cost and How Do We Pay For It?

This plan has been estimated to cost $1.38 trillion per year.


  • A 6.2 percent income-based health care premium paid by employers. Revenue raised: $630 billion per year.
  • A 2.2 percent income-based premium paid by households. Revenue raised: $210 billion per year
  • Progressive income tax rates. Revenue raised: $110 billion a year. Under this plan the marginal income tax rate would be:
  • Taxing capital gains and dividends the same as income from work. Revenue raised: $92 billion per year.
  • Limit tax deductions for rich. Revenue raised: $15 billion per year
  • The Responsible Estate Tax. Revenue raised: $21 billion per year
  • Savings from health tax expenditures. Revenue raised: $310 billion per year.

OK, so he's given us a plan...or at least the outlines of a plan. Unfortunately, as Ezra Klein puts it:

Only what he released isn't a plan. It is, to be generous, a gesture towards a future plan.

To be less generous — but perhaps more accurate — this is a document that lets Sanders say he has a plan, but doesn't answer the most important questions about how his plan would work, or what it would mean for most Americans. Sanders is detailed and specific in response to the three main attacks Clinton has launched, but is vague or unrealistic on virtually every other issue. The result is that he answers Clinton's criticisms while raising much more profound questions about his own ideas.

Sanders promises his health care system will cover pretty much everything while costing the average American almost nothing, and he relies mainly on vague "administrative" savings and massive taxes on the rich to make up the difference. It's everything critics fear a single payer plan would be, and it lacks the kind of engagement with the problems of single-payer health systems necessary to win over skeptics.

As for myself, here's what I'll say: The only way that anything even close to such a plan would possibly manage to make it into law would be if all of the following happened:

  • 1. Bernie Sanders is elected President this November.
  • 2. 60+ progressive Democratic Senators are elected this November (that is, 60+ in office come January)
  • 3. 218+ progressive Democratic Representatives are elected this November (again, not just Democrats, but progressives, every one of them)

Obviously, that's not going to happen. It simply will not, period, and I say that as a staunchly progressive, fairly optimistic Democrat; it just won't...and these are the bare minimum requirements. We're talking planetary alignment here.

Now, there's nothing wrong with aiming high and negotiating from there...but that's not what Sanders has been campaigning on. Unlike President Obama, who never campaigned on single payer in the first place, and who always campaigned on a platform of "bridging the divide" and "reasonable compromise" (even if many of his supporters at the time came down with selective memory about this point), Sen. Sanders absolutely is campaigning on a strict, unapologetic "no compromises" "political revolution". If elected, as far as I can tell, he would not be willing to accept anything short of universal single payer (or some close semblence of it).

To be honest, that's a question I would've loved to hear him answer: What, if anything, would you be willing to accept short of your single payer goal? Of course, he's unlikely to answer that before securing the nomination, the White House and actually starting the negotiation process; you don't show your cards before you even start to play. Still, I'd like to know what's really going on inside his head on this issue.

Anyway...let's suppose, for the sake of argument, that Sanders does somehow manage to achieve all three of the above minimum requirements, and managed to push through his vision for Single Payer for America. What would that actually mean?

Thankfully, Harold Pollack has already done the hard lifting for me here with an excellent, point-by-point explanation of just how many people, institutions, programs, laws and powerful interests would be massively disrupted all in one shot:

As I have written at-length in the Journal of Health Politics, Policy, and Law (and draw upon here), an American single-payer system would be more complex and kludgy than many proponents have considered or admitted. The source of these problems resides in American politics rather than the technocratic or ideological premises of our health care system. A different system operating through the same political mechanisms would produce similar complexity and kludge.

The pitch for single-payer is admirably simple: We cover every (legal) resident. We mail a Medicare card to everyone. Everyone is covered. That’s a lot easier to explain and market than it is to explain the convoluted structures of Medicaid and state marketplace plans.

This is also a caricature of how such a single-payer plan would be passed, and how it would touch the lives of millions of Americans. Single-payer would immediately raise a myriad of intricate and divisive transition issues. It would potentially uproot thousands of critical arrangements President Obama, Speaker Pelosi, and Senator Reid struggled to leave intact.

After all, ACA’s sales pitch to the healthy and insured was, "If you like your insurance, you can keep it." This pledge proved politically damaging when it could not be fully kept for several million people. Single-payer would be far more disruptive to even more people.

It's important to reiterate here that I am a strong supporter of some form of single payer (or close to it) healthcare myself...but IT WILL NOT HAPPEN IN ONE (OR EVEN TWO OR THREE) STEPS.

Klein and Pollack both lay out the reasons why in great detail (and far better than I could). Instead, I'm just going to try and present the complexity involved here visually with a VERY rough representation of what the U.S. Healthcare Coverage situation was prior to the Affordable Care Act and where things stand today.

It's important to note that while the relative widths of the sections below should be reasonably accurate in terms of the total population, the relative proportions of the colored sections are mostly guesswork on my part. I'm not saying that taxes cover 85% of all Medicare expenses and 90% of Medicaid while only 70% of Public Employee coverage; any or all of these could be somewhat higher or lower. My point is that it's a complex mish-mash of different risk pools, programs, subsidy levels and so forth. In fact, I'm very open to modifying/tweaking the red/blue proportions for each section if others can provide harder numbers about them; feel free to post comments or email me directly.

Even here, I've drastically oversimplified the situation. Each of the columns below--both pre- and post-ACA--are further stratified into dozens or hundreds of different smaller programs, companies, risk pools and/or payment mechanisms. For instance, Medicare and Medicaid are mostly paid for by taxes...but those taxes are still in turn paid, in large part, to private insurance companies who manage the programs. Meanwhile, the federal government may pay 50% of one state's Medicaid program and 70% in another. Each of those states might have different thresholds for Medicaid eligibility depending on whether a given resident is a pregnant woman, a newborn, an adolescent or a single parent, depending on their income level. There are thousands of private insurance companies operating both the large group/small group markets (employer-based) as well as the individual (non-group) market, and so on. Remember that each state has their own rules/regulations/laws for many of these things as well, so you have to multiply the charts below by at least 50x to begin to get the full picture.

And remember, every one of these programs, whether privately or publicly funded, has laws, amendments, contracts and/or other legally-binding mechanisms holding them in place. The chaotic potential for lawsuits, confusion and coverage to get lost through the cracks in the event of an all-at-once switchover to a single, new system would make the headaches of the transition to the ACA a downright wistful memory.

Having said that, I still believe that much of this mess can and should be cleaned up via some form of single payer system, and that doing so would indeed result in both increased efficiency and cost savings as well as far greater coverage and higher-quality, comprehensive treatment...but it simply wouldn't play out that way even in the "complete progressive sweep of everything" scenario noted above.

In the near future I'll explain how I could see getting to a single payer system. Spoiler: It'd take a bare minimum of 10-15 years or more under the best of circumstances.