Bernie, Hillary, & Single-Payer Healthcare

Bernie Sanders' presidential campaign has reopened discussion about what would it take to get truly universal healthcare in the U.S. This lesson, which includes two student readings and discussion questions, examines the debate over Sanders' proposal for a "single-payer" national healthcare system, and efforts by states to adopt a single-payer program.  


Ask students what they know about where the 2016 presidential candidates stand on the issue of healthcare:

  • What have they heard about Republicans' views on this issue?
  • What about the two Democratic Party contenders, Bernie Sanders and Hillary Clinton?

Elicit or explain that Republican candidates' views about healthcare center on their opposition to the Affordable Care Act (ACA), or Obamacare.  This law, passed in 2010, is President Obama's landmark legislation. The law requires Americans who are uninsured to purchase private health insurance, often with financial assistance from the government. Millions of Americans have gained some level of health insurance as a result of the law, although many remain uninsured or are "insured," but still can't afford needed medical care.

  • Republicans have been strongly critical of the ACA, arguing that it is expensive, ineffective and represents an overreach of government. 
  • Democratic presidential candidate Hillary Clinton has defended Obamacare, though she has said that it needs to be improved.  
  • Democratic presidential candidate Vermont Senator Bernie Sanders' has said that ACA does not go far enough. He has called for a new universal healthcare system in the U.S. called "single-payer."  

Share with students the reading below, which describes Sanders' single-payer proposal and Clinton's opposition to it.

Note to teacher:  See these earlier TM activities for more exploration of Obamacare and single-payer


Reading 1:
Sanders Campaign Renews the Debate Over Universal Healthcare

One of the landmark achievements of Barack Obama's presidency was the passage of the Affordable Care Act (ACA) in 2010. This law made important advances by covering some of the tens of millions of Americans who had previously been without health insurance. At the same time, even under the ACA, America falls short of having a truly universal healthcare system. Experts estimate that as many as 33 million people are still uninsured. Millions more Americans have inadequate health insurance plans that force them to pay thousands of dollars in deductibles and co-pays to get treatment. Moreover, critics argue that the ACA has further entrenched the insurance industry by increasing pressure on the uninsured to purchase plans from private corporations.

Vermont Senator Bernie Sanders’ campaign for president has reopened discussion of the question, what would it take to get truly universal healthcare in the United States? In particular, what would be the potential benefit of adopting a "single-payer" healthcare system in this country, as Sanders advocates?

The Sanders campaign has attracted a significant amount of attention and support, in part because of the senator's firm commitment to establishing a universal, government-administered healthcare system. The type of system he advocates is known as "single-payer" healthcare, because one entity—the government—pays for all healthcare costs, as opposed to having hundreds of private insurers paying. This system, which has been adopted by Canada and most other industrialized countries, allows the government to negotiate with doctors, hospitals, and other healthcare providers over the cost of treatment and therefore to lower costs. The system also lowers costs by eliminating the role of private health insurance companies, whose profits and overhead now add billions to the cost of healthcare in the U.S.

Under a single-payer healthcare plan, the government provides the health insurance - but it does not directly hire doctors or run clinics (as it does in the UK, for instance). People would continue to have a choice of doctors and clinics - and in fact would have a much wider choice of doctors and clinics, since they would not be restricted to going to healthcare providers approved by their particular private health insurance company. 

Sanders' plan would resemble America's already existing Medicare system. Medicare essentially acts as a single-payer universal healthcare provider for all Americans over age 65. The Sanders campaign describes his plan in this way:

It has been the goal of Democrats since Franklin D. Roosevelt to create a universal healthcare system guaranteeing healthcare to all people. Every other major industrialized nation has done so. It is time for this country to join them and fulfill the legacy of Franklin D. Roosevelt, Harry Truman, Lyndon B. Johnson and other great Democrats....

Twenty-nine million Americans today still do not have health insurance and millions more are underinsured and cannot afford the high copayments and deductibles charged by private health insurance companies that put profits before people....

The U.S. spends more on healthcare per person, and as a percentage of gross domestic product, than any other advanced nation in the world, including Australia, Canada, Denmark, France, Germany, Japan, New Zealand and the United Kingdom. But all that money has not made Americans healthier than the rest of the world. Quite simply, in our high-priced healthcare system that leaves millions overlooked, we spend more yet end up with less.

Bernie’s plan would create a federally administered single-payer healthcare program. Universal single-payer healthcare means comprehensive coverage for all Americans. Bernie’s plan will cover the entire continuum of healthcare, from inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing and oral healthcare; mental health and substance abuse services; as well as prescription medications, medical equipment, supplies, diagnostics and treatments....

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

By moving to an integrated system, the government will finally have the ability to stand up to drug companies and negotiate fair prices for the American people collectively. It will also ensure the federal government can track access to various providers and make smart investments to avoid provider shortages and ensure communities can access the providers they need.

Sanders' chief rival on the campaign trail, former New York Senator and Secretary of State Hillary Clinton, has attacked Sanders' single-payer proposal. As reporters Abby Phillip and Philip Rucker wrote in a January 11, 2016 article for Washington Post:

Speaking at an event in Iowa, Clinton pointedly contrasted her healthcare plan with Sanders's, claiming that his proposal would turn over health insurance to Republican governors.

"His plan would take Medicare and Medicaid and the Children's Health Insurance Program and the Affordable Care Act health-care insurance and private employer health insurance and he would take that all together and send health insurance to the states, turning over your and my health insurance to governors," Clinton said, naming the state's Republican Gov. Terry Branstad. "I don’t believe number one we should be starting over. We had enough of a fight to get to the Affordable Care Act. So I don’t want to rip it up and start over."

Clinton called Sanders's plan a "risky deal."...

Clinton said, as she has in the past, that Sanders's plans would cost up to $20 trillion and would increase the deficit and require higher taxes on the middle class. Clinton has pledged not to increase taxes on the middle class.

"I want to be an aggressive Democrat who gets things done," Clinton said. "I want to do it in a responsible way, paid for in ways we can afford."

In response to Clinton's claims, journalist Tara Culp-Ressler argued in a January 14, 2016, article for that the Clinton campaign has mischaracterized Sanders' healthcare plan. Culp-Ressler wrote:

This week, the Clinton camp has been repeating an argument against Bernie’s plan that amounts to an unfair characterization of how universal healthcare actually works. Clinton argues that Bernie wants to "take everything we currently know as healthcare, Medicare, Medicaid, the CHIP Program, private insurance, now of the Affordable Care Act, and roll it together" — suggesting that could cause millions of people to lose their health insurance.

It’s true that a single-payer system would replace all of the different types of insurance that we have now, and it’s true that Americans would initially have to shift to new plans. But that’s not a problem with Sanders’ proposal — it’s actually the whole point.

Proponents of universal healthcare argue it will be more efficient and more equitable for the government to administer one centralized healthcare program.

"If anything, a single-payer plan like the one Sanders envisions would result in more coverage than current arrangements would allow," the Huffington Post’s Amanda Terkel and Jonathan Cohn point out. That’s because, while there are still people who remain uninsured under Obamacare because they haven’t signed up for a plan, a Medicare-for-all system would treat insurance like a public good and require states to automatically enroll their residents in plans.

Clinton also argues that Sanders’ plan would result in a massive tax hike for the middle class. While it’s true that a single-payer system would necessitate a big raise in taxes, this is a misleading way to frame it. Clinton doesn’t include that fact that Sanders would also eliminate the healthcare costs currently plaguing Americans in the form of premiums, deductibles, and co-pays.

Although the Affordable Care Act represented a step forward in providing healthcare coverage for many uninsured Americans, the continued high cost and complexity of healthcare for many American families has fueled widespread interest in Bernie Sanders' call for a single-payer system.


For Discussion:

  1. How much of the material in this reading was new to you, and how much was already familiar? Do you have any questions about what you read?
  2. According to the article, what is a "single-payer" healthcare system? How does it differ from the current system in place in the United States?
  3. Hillary Clinton charges that a single-payer system would require raising taxes. How do advocates of single-payer healthcare respond?
  4. Under our current system, many of our healthcare dollars are spent by patients who must cover premiums, deductibles, and co-pays in order to be covered or get care. Under Sanders' single-payer system, costs would be covered through a shared payroll tax. What impact might these two forms of payment have on how people use healthcare and on the accessibility of healthcare to all Americans? 
  5. What do you think? Would a single-payer healthcare system in the United States offer benefits, or do you believe that it would be a mistake? Explain your position.



Reading 2
Bringing Single-Payer to the States

Even as discussion of single-payer universal healthcare has intensified on the national stage, some local politicians and healthcare advocates have also pushed to implement single-payer systems in a number of individual states.

One of the first states to pass a single-payer law was Senator Sanders' home state, Vermont, in 2011. The law was ultimately shelved in 2014, however, due to funding concerns. Reporter Jay Fitzgerald wrote in a January 25, 2015, article for the Boston Globe that, for some observers, the failure to implement the law represented a devastating blow to the hopes of healthcare access advocates:

The decision [to step back from the single-payer plan] not only stunned and angered supporters in Vermont, but also signaled that the dream of universal, government-funded healthcare in the United States may be near its end. Vermont’s experience, analysts said, shows how difficult — and costly — it can be to shift from a system long-dominated by private health insurance, and that the future of universal healthcare lies within the private market.

Although the difficulties implementing a single-payer system in Vermont have no doubt been a setback, it has hardly deterred single-payer activists from continuing to press for reform in a number of other states. Indeed coalitions of labor unions and other healthcare access organizations have made real headway since the Vermont law's failure. As labor activist Mark Dudzic wrote in an August 3, 2015, article for In These Times magazine:

New York’s State Assembly in May overwhelmingly passed a bill to establish a single-payer-style healthcare system. 

The bill isn’t expected to pass the Senate or be signed into law anytime soon. But getting it through, with unprecedented support from big unions, shows that state-level campaigns are still a fertile ground for healthcare justice organizing, despite the recent setback in Vermont. 

The New York Health Act would eliminate private health insurance and cover all New Yorkers in a publicly financed, universal plan with no patient premiums, deductibles, or co-payments....

While most healthcare justice activists would prefer a national, Medicare-for-All reform along the lines of Rep. John Conyers’ H.R. 676, in recent years the momentum has been growing for single-payer-style reforms at the state level...

The ACA may help facilitate these efforts—because, beginning in 2017, the federal government is authorized to grant states "innovation waivers."

Such a waiver frees the state from the requirement to establish a private insurance exchange. Instead, it can reallocate federal subsidies for private insurance and Medicaid into funding its own plan.

To be approved, the state’s plan must meet the law’s minimum requirements for coverage and cost-sharing, and cover at least as many residents at a cost no higher than what the federal government would have assumed.

"We believe that a victory for a publicly financed, universal plan in one or more states can provide a powerful impetus to the movement for national healthcare," said Ben Day, executive director of HealthCare NOW....

In Colorado, healthcare activists have recently made progress in their state-level drive, garnering enough signatures on a petition to have single-payer put to a popular referendum in the fall of 2016. In a December 19, 2015, report for National Public Radio's Weekend Edition, reporter John Daley discussed the campaign:

On a brisk morning in Denver recently, an ambulance pulled up in front of a downtown office tower. "I think the patient is going to make it," Dr. Irene Aguilar said as a team rolled out the gurney.

This wasn't a medical emergency, but rather a bit of political theater. The gurney held several big boxes of signed petitions to be delivered to Colorado's Secretary of State's office. The group ColoradoCareYES gathered enough signatures — more than 100,000 — to put a single-payer health system on the ballot next fall.

Under the plan, Coloradans would still pick their own providers of healthcare, but the new system would pick up all the bills. There would be no deductibles and fewer and smaller co-pays....

"This is not going to be an easy fight," Aguilar says. Obamacare has been a good start, she says. It has sliced Colorado's uninsured rate in half. But many people are still uninsured, and others struggle to pay their premiums and out-of-pocket costs....

Here are some key features of the proposal: Seniors would stay in the Medicare system, and those in Tricare, the military health system, could keep that insurance. And anybody would be free to buy private coverage from a private insurer, though they would still have to pay for ColoradoCare. It would work like a single-payer plan, in the sense that everybody pays in, and everybody would be automatically covered, one way or another.

To finance the project, Colorado employers would pay nearly 7 percent in a payroll tax. Employees would pay 3 percent or more of their gross pay toward the health plan. The self-employed would need to pony up 10 percent of their annual net income (to cover the employee's contribution plus the employer's contribution — analogous to the formula used to calculate federal self-employment tax). All in all, supporters say, these proposed tax hikes would raise around $25 billion, and save residents money in the long run.

As the spread state-level single-payer campaigns demonstrates, efforts to implement truly universal healthcare in the United States may find a way forward even if progress at the national level is stalled.


For Discussion

  • How much of the material in this reading was new to you, and how much was already familiar? Do you have any questions about what you read?
  • What do you think are the benefits of pursuing a state-by-state strategy to achieve single-payer healthcare? What might be the limitations of this strategy?
  • According to the reading, what are some of the states that are pursuing single-payer healthcare? Are you aware of any similar campaigns in other states?
  • Do you think healthcare should be a right of all citizens? Or should it be a service provided by the market? Explain your reasoning.
  • Do you think it is fair to create higher taxes to pay for a universal healthcare system even if that means that some might pay more than others? Why or why not?



Extension Activity

Now that students have a grounding in the debate over what kind of healthcare system the U.S. should have, ask them to evaluate what candidates say about the issue in their next debate.  

Ask students to take notes on arguments or assertions they hear from the candidates.  

  • Which statements were especially convincing? Why? 
  • Which statements did you strongly disagree with? Why?
  • Which statements raised questions that need answering?  What are those questions?

 In the class following the debate, ask students for their opinions and observations, and consider how to answer any questions.