A Single Payer Health Insurance System for the U.S.?

Many are fervently for, others are fervently against national health insurance. Student readings provide a critical overview of the U.S. health care system and discuss the pros and cons of national health insurance. A DBQ exercise and activities follow.

Americans' widespread dissatisfaction our health care system has led many reformers to advocate a universal national health insurance system. But national health insurance is very controversial and meets with fierce opposition from private health insurance companies and other critics. One student reading below provides a critical overview of the U.S. health care system; the other discusses the pros and cons of national health insurance.

The Document-Based Question exercise that follows the two readings might be used for individual student responses in writing or as a basis for class discussion. See a suggested approach for the latter following the DBQ.


Student Reading 1:

Problems with the U.S. health care system

Tammy Dougherty of El Paso, Texas, is not happy about her family's health insurance. "Every year we wind up paying more and getting less coverage," she says. Recent statistics bear her out. Most U.S. employers still provide some kind of health insurance for their workers. But average premiums (consumer payments) for the most popular insurance plans have risen 87 percent since 2000. Meanwhile, workers' earnings have barely risen.

Census Bureau statistics show that more than 46 million Americans have no health insurance. The Bureau also reports that in 2005 there were more than 8 million uninsured children, or more than 11 percent of all children. (www.usatoday.com, 10/16/06). There are millions more Americans with inadequate health insurance. In 2000, 64 percent of Americans had health insurance through their jobs; by 2005, that figure had dropped to 59.5 percent.

Why are employers dropping health insurance for their workers? One reason is rising medical costs. Some of this cost rise is due to new medical technology and new drugs—and Americans do want the latest treatments. "Advances in medical technology...lead doctors to spend more on their patients," write Paul Krugman and Robin Wells in "The Health Care Crisis and What to Do About It," ( The New York Review of Books , 3/23/06).

"This leads to higher insurance costs, which causes employers to stop providing health coverage. The result is that many people are thrown into the world of the uninsured, where even basic care is often hard to get," say Krugman and Wells.

An obvious result of being uninsured is that adults are less likely to go to a doctor when they think something is wrong. They may also be less likely to take their children in for regular check-ups. Both adults and children are then more subject to illnesses and diseases that, if treated earlier, would have been less serious.

Although the U.S. leaves more people uninsured than any other industrialized country, the U.S. spends twice as much for health care as those other nations. One reason, say Krugman and Wells, is that American doctors are paid more. But there are other significant factors:

(1) In the U.S., private insurers spend a lot of money trying to identify and screen out potential customers who are likely to run up big medical bills. These customers will cut into their profits.

(2) Private insurers have many expenses, including overhead, underwriting, billing, sales and marketing departments, huge profits and high executive pay. Doctors and hospitals must maintain costly administrative staffs to deal with the bureaucracy.

(3) Private insurers don't have the power to bargain with suppliers to lower drug costs.

(4) Decisions about health care are made by hundreds of private health insurance companies, not by a single public entity that is charged with making nation-wide decisions on health policy aimed at promoting health. Often private insurers make poor treatment decisions, leading patients to develop expensive health problems.

Even as the U.S. spends much more on health care than other developed nations, it does not perform as well by such standard measures as life expectancy and infant deaths:

Life expectancy:
Britain 78.1
France 79.2
Canada 79,7
U.S. 77.1

Infant mortality per 1000 births:
Britain 5.0
France 4.5
Canada 5.2
U.S. 6.5

(Figures, quoted in Krugman, come from Organization for Economic Cooperation and Development, 2004)

One U.S. health care insurance program, Medicare, which covers all Americans over 65 as well as people with disabilities, has some of the same financial advantages as a national health insurance system (except, of course, it's not universal). Medicare does not screen out anyone and the savings in administrative costs are similar to those realized by a public health care insurance system.

The health care the U.S. provides for its military under the federal Veterans Health Administration goes one step further. Under the VHA, the government is not only the insurer, it provides the actual health care in VHA hospitals staffed by VHA doctors. This resembles Britain's National Health Service, which also relies on government-paid doctors. The VHA is able to keep healthcare costs down in part by keeping closer tabs on patients. Because veterans are often treated by the VHA throughout their adult lives, VHA doctors have excellent records about how best to treat each individual in their care. Many medical errors are avoided, and people are more likely to be treated in the early stages of a disease. This saves both lives and dollars.

Medicare, VHA programs, and Medicaid (the U.S.'s program for poor people) covered more than 45 million people in 2005. Government health insurance covered another 18 million public service workers and millions of their dependents in state, federal and local governments, public schools, and state universities. Add in the government subsidy for private employer-provided health insurance premiums that are exempt from most taxation, and U.S. government expenditures account for 61 percent of the money spent on health care.

"In 2004 government spending on health care equaled 9.6 percent of the gross domestic product, compared with 8.9 percent in Canada, which has a single-payer universal health care program," said David Himmelstein, associate professor of medicine at Harvard Medical School. But much of this money goes to subsidizing inefficient private insurance or for tax breaks on the health insurance expenses of the well-to-do. "We're paying for national health insurance, but we're not getting it," Dr. Himmelstein added... And if the price of health insurance keeps rising at a much faster rate than the average earnings of lower-income people, more and more of the working poor will be priced out of the market." ( New York Times, 12/3/06)

For discussion

1. What questions do students have about the reading? How might they be answered?

2. What are the major reasons for rising health care costs?

3. Why are so many Americans without any health care insurance? What consequences are they likely to suffer?

4. Why does the U.S. spend so much more than other nations on health care?

5. What are two U.S. public health care programs? Why are their costs much lower than that of private programs?

6. Explain Dr. Himmelstein's comment: "We're paying for national health insurance, but we're not getting it."

Student Reading 2:

The "single-payer" system debate


The problems of the U.S. health care system help to explain why there is support for universal health coverage like that of other developed nations. Such coverage might take one of various forms, the most popular of which is a "single-payer" system. Under this system, the federal government would provide insurance for everyone-it would be the nation's "single payer" of insurance. The role of private health insurance companies would be virtually eliminated.

In endorsing a single-payer system, the American Federation of Teachers stated that "the United States now has a crazy quilt of financing and payment for health care that relies on public (Medicare, Medicaid and Veterans Administration) and private insurers alike." ( American Teacher , December 2006/January 2007) That "crazy quilt" includes hundreds and hundreds of different private insurance plans.

Physicians for a National Health Program (PNHP), an organization of 14,000 physicians, advocates for a single-payer system, under which "all Americans would be covered for all medically necessary services, including: doctor, hospital, long-term care, mental health, dental, vision, prescription drug and medical supply costs." Patients would be free to choose any doctor and any hospital. They would have no out-of-pocket payments.

PNHP says a single-payer system would be financed by (1) eliminating private insurers and their "administrative waste" and (2) modest new taxes to replace premiums and out-of-pocket payments.

In such a single-payer national health system, a public or partly-public agency would run the plan but patient care itself would still be provided by a mix of public, private, non-profit and for-profit hospitals and institutions. Since the single-payer system would eliminate the jobs of hundreds of thousands working for private insurers, says PNHP, "These workers must be guaranteed retraining and placement in meaningful jobs." (www.pnhp.org)

The organization Public Citizen adds that a single-payer plan would be good for business because:

  • it would cost employers far less in taxes than their current costs for insurance
  • it builds on U.S. experience with Medicare, which is essentially a single-payer system
  • it promotes great accountability to the public because unlike in the current fragmented health care system, "benefits and payments would be decided by the insurer, which would be under the control of a diverse board representing consumers, providers, business and government."

(Public Citizen Health Letter, August 2006)

The U.S. is the only developed nation that does not provide all its citizens with some form of universal health coverage. In Europe the plans in such countries as Britain, Germany, and France differ in detail, as do the plans in Asia for Taiwan and Japan, and all of these plans differ in detail from Australia's. But the most significant fact is that all of them provide health insurance for every citizen—and they do it for less money than the U.S. currently spends.


Critics of a single-payer system such as The Heritage Foundation argue that consideration of this system should "focus on the performance of existing models," that is, for example, those in Britain and Canada. In doing so, Dr. Kevin C. Fleming writes that those existing models:

  • produce long waits and reduced quality. According to the Fleming, over 800,000 people are waiting for hospital care in the U.K. In Canada the wait between a general practitioner's referral and consultation with a specialist has been "over 17 weeks." Other problems include "strict drug formularies, limited treatment options and discrimination by age in the provision of care." Price controls "result in reduced drug, technology, and medical device research."
  • result in funding crises. Since the individual doesn't pay the direct costs of treatment, demand expands. The government then needs to control costs and rations products and services. That, in turn, leads to the retention of outdated facilities and medical equipment—for example in Canada, where an estimated 60 percent of radiological equipment is outdated, according to Fleming.
  • create new inequalities. Fleming charges that there is often favoritism for the politically connected, limitations on surgeries for the elderly and care for premature babies and restrictions on access to specialists.
  • foster labor strikes and personnel shortages. In 2004 a Canadian strike in British Columbia resulted in the cancellation of 5,300 surgeries and numerous MRIs and CAT scans. In Britain, recruiting and retaining doctors is a problem.
  • lead to politicization and lost liberty. The elite dictate health care needs, in the Heritage Foundation view.

("High-Priced Pain: What to Expect from a Single-Payer Health Care System," www.heritage.org, 9/22/06

The American Enterprise Institute is also critical: "Single-payer systems do not guarantee universal access and do not necessarily result in high-quality health care. State-run systems have trouble keeping up with changes in consumer demands and new medical technology." (Robert L. Ohsfeldt and John E. Schneider, "The Business of Health," www.aei.org, 10/3/06)

The Bush administration opposes any government-run system. A serious effort to move the U.S. toward a single-payer system will also face the opposition of the politically powerful private health insurance and pharmaceutical companies.

For discussion

1. What questions do students have about the reading? How might they be answered?

2. What are major arguments for a single-payer health insurance systems? Against?

3. Which arguments—pro and con—seem most convincing to you? Why?

4. Why do you think private health insurance and pharmaceutical companies oppose single-payer health care?

5. Why might changing the U.S. health care system present significant political problems?

For inquiry

Have students frame questions for inquiry on the following subjects. Then subject the questions to close examination. For detailed suggestions on such a process see "Thinking Is Questioning" and "Teaching Critical Thinking," both of which are available on this website.

  • Health insurance coverage and concerns in their families
  • Medicare
  • Veterans Health Administration
  • Medicaid
  • A private health insurance company and its administrative costs; its profits
  • A pharmaceutical company and its drug development costs; its profits
  • Cutbacks, even the elimination of health care benefits, by a U.S. company
  • The $1,500 additional cost of a General Motors automobile and employee health care benefits
  • A single-payer health care system like that of Canada, Japan or Australia
  • A national health service system like that of the U.K.
  • Political problems associated with changing the U.S. health care system

For writing and citizenship

Assign students a 300-500-word letter to their U.S. representative or senator supporting or opposing a single-payer plan for the U.S. health care.




DBQ: A Single-Payer Health Insurance System for the U.S.?

Read each paragraph, and then answer the question following it. After you have read all of the paragraphs, write an essay in response to item G.


Most disturbing is the report that 57 percent of low-income adults and 51 percent of sicker adults in the U.S. went without medical care, did not get recommended tests or follow-up care and went without prescription medications due to costs. This is twice as high as the access problems in Canada and four times as high as that in Britain. This is not just a problem for low-income people; overall, the U.S. has the highest percentage of adults reporting some type of cost-related access problem. It is hard to believe that, in the wealthiest nation on the planet, 77 million people—37 percent of all adults—reported having difficulty paying medical bills or medical debt. In this regard, we do stand out among the world's leading nations; we are the only one that fails to insure that health care is affordable for all.

—Former Senator Tom Daschle, "Paying More But Getting Less," www.americanprogress.org, 11/05

Question: What major problem do many Americans have about their health care that Canadians and the British do not have, in Daschle's view?


While advocates of a single-payer system say that it will bring about equality in care, the reality is invariably different. For example...Canadian doctors have allowed prominent people, wealthier residents, and personal contacts faster access to services. Similar queue jumping by famous sports figures and politicians has also elicited complaints... A 2002 investigation found that more than 10,000 private-pay patients were given preference over National Health Service patients in Britain's most respected hospitals.

—Dr. Kevin C. Fleming, "High-Priced Pain: What to Expect from a Single-Payer Health Care System," www.heritage.org, 9/22/06

Question: Why are supporters of a single-payer system wrong to think that it will produce equality in health care, according to Fleming?


The main reason why other countries [with government-provided health insurance] can spend less on health care is that availability of medical services is limited by government policy... Health care rationing is one way to cut back on medical procedures that are not cost-effective. However, it would represent a radical change for the American health care consumer... Today the United States has two large government health care systems-Medicare and Medicaid-that do not display the efficiency [ascribed] to single-payer programs, and despite the government's use of its leverage to hold down the fees charged by health care providers, the spending by the U.S. on its elderly population, on a per capita basis, is as high relative to that of other countries as is spending on the under-65 population.

—Arnold King, "Is Socialized Medicine the Answer?" www.cato.org, 3/16/06

Question: What evidence does King cite that Americans would not be better off with a single-payer health care system?


We already have rationing... Rationing in U.S. health care is based on income: if you can afford care you get it, if you can't, you don't. A recent study by the prestigious Institute of Medicine found that 18,000 Americans die every year because they don't have health insurance. That's rationing. No other industrialized nation rations health care to the degree that the U.S. does... We spend at least twice more per person than any other country and still find it necessary to deny health care.

—Dr. Steve B, "Single Payer Health Insurance," www.dailykos.com, 11/30/06

Question: What is the basis of health care rationing in the U.S., according to Dr. Steve B.?


Single payer proponents argue that Canada, Britain and others deliver health care more cheaply, more efficiently and more equitably; but in Lives at Risk these lofty claims dissolve beneath mountains of data. In the United States, five percent of patients have to wait more than four months for surgeries; in Australia, New Zealand, Canada, and Britain the percentages are 23 percent, 26 percent, 27 percent and 36 percent, respectively. Wealthier British citizens receive better care than poorer citizens; the poor suffer higher cancer rates than the wealthy. Americans of all social classes have better access to MRIs, CTs (CAT scans)...and so forth.

—Robert F. Graboyes, review of Lives at Risk by John Goodman and others, 4/1/05

Question: What is one reason to oppose a single-payer health care plan, according to Graboyes?


Under a single-payer system, never again would you be asked, when calling to make a medical appointment, "What type of insurance do you have?" Never again would doctors need bloated office staffs to track what is and is not covered under thousands of insurance plans. Never again would you have to worry about being bankrupted by a medical emergency... A unified single-payer system could do more than pay the bills. It could gather information to more accurately identify the surgical procedures and drugs that work, and those that don't... [It] could track medical errors across the country to increase accountability and to identify hospitals or surgeons who make repeated mistakes... In short, over time such a system could transform the practice of medicine and give all Americans the first-class health care they deserve without breaking the bank.

Donald L. Barlett and James B. Steele, op-ed, New York Times, 10/24/04

Question: What is one major advantage of a single-payer health care system, according to Barlett and Steele?


Viewpoints differ on the desirability of a single-payer health care system for the United States.

Using information from the documents and your knowledge of the pros and cons of the current U.S. health care system, write a well-organized essay that includes an introduction, several paragraphs and a conclusion in which you:

  • compare and contrast different viewpoints on whether the U.S. should develop a single-payer health care system
  • discuss your own viewpoint and the reasons for it.

For discussion

1. Have students read each item in the DBQ, then answer the question in writing in a sentence or two. Discuss with class.

2. Organize groups of four to six students to discuss their response to item G. Assign one student in each group to summarize its discussion for the class.

3. After reporters offer their summaries, invite class discussion of them. Can the class reach consensus in their response to item G?


This lesson was written for TeachableMoment.Org, a project of Morningside Center for Teaching Social Responsibility. We welcome your comments. Please email them to: lmcclure@morningsidecenter.org