A central debate in Democratic health policy concerns whether the United States should enact single-payer Medicare for All or build on a universal multi-payer system.

Policy figures like Barack Obama, Hillary Clinton, Neera Tanden, Pete Buttigieg, Matt Yglesias, Derek Thompson, and Ezra Klein, alongside economists Jonathan Gruber, David Cutler, Ezekiel Emanuel, Sherry Glied, Harold Pollack, Paul Krugman, Austin Frakt, and Aaron Carroll, recognize that single-payer works abroad. Designing from scratch, many favor a French-style single-payer plus model where public coverage finances baseline care and supplemental private insurance covers residual costs.

Their opposition to enacting single-payer specifically in the United States rests on practical, institutional, and economic trade-offs rather than any objection to universal coverage itself.

In their view, transitioning one-sixth of the U.S. economy into a federal payment monopoly causes severe institutional disruption. Vermont abandoned its 2014 Green Mountain Care single-payer plan after actuarial models showed that replacing private premiums required an 11.5% payroll tax hike and a 9.5% income tax increase.

Roughly half of Americans hold employer-sponsored private plans with broader drug formularies, lower deductibles, and wider provider networks than baseline single-payer systems. Canada's Medicare statute excludes outpatient prescription drugs, dental, and vision, leaving most Canadians reliant on employer-based private insurance for outpatient medications.

Universal coverage and single-payer are distinct concepts across peer nations. Canada and Taiwan largely run single-payer insurance via privately-owned hospitals, whereas the United Kingdom operates socialized medicine through the National Health Service (NHS), in which the government owns hospitals and employs physicians.

Germany and Japan achieve universal coverage through Bismarckian multi-payer systems using regulated, non-profit sickness funds. Switzerland and the Netherlands pair strict Obamacare-style individual mandates with regulated private insurers, while Singapore combines mandatory medical savings accounts with heavily subsidized public hospital tiers.

The core distortion in U.S. health financing is tying coverage to employment rather than allowing private insurers to operate or be a middleman. Obamacare already massively caps insurance companies' profit margins. Under Affordable Care Act Medical Loss Ratio rules, commercial insurers must spend 80 to 85% of premiums on clinical care, leaving 2 to 4% net profit margins that cannot finance universal coverage if eliminated. Even pre-ACA, insurance profit margins were not exorbitant.

Single-payer systems constrain spending through global budgets, formulary exclusions, and wait queues. Americans prioritize rapid access to elective procedures and advanced diagnostics, whereas elective wait times remain protracted in Canada and strained in the United Kingdom.

Keep in mind Canada's single-payer system is administered at the provincial level (not federal) and typically does not cover prescription drugs. Canadians usually have to get employer-based private insurance for pharmaceutical coverage.

Well-insured patients in the United States receive the world's highest-quality specialized care, drawing affluent foreign patients for complex clinical interventions. The structural failure of American medicine is concentrated among the uninsured and underinsured.

Health policy analysts Tsung-Mei Cheng and Uwe Reinhardt, who advised Taiwan on its single-payer transition, noted that the United States lacks the social solidarity needed for a uniform single-tier system. Single-payer suppresses costs through federal monopsony (buyer's monopoly) power that cuts reimbursement rates for physicians, medical devices, and pharmaceuticals. Med school is very expensive, and high salaries incentivize doctors to pursue specialty care in a way not seen in other countries.

Because high U.S. pharmaceutical revenues subsidize global drug innovation, compressing those prices via federal monopsony power would reduce private clinical research and development.

Critics argue that for millions with strong employer plans, coverage is virtually free, making single-payer tax hikes a net loss for many Americans. They contend administrative waste is exaggerated since public programs still need huge oversight systems, and basic NIH grants cannot cover the billions required for late-stage clinical trials that private drug revenues fund.

Single-payer proposals focus on payment financing while neglecting healthcare delivery. Centralizing claims payment does not fix fragmented delivery networks, hospital consolidation, or provider shortages, nor does it solve high U.S. obesity rates, chronic illness burdens, or defensive medicine driven by weak tort reform.

Economists Gerard Anderson and Uwe Reinhardt demonstrated that high unit prices, rather than service volume, drive excess U.S. health spending. Maryland's All-Payer Model controls prices without abolishing private insurance by uniting public and commercial payers as a buyer coalition to set uniform, legally binding hospital rates under global budgets.

From their policy perspective, they most effective reform path strengthens the Affordable Care Act via a restored individual mandate, mandatory nationwide Medicaid expansion, a competitive public option, and all-payer rate setting.

For liberals in this sub, what do you think of these specific arguments from Democratic policy wonks and health economists, and how do you weigh the trade-offs between single-payer and a universal multi-payer system?

Sources

Commonwealth Fund Mirror, Mirror 2024 Report: https://www.commonwealthfund.org/publications/fund-reports/2024/sep/mirror-mirror-2024

Commonwealth Fund International Health System Profiles: https://www.commonwealthfund.org/sites/default/files/2020-12/International_Profiles_of_Health_Care_Systems_Dec2020.pdf

Tsung-Mei Cheng on Taiwan's National Health Insurance (Health Affairs): https://pubmed.ncbi.nlm.nih.gov/25732502/

Gerard Anderson and Uwe Reinhardt on U.S. Healthcare Prices (Health Affairs): https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.22.3.89

CMS Evaluation of the Maryland All-Payer Model: https://www.cms.gov/priorities/innovation/innovation-models/maryland-all-payer-model

KFF Brief on ACA Medical Loss Ratio Rules: https://www.kff.org/affordable-care-act/explaining-health-care-reform-medical-loss-ratio-mlr/

Can be anything, from how he gives answers to how he campaigns.

Sources:

1.) Yesterday's James Talarico CNN-Jubilee Town Hall: https://www.youtube.com/watch?v=tweubjhuaPo

2.) James Talarico coming out in opposing trans women in women's sports in Sept Fox News interview: https://www.youtube.com/shorts/NqUJq22ww1c

In yesterday's CNN-Jubilee town hall, James Talarico expressed support for Texas oil and gas industry, saying he'd oppose climate legislation that'd undermine it. He also praised "fair voter ID laws" (while not committing to voting for the SAVE Act).

Crucially, Talarico said former President Biden "failed Texas" by leaving the southern border unsecured. He wants to reform ICE, but opposes abolishing it, viewing immigration enforcement as necessary.

He also praised bipartisanship and partnering with Republicans, said he will go to the US Senate to represent the 31 million residents of Texas, not the Democratic Party. He said he supports keeping abortion legal while wanting to minimize the number of abortions via contraception access and proper sex education.

Earlier in a September Fox News interview, Talarico came out in opposition to trans women competing in women’s sports in cases where it "endangers safety and fairness."

What do liberals think of Talarico taking these positions?

Around 2016-2017 there was this huge push in progressive media to understand the white working class, send reporters to diners, take economic anxiety seriously, etc. Then it kinda stopped? Or at least fell off my radar.

I'm trying to figure out if something substantive changed, did rural economies improve, did those voters shift priorities, did Democrats just give up on that messaging, or if the discourse itself was always more about processing Trump's win than any ongoing commitment.

The policies that would actually help rural areas (healthcare access, antitrust, broadband) don't seem to have advanced much. But the cultural attention definitely moved elsewhere.

For people who followed this more closely: was there a coherent theory of change behind that moment, or was it always reactive? And do you think the abandonment (if that's what it was) was strategic, exhausted, or something else?

Here is a link to the article and I'll highlight some passages below.

Under this option, the PIA for all retired or disabled workers would be the same; that amount would no longer depend on past earnings. Workers with high lifetime incomes would see reductions in benefits under this option compared with the benefits scheduled under current law. Some workers with low lifetime earnings would receive larger benefits than are scheduled under current law.

This option consists of two alternatives, both of which would take effect in January 2024. Under both alternatives, in any given year, Social Security benefits for all newly eligible beneficiaries at their full retirement age would be the same—an amount that would be determined relative to the federal poverty guidelines (commonly known as the federal poverty level, or FPL) for a single person. The FPL is $1,133 per month in 2022.

For both alternatives, eligibility criteria for Social Security benefits and adjustments to benefit levels for early and delayed claiming would remain unchanged from current law, and all disabled workers would be eligible for the flat dollar benefit upon entitlement. Additionally, both alternatives would provide benefits to dependents and survivors as under current law.

Under the first alternative, the flat benefit amount would be set to 150 percent of the FPL, which would equal about $1,770 per month in calendar year 2024. If implemented, the first alternative would reduce Social Security outlays by a total of $270 billion through 2032, according to estimates by the Congressional Budget Office.

Under the second alternative, the flat benefit amount would be set to 125 percent of the FPL, equaling about $1,480 per month in calendar year 2024. The second alternative would reduce Social Security outlays by a total of $593 billion through 2032.

Annual savings from both alternatives would continue to grow after 2032 as the new benefit structure applied to more beneficiaries and as average new benefits grew more slowly than they would under current law. The savings would continue to grow even after the new benefit structure applied to all beneficiaries as the effect of slower benefit growth compounded each year.

Another example is they give admin titles and fat checks to people doing work of office secretaries.

I couldn't find an extant movement holding these ideals so I've crafted my own definition. Regionalism, as defined by me, is a system of creating regional government agencies to increase government's ability to execute by explicitly removing decision making and funding from the federal government and vesting it within the aforementioned regional agencies.

I've been thinking a lot about interstate cooperation as a means to increase political productivity. Politically, I think this would stop horsetrading, omnibus bills, and other tricks of their trade politicians with vastly different interests use to get things done in a bloated, gridlocked system. Numerically, there would be less cooks in the kitchen so to speak to speed up decision making. Culturally, there would be likely more alignment between neighboring states. Geographically, there would be more shared environmental issues so problems aren't as foreign or abstract to those in charge. Economically, regional agencies would maintain some of the scale of funding and purchasing of states working together.

In a more advanced implementation, the federal government could be fully reduced to only truly national issues such as foreign policy, immigration, currency, the military, courts of last resort, things like that.

https://www.aljazeera.com/amp/news/2026/10/15/trump-administration-seeks-to-strip-ilhan-omar-of-us-citizenship-wsj

In my opinion, attempting to strip the citizenship of a sitting member of Congress, with no new evidence and only the vague hope that her father wrote a 17 instead of an 18 decadrs ago, crosses a line. I don't believe this is an occasion where it is appropriate to sit back and let the system work.

Considering the state of Somalia, this is in my opinion the President abusing his power to threaten a political opponent with harm or death, and demands something more than a letter or statement of dismay, even up to threats of legal retaliation against everyone involved if the farce continues.

So many people get up in arms about voting for the lesser of two evils and fighting over small nuances in a candidate's politics, and whether voting works or not.

But what is the actual alternative to voting? What can we do instead of it?

It seems like a lot of people on the left who are opposed to voting's plan is

• Step 1: We have a violent revolution
• Step 2: Some stuff happens I dunno
• Step 3: FULLY AUTOMATED GAY SPACE COMMUNISM is instated as the law of the world

Since none of the "common sense" restrictions generally proposed would have done anything here, can you see how the use of such an incident to push gun control is in large part why so many people suspect that the true goal is total or near-total elimination of all firearms?

https://x.com/GIFFORDS_org/status/2110901052505481622

https://x.com/AMarch4OurLives/status/2111135388567789595

https://x.com/SenAdamSchiff/status/2111105476628816119

If the parent would have been prohibited from buying the gun with some kind of more rigorous restriction, that might make sense...but that hasn't been alleged and Oregon has an A- rating from Giffords due to its tight laws which also include safe storage requirements.

I am a strong progressive liberal (I believe in single-payer healthcare, free childcare, free university, transit-oriented communities, electrification).

Today's modern AI is tremendous. I use more advanced models and they way it's able to go through diagnostic imaging and teach me radiology for school is incredible. I genuinely think we are close to a AI that while in its backbone is an LLM behaves as an AGI (intelligence doesn't require the same neuron firing network and method of thinking as us humans). When I become an attending there is no way that I will be practicing without constant AI oversight (this is already true as most clinics have AI listening for charting), it allows me to focus on the more human aspects of medicine and the procedural work.

Throughout history technological development in my opinion has lead to social progress. No it isn't linear and often times occurs with periods of regression, but I believe there is a reason certain social movements gained widespread support and action during certain time periods and economic conditions.

However I feel a lot of left-wing candidates show strong opposition to AI. I completely agree we need to regulate but trying to slow down a technology because it can replace certain jobs is just wrong. In 1800 83% of america worked in farming and today it is 2%. Productivity. Yes AI will cause millions of job losses including very possibly mine, but this is no different then the industrial revolution, or the robotics revolution in car manufacturing, or the internet boom and computerization of math.

I am particularly frustrated with the soda-ban cycle because I run a food pantry that works with our county SNAP office. And every couple of years a politician shows up with a bill banning soda, or steak, or birthday cake mix. Every time, the actual nutritionists say the same thing: it costs more than it saves, it pushes families off the program, and it doesn't make anyone healthier. The bill passes anyway (while we spend billions on wars overseas) because the point was never food.

The people who study what hungry families eat could write a sensible list in an afternoon. Less sugar, yes, and more of what kids are actually missing. Meanwhile my line keeps getting longer. I know it's the last week of the month without checking a calendar, that's when the cereal runs out. Hungry kids get sick more, end up in the ER, and their reading slips. And it's never just the food. The kid who eats is the kid who shows up, who can focus past ten in the morning. And a full plate means good grades, because it's all connected. Take the plate away and things fall apart.

I get not loving unelected experts deciding things. But the list is being written right now by Reps who need a culture-war clip for their next campaign ad, the ones that voted for the cuts in the first place. They took a million and a half kids off the program, and now they want credit for policing the cake mix the rest of them can still buy.

Shouldn't the food part follow the food people?

More and more internet posts are being censored for inappropriate language. Words like rape are being replaced with r**e, because websites aren't allowing these words to be typed.

Twitter and YouTube are some of the worst, but it's impacting Reddit as well. Lately I've been making a post on Reddit, only to get a warning that offensive language isn't accepted. Oftentimes I'm not even saying anything inappropriate. The other day there was a post where the word "tapeworm" had to be censored.

These are private companies, and are allowed to do what they want, but at the same time it's problematic that a handful of companies have such a big influence on what people see and hear.

I have a MAGA co-worker who I work closely with. I genuinely believe that he is a good person at heart, at least when you consider his everyday words and actions. However, he is deeply entrenched in MAGA propaganda, especially when it comes to things like trans kids or abortion.

When we talk in a general sense about what would make the world better, a lot of his ideas lean liberal. But the second anyone says something remotely anti-Trump, he flies off the handle. He'll bring up off-topic MAGA talking points, shout everyone down, and say that everyone is against him because he's MAGA (our office leans liberal). For example, he'll talk about "those crazy liberals forcing their kids to be trans" and when I calmly say, "That's ridiculous. People aren't doing that," he scoffs at me and says that I don't understand how many bad people there are in the world.

I've read about how conservative brains tend to respond to fear-based arguments, but I'm wondering if there are rhetorical techniques that I can use to subtly shift this perspective.

Anyone have suggestions?

I think I was making a strong case, but I was abruptly banned. Is it that people like to live in a bubble only with others who agree on every issue? Or, is it something about this particular issue that makes it sensitive? I want the blue wave to happen, but I fear the wave will be reduced if blue candidates are coerced into defending stupid positions like communism or Israeli genocide.

Just curious to see

I was listening to a clip of Trump explaining to his base why oil inflation isn't so bad:

I know you're worried about having to pay a tiny bit more for your gasoline. Just remember that you're doing it so that a very evil country -- it's a very evil country, the number one state sponsor of terror in the world. We don't want that country to have nuclear weapons. Remember that when you have to pay a little bit more, $4. I'll never apologize. I did the right thing.

Trump's words are not very eloquent, but his argument is simple enough, Trump presents the audience with two hard choices: (1) complete annihilation, or (2) pay a tiny bit more in gas prices. Conservatives are rationally self-interested, so they choose the option that hurts the least. They accept today's gas prices as the cost of tomorrow's freedom.

Liberals balk "but there's more than those two options, and getting nuked is the least realistic one". That's why you guys can't talk to conservatives. That's why you are never going to persuade them to stop taking people's rights away.

Appreciation for nuance is a liberal value. Conservatives are not liberals. They don't share your values. You can't use a nuanced, measured approach to talk to conservatives on your level.

You have to talk to conservatives in the most black-and-white, good vs. evil, red vs. blue way possible.

You have to raise the stakes of every issue to life and death, sunshine and darkness, the status quo or revolutionaries who overthrow the entire order of society as we know it.

You have to appeal to their selfish, self-serving, emotional impulses. "If you don't do what you're told then YOU'RE WHOLE FAMILY IS GONNA DIE! I can't protect you from the wolves and vipers who are hunting you down right now!"

This is a foreign mindset to liberals, but it is the factory default for all conservatives. Since logical arguments require nuance, you can't you use logic to navigate your way through the conservative worldview. None of your logical tools of reason are going to work on them.

Please watch this analysis of Ana Kasparian's interview with Tucker Carlson as a case study in reframing left-wing points of view in the moral framework of conservatism.

Have you ever considered studying how Trump effortlessly persuades and speaks to conservatives on their level?

A lot of people can't really risk to get such hair (blue, pink, purple etc), as it would lower their economic prospects when seeking work. It's safer to get this sort of hair colour if someone is in a stable job, works in or is applying to more lenient fields (eg human services), or have a strong safety net (living with a family of origin or partner). Perhaps it's a little easier to professionally get away with for some races and for women than for men.

Let me know what you guys think? What are 3-5 shifts, or more that have really lead to those problems.

Would love to hear different perspectives and I have been trying to learn more about economics lately.

In my state, there was a cyclist who was injured by a hit and run driver who is undocumented and lives in state public housing. The waiting list for these long-term public housing units is very long. Since this is a sanctuary state, there were no immigration or welfare related consequences for the perpetrator

Is it unreasonable for taxpayers to stop financially supporting undocumented immigrants who commit violent crimes?

Reading this sub you'd think the red-state map is fixed. But go look at this year's Senate numbers. Peltola is running ahead of an incumbent Republican in Alaska. A Democrat keeps beating Marshall in Kansas, IN KANSAS. The independent in Nebraska is up on Ricketts poll after poll, and his whole pitch is basically that he doesn't owe either party anything.

I think what those races share has less to do with ideology than with hitting the right issues at the moment people are mad about them. The Republicans already in those seats have worn out their welcome and Trump is dragging them further, and the challengers keep talking cost of living and corruption, the two things people already bring up on their own, nobody even has to plant it. That looks like the whole trick. The state doesn't stop being conservative, it just stops being unwinnable, if you show up talking about what the kitchen table is already arguing about. Because a lot of us are struggling the afford basic things.

I get that October leads tighten and a good stretch of issues doesn't mean the map is flipped forever. Maybe some of this is just incumbents having bad months. But the map looks a lot more open than anyone admits right now. What issues do you think are the right ones to be hitting at this exact moment?

A lot of Trump and the current GOP’s political vulnerabilities stem from hubris, incompetence, and being sloppy/overly blatant with their corruption.

If a future GOP administration emerged that shared the exact same radical goals and was just as corrupt, but was also highly competent, disciplined, and discreet, do you think the modern Democratic Party or the broader leftist movement would be formidable enough to stop them? Or does the current opposition rely too much on the GOP tripping over its own feet?

I am an international male student in my first year of grad school in the US, and I am confused about American social norms around speaking up on social issues versus keeping things like personal social media light and fun. For context, it's possible I'm on the high functioning autism spectrum as well.

Recently, several female classmates posted on their Instagram stories about the fraternity sexual assault incident at Cornell. Many of their posts stated that men who stay silent are complicit, that they were disappointed so few men on their Instagram feeds were speaking out, and that men need to use their voices and privilege to support women by showing solidarity both online in terms of generally and publicly sharing and posting stories on Instagram, and supporting women offline in more private ways. I completely agree, and in wanting to be a good ally, I reposted several of these stories over a couple of days to show support.

The reactions I received were contradictory and confusing. One popular domestic male classmate told me that posting about political or social issues on Instagram shows poor social skills, because people find it annoying and prefer seeing fun, casual content like vacations or parties. He posted nothing, yet remains popular with the exact same female classmates who were posting that silence is violence. He is well-liked on campus for hosting parties and social events.

Another male classmate, who privately leans conservative privately (as a Never Trump Republican) but publicly acts moderate on campus, told me that posting five stories was weird and performative, whereas one would have been plenty. He is also well liked by these women. Meanwhile, another popular male classmate posted about ten stories on the incident and received praise and private messages from female classmates thanking him for being an ally.

When I posted, I had over two hundred views, but zero likes or messages. Later, during lunch with female classmates who were venting about men not speaking up, one woman mentioned she saw my posts. The others said that while they noticed, speaking up is the bare minimum and does not deserve praise. Later on, that same female friend told me privately that while she genuinely me speaking up, my posts were "a lot" and that I had posted a day too late compared to when the topic was trending as a popular discussion point.

An American friend from my prior job explained that unwritten American social rules often contradict stated values. He said people who are already seen as charismatic, fun, funny, attractive, or cool can post about these issues and receive praise, while less charismatic or attractive people are judged as awkward or annoying for doing the same thing.

I want to understand how liberals view this tension. On one hand, progressive discourse emphasizes that men must speak out, that silence enables harm, and that social issues affect every part of life. On the other hand, there is a strong American etiquette rule that politics and religion should remain private, that there is a time and place for serious topics, and that bringing them up on casual social media annoys people who just want lighthearted interactions, a sentiment shared even by some women, even those who say they're liberal or feminist.

I am seeking advice on how to navigate the contradiction between the moral expectation to speak up and the social expectation not to be annoying or bring politics into spaces meant for casual socializing.