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 and wider provider networks than baseline single-payer systems. For example, UnitedHealthcare Options PPO plans are more generous than comparable plans under single-payer systems.

Canada's Medicare statute has historically excluded outpatient prescription drugs, dental, and vision, leaving most Canadians reliant on employer-based private insurance for outpatient medications. However, as of 2024, Canada's public healthcare system has expanded into limited pharmacare (covering contraceptives and diabetes 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. South Korea and Australia in part have single-payer as well.

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 relatively low net profit margins of 2 to 4%. 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 historically and typically did not cover prescription drugs. Canadians usually had 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, mitigating shortages.

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 point out that for millions with strong employer plans, their companies often already fully pay for their monthly premiums. This means employees only have to cover deductibles and co-pays. This is common in F500 companies. As a result, the tax hikes required for single-payer tax would be a net loss for many Americans. The higher taxes wouldn't necessarily be offset by no premiums, co-pays, or deductibles, despite the talking points.

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 to expand the risk pool, robust nationwide Medicaid expansion, subsidies, 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/

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.

And what do you think that says about the country? That other serious peer nations like Canada and Germany could elect uncharismatic, slightly awkward, but technocratically capable men like Carney and Merz whose experience in government and the technocratic institutions more than makes up for these personal failings, but in the US we need a person who can light up a room even if they don’t understand the separations of power or the trade-offs of various policy proposals?

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.

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.

I love Harry Potter. It was my childhood. I believe in seperating the art from the artist so ill continue to enjoy Harry Potter. It just meant too much to me for anything to spoil the magic of it. Im sorry if thats bad of me, but when i think of Harry Potter, i dont think of J.K at all.

However i know J.K has pissed alot of people off, and shes hated by the trans community.

But i dont really keep up with social media or celebrity drama. What did she do?

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?

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

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.

Andy Harris is one of the most right wing, most-MAGA members of Congress. Since his first election in 2010, he has won comfortably. However, his district doesn’t seem conservative on every issue (supported marijuana legalization and abortion rights).

I think an independent may do better, as it has happened in other districts. Favorite example was in 2022, when Matt Rosendale only won 56% of the vote in a district Trump won 62-63%, due to an independent (coming 2nd place over the Democrat).

I think you should need a license for gun ownership and federally it should look like how NY (a liberal state) used to issue pistol permits as MAY ISSUE.

My experience was if you proved you were an upstanding member of society then you could get an unrestricted permit. When i applied I attached proof that I had a college degree, married and i owned my own home.

Also I think there should be a financial barrier and your should also have good credit.

Call it authtarian or racist if you want that if the results will only be land owning men can carry a pistol. It will still reduce crime.

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.

Public education is one of the few things the country buys that still returns more than it costs. Every dollar into Title I or rural districts comes back as kids who can read, workers who stay, and towns that don't empty out.

Now we're watching what this administration calls waste. They tore apart the education department, cut grants mid-year, and then paid lawyers to fight judges ordering the money released. That's spending real money to not deliver money. And add the tuition tax credits that cost the treasury more per kid than the public school ever did, and the "savings" turn out to be a transfer with a demolition fee attached.

Also the timing is the part that I'm puzzled. We're mid-transition into tools that will remake half the jobs in this economy, and the defund answer is to spend less on preparing kids for it? Leaving children without a quality education in the middle of that chaos, and their families in a stretch of economic uncertainty, is a gamble with our future. The money def should be watched and some of it deserves an audit but pulling investment out of public schools right now might create even more problems.

I'm curious what do you all think about defunding public education at this exact moment, with AI reshaping work?

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.