As I mentioned recently, Bernie’s Sanders’s health care proposal has been criticized for being weak on the technical details and not making tough choices. I don’t really have an issue with that per se. What I do want to emphasize, however, is that it would be a serious mistake to conflate “universal health coverage” with “single payer”:

The problem with Sanders’s single payer proposal isn’t that it is too vague to allow voters to assess its feasibility and its flaws. The problem with his plan is that it reinforces the idea that European-style universal health care is synonymous with “single payer”; that is simply untrue. There are models that deliver similar or better results than single payer systems, and they are more politically viable within the American system.

In terms of viability, it’s vital to understand the massive economic disruption that implementing single payer in this day and age would cause, and how that would make it a political non-starter regardless of which party controlled Congress. As Paul Starr argued recently in the American Prospect, when President Truman proposed universal health insurance, health care costs were only 4% of GDP; had the US gotten single payer then, health care would be much less costly today. Since then, however, health care costs have ballooned, and that makes a public takeover of the health insurance industry far more difficult.

From the Social Security Act to the Affordable Care Act, major progressive reform in the United States has always involved compromises to buy off vested interests. And, even in countries where there are fewer institutional mechanisms to thwart change, medical lobbies have serious influence. Even with the advantages of a political system that makes it easier for major reforms to pass, nationalized health care was able to pass in the UK only because Labour Health Minister Aneurin Bevan “stuffed the mouths” of medical practitioners “with gold”. It’s one thing to do that in the UK in 1948; the amount of gold that would have to be stuffed into the millions of mouths of the American health industry to make single payer viable in the 21st century would require insanely high (and obviously politically unsustainable) levels of taxation and would also defeat much of the purpose of converting to single payer in the first place.

To implement a single payer health care system from scratch in 2017 would mean not only nationalizing the insurance industry, but severely cutting payments to doctors, hospitals and other areas of the health care industry if it were to bring any cost savings. A lot of people working for politically powerful lobbies would be thrown out of work or bankrupted, and many others would be looking at whopping pay cuts; that would never be politically viable even if it was desirable as policy.

To put it another way, single payer in the contemporary US faces intertwined political and policy problems that are insurmountable. The effects of the lack of cost controls in the American system for decades can’t be undone overnight.

Still, the fact that single payer is probably politically unviable shouldn’t stop anyone from focusing on single payer as a long-term goal if it was the only way of achieving real universal health care. But it’s not.

Many liberal democracies, including Switzerland, France and Germany, have achieved true universal coverage with hybrid public/private models. The Netherlands actually changed its single-payer system to a hybrid system in 2006. When compared to single-payer Canada, the hybrid models in general rank better in quality and efficiency and are as or more equitable. And like single-payer, they deliver better results for far less money than the US spends.