It should come as no surprise that single-payer universal health care is now at the center of a fierce debate, both in the Democratic primary and the national political discourse.

Why? Because the path we have taken so far – with the passage of the Affordable Care Act – has left many of the gravest shortcomings of our health care system intact, even as it has expanded coverage. This is unfortunate, but not surprising.

As many have observed, the health care law is the intellectual descendent of the health care proposal of none other than Richard Nixon. Nixon's plan was designed to parry the single-payer proposal of Massachusetts Sen. Ted Kennedy, which was itself the descendent of Harry Truman's plan from some two-and-half decades earlier. What was once a Republican plan has now become a Democratic plan. What was once a Democratic plan – single-payer – is now being assaulted by many Democrats.



The Affordable Care Act approach is inadequate for a multitude of reasons. First, it leaves millions uninsured, indefinitely. Second, a hugely wasteful health care bureaucracy – currently costing us an unnecessary $375 billion annually by one estimate – will continue to grow. Third, rising copayments and deductibles are being increasingly used to deter care and pass down costs, squeezing the working class. Fourth, the law does not do enough to combat racial health inequalities: Separate health care for different groups is, to borrow a phrase, inherently unequal (among other issues).

A number of critiques have recently been leveled at single-payer from liberal quarters. Before Sunday's debate came Hillary and Chelsea Clinton's fuzzy contention that single-payer would subject health programs like Medicare to the whims of state governors. This was largely laughed off at the time and has now been made moot by Bernie Sanders' new fully federal proposal.

Another point sometimes raised is that single-payer would require new taxes on the middle class. Not always emphasized, however, is that such taxes would replace not only existing premiums, but also most out-of-pocket health costs.

