Dead on arrival: why Washington's power elites won't consider single payer health reform.

• Author: Hamburger, Tom
• Position: Cover Story

In February, Dr. Quentin Young flew to Washington from his home in Chicago, pleased to have been asked to consult with top White House officials on health care. Young, the past president of Physicians for a National Health Program, was looking forward to plumping for his organization's favorite cause: Adapting Canada's national health insurance system to the United States.

Young had an attractive case to make: Canada, where provincial governments act as single insurers, annually spends 30 percent less per capita than we do for health care, providing universal coverage, cost controls, and choice of physician. The U.S. fails to insure 37 million people and has no control over rising costs, and a Harvard University survey of 10 nations found that Canadians were the most satisfied with their health-care system; Americans were the least.

But Young's enthusiasm quickly withered within the White House gates. It turned out, in Young's words. that he had been invited for "pseudo consultation." White House staff made it clear that single payer was off the table. "Why?" Young asked, amazed. A senior White House health adviser, Walter Zelman, put it bluntly: "Single payer is not politically feasible."

In a separate session with Hillary Rodham Clinton, Dr. David Himmelstein of Harvard Medical School (a close colleague of Young's), also pressed the single-payer point. Canada's solution, he said, made sense for the United States. Himmelstein's studies, published in The New England Journal of Medicine since 1986, show that the U.S. could save as much as $67 billion in administrative costs alone by cutting out the 1,500 private insurers and going to a single government insurer in each state - easily enough to pay to cover every uninsured American.

Hillary Clinton had heard it all before. How, she asked Himmelstein, do you defeat the multi-billion dollar insurance industry? "With presidential leadership and polls showing that 70 percent of Americans favor [the features of] a single-payer system," Himmelstein recalls telling Mrs. Clinton. The First Lady replied: "Tell me something interesting, David."

So by February, fewer than six weeks into the Clinton presidency, the White House had made its key policy decision: Before the Health Care Task Force wrote a single page of its 22-volume report to the President, the single payer idea was written off, and "managed competition" was in. But why should an intelligent First Lady and her 500 health care advisers not want to debate every option, especially examples available from nations that have combined universal access and cost control?

Because in Washington's political culture, incremental change is the coin of the realm, and a move to single payer is seen as anything but incremental. (Though in fact, managed competition proposes a more drastic in health care delivery for most Americans than single payer does.) "I've been in so many meetings in Washington where people say, |We've got to fashion something that's acceptable to the interest groups,"' says Minnesota Senator Paul Wellstone, one of the few single payer champions. "And I know what groups they put at the top of the list - the heath care and insurance lobbies." But there's more to the failure to discuss single payer than lobbyists and their clout. Some politicians fear being caricatured as advocates of "big government" in an age of sound bite politics. And some fear being dismissed as irrelevant for supporting a cause that's thought to be outside the mainstream. What constitutes the mainstream? To understand that, consider how the capital's three established tribes - the politicians, the press, and the experts - slid single payer off the table without allowing people to decide for themselves whether it should be adopted:

* First, politicians like Mrs. Clinton fear the bitter, unique opposition of the health insurance industry to single payer. Doctors, hospitals, and health insurers will oppose elements of any reform, for only a single payer plan means the virtual abolition of an entire industry as we know it. Politicians who are reluctant to take on established interests in Washington ($60 million in medical and insurance PAC contributions since 1980) and back home (insurance agents in every Rotary Club in every district) are terrified by the anger that would result from putting health insurers out of business. Combining this with the normal opposition any reform provokes and with a political process that discourages full debate, politicians duck the merits of the issue and dismiss single payer as not feasible.

* Once this political fact has been established in the hearts and minds of politicians, the people who might be expected to raise out-of-the-mainstream questions - reporters - are generally too focused on politics, not on substance, to do anything more than reflect prevailing opinion rather than informing it.

* Finally, the experts who might be expected to rise above the political currents resists seriously appraising Canada for fear of being dismissed as cranks or...