Americans' opportunities for healthcare reform come around very rarely, maybe not quite as infrequently as Haley's Comet, but only about every 15 to 20 years.

The last time around when reform was on the agenda in 1994,Bill and Hillary Clinton began by ruling out a Canadian-style "single-payer" plan that: a) represents MAXIMUM-STRENGTH reform in terms of costing roughly half of US per-person health expenditures while offering far better outcomes (life expectancy, infant mortality, etc.), covering every single citizen (as opposed to leaving 47 million Americans without insurance) and more streamlined care (more doctor visits, longer hospital stays) than the US.

The single-payer model is able to achieve these results because the huge costs imposed by the dominance of private insurers are eliminated--underwriting costs, commissions, CEO pay, huge office buildings, and enormous staffs devoted to rejecting enrollees with health problems and turning down claims for care. US administrative costs are over 31% compared with roughly 16% in Canada. b) Single-payer is relatively SIMPLE and FAMILIAR, since it is much like our own popular Medicare system in that patients choose their own doctors, doctors remain in private practice, and hospitals stay privately-owned. (However, a single-payer plan would lift doctor and hospital reimbursements to more reasonable levels than possible now. As with Medicare, a single-payer plan essentially pushes private insurers out of the driver's seat of health care.(Although during the Bush years, there has been a huge expansion of subsidies to private insurers seeking to tap healthier and wealthier Medicare patients.) In the insurers' place, each Canadian province has one non-profit entity that pays the bills and negotiates with hospitals and doctors. c) The single-payer model is HUGELY POPULAR: a Wall St. Journal poll in 1993 showed 69% support among American citizens for a Canadian-style plan. But the Clintons rapidly disqualified this alternative, as it would alienate the major campaign donors from the giants of the insurance and HMO industry. In its place, the Clintons designed a hopelessly complex Rube Goldberg machine based on the concept of "managed care." However, the smaller and medium-sized health insurance firms launched the infamous "Harry and Louise" TV ads to undermine public support for reform, since they were being cut out in favor of larger firms.

Meanwhile, consumers were not particularly enthused about a plan so complicated and so heavily based on Health Maintenance Organizations, which are widely seen as intruding into patients' choice of doctors and doctors' decisions on care (like demanding "drive-through deliveries" and other too-brief hospital stays. So the "HillaryCare" plan managed to arouse the opposition of part of the insurance industry and utterly failed to ignite much enthusiasm among the millions who were seeking both decent coverage and relief from their private insurance bureaucracies. Further, top Republican strategies like William Kristol recognized that passage of meaningful health reform would help rebuild the Democratic base created by the New Deal, the GI Bill, civil rights legislation, and Medicare. Real healthcare reform would be a landmark achievement that would generate enormous support for the Democrats, so the Republicans resisted the tiniest changes.

WINNING THROUGH SURRENDER After waiting some 13 years for another shot at reform,some reformers are so eager to get anything with a "reform" label passed that they are willing to overlook the basic flaws with any plan that keeps private insurers running our healthcare system. Unfortunately, one of those reformers is Dr. Atul Gawande, a columnist for the NY Times who has written movingly in the past on the burdens imposed by private insurers. But in his May 31 column, Dr. Gawande cites the chief barrier to reform not as the upcoming propaganda assaults of the health-insurance and pharmaceutical industries and their allies, but the danger that reformers will not simply surrender to these forces. "If we as consumers, health professionals and business people sit on our hands, unwilling to compromise and defend change, we will be doomed to our sliding global competitiveness and self-defeating [health] system."
But Dr. Gawande fails to recognize several key realities:
1) AMERICANS WANT SINGLE-PAYER US citizens--and that now includes doctors--want maximum-strength reform, not tinkering that leaves the insurers in charge. Polling by Business Week in 2005 showed "67% of all Americans think it's a good idea to guarantee healthcare for all US citizens, as Canada and Britain do, with just 27% dissenting." Remarkably, the incursions of insurers into health decisions and intensifying commercial pressures have also galvanized doctors. The result has been an increasing openness to a universal single-payer healthcare plan along the lines of Canada's, where doctors and hospitals remain private but the insurance function is "socialized." Polls of Massachusetts and Minnesota both showed a stunning 64% of doctors favoring a single-payer approac want a single-payer system.
2)SURRENDER WILL "DOOM US," TOO: Unless we take on the insurance and drug industries, the system will not fundamentally change. Costs will remain out of control, eating more and more of our GNP (now at about 16%). US products will become more and more uncompetitive unless employers keep dumping more and more costs on to workers, or cutting off insurance entirely.And that means that efforts to establish universal care will eventually be undermined (probably sooner rather than later)
3) SOMETHING WORTH FIGHTING FOR: The insurance and drug industries have billions in profits to hire legions of lobbyists, clever PR people to invent false attacks on single-payer, and of course tons of money to give as legal "payoffs" to congressional and presidential candidates in exchange for hoped-for inaction on healthcare. The only way that organized money can possibly be defeated is with organized people. And the people will not get organized and get mobilized unless they see a clear and dramatic shift from the status quo. Giving in to the insurers and drug industries, as Dr. Gawande prescribes, is actuallythe surest way to guarantee that real health reform remains a distant dream.