Should Our Healthcare System Move to Single-Payer?

Arthur L. Caplan, PhD; Nicole B. Saphier, MD; Elizabeth R. Rosenthal, MD


May 29, 2018

Arthur L. Caplan, PhD: Hi. I'm Art Caplan, head of Medical Ethics at NYU School of Medicine. I want to welcome you to Medscape's ongoing series, Both Sides Now. Today we're going to look at a controversial topic: whether a single-payer system would reduce healthcare costs and benefit both patients and physicians in the United States, or whether it would have the opposite effect.

National health insurance administered by a single payer has been considered in the United States for many years. It's been debated for as long as I've been breathing, and the topic is very controversial. It's made it into the news more recently because of efforts at health reform and efforts to rethink the current system. Recent challenges to the Affordable Care Act have set off more debate about the merits of single-payer. There are strong advocates on both sides.

When we talk about single-payer during our show today, we're talking about a government payer for an individual's healthcare costs rather than having a variety of insurance companies handling insurance and reimbursement for those costs. Single-payer will cover the cost of care for all US residents. In single-payer there would be one insurance system and one, if you will, government administration, as we have for Medicare and the VA. Then we would still retain private doctors and private hospitals.

Some say single-payer would reduce healthcare costs by cutting down on administrative fees, eliminating commercial insurers' drive for profits. Many of those who oppose it say that single-payer would have free reign to lower physician reimbursement and payments. It would also build up its own inevitable bureaucratic inefficiencies. Additionally, it needs to be noted that if insurance companies were put out of business, there's a lot of people, upwards of 800,000, who would suddenly be out of jobs from the private-sector insurance.

Today we have two guests who I'm certain are going to shed light on the pros and cons of this complicated topic. Dr Nicole Saphier is a board-certified radiologist and director of breast imaging at Memorial Sloan Kettering Monmouth. She believes that preserving an open, consumer-, market-driven system rather than a closed, single government insurance system is essential to achieving long-term societal and individual health.

Also joining us is Dr Elizabeth Rosenthal, a retired dermatologist. She sits on the board of directors of the New York Metropolitan Chapter of Physicians for a National Health Program. She supports an expanded and improved Medicare-plus system for all of America's residents.

Thanks for joining us and thanks for appearing on Both Sides Now. I'm going to get right into this with a question to Nicole first. What do you think would be the advantages and disadvantages for physicians in particular if we went to a single-payer insurance system?

Our Healthcare System 'Is Not Working'

Nicole B. Saphier, MD: Without a doubt, our current healthcare system is not working. It's expensive, it's overutilized, and it's not working for patients, physicians, and the taxpayers. I can appreciate the merits when people are advocating for Medicare for all, single-payer. I understand the merits. There are also merits to having a privatized system. Unfortunately, our capitalistic ways in America have made the cost of healthcare so expensive that it's really hard to just stop right now and implement a single-payer system. The reason that some of these systems can work in other countries is because they've put price caps for decades. Their healthcare cost hasn't grown like it has in America.

Caplan: They're bargaining their price, so to speak.

Saphier: Right now, if we were to impose a single payer, that would be like having a semi-truck going full speed and then just stopping. It will be, in my opinion, catastrophic in the short term. For physicians, again in the altruistic sense, we all want to help people. As a practicing physician, I see everyone. I do not check insurance cards at the door. I have no idea what their insurance is, and maybe that's a detriment, but I also just want to look at my patients. I do want patients to have access to care.

We currently have tens of millions of people still without healthcare insurance. That is an issue. That is a problem that we need to address. However, in the single-payer system, I believe that by having this government control, you're going to drastically cut reimbursements to physicians in the way that you're describing; and not only will that make our doctor shortage even more so, but I believe truly that the innovation is not going to be there.

Caplan: A lot of doctors complain to me bitterly, saying that in this current system, "I am spending forever, or I hire people, to handle of all these different insurance forms. There's a huge burden on me as I try to figure it all out." In the back office there are four or five people just sorting out insurance forms. What would you say to that criticism?

Saphier: Without a doubt, with the insurance industry right now we are completely inundated with paperwork. We spend more time doing administrative work than seeing our patients, which is not a good thing. That is not why we went to medical school and did so much training. We do need insurance reform. That doesn't necessarily mean you need a single-payer system.

By having a single payer, you're just going to be replacing one middleman with a government middleman.

We really need to restructure the way that insurance and care are delivered. We should not have to be clicking so many things to make sure that insurance is covering what we're recommending for our patients. It needs to be easier for physicians and hospitals to be reimbursed for the care and the work that was performed and delivered. Insurance companies have made it so increasingly difficult for physicians to get reimbursed; that is where those check boxes come in. Just by having a single payer, you're just going to be replacing one middleman with a government middleman.

The biggest concern for me is the political agenda, and each annual budget is going to be shifting. What healthcare services are going to be covered or not because we're going to be solely dependent on what the government's doing that year?

Caplan: Elizabeth, I'm going to come back to some of these issues with you.

Elizabeth R. Rosenthal, MD: There is so much to disagree with.

Caplan: If we looked at it just from the point of view of that initial question I raised, benefits for physicians—and I promise I'll come back to some of the other points Nicole made—what would you say to our viewers? Why do you not get behind this single-payer idea in terms of what their interests are as doctors?

Rosenthal: I went to medical school to treat patients just as Nicole did, and I was frustrated by the same things that she is. I think that for doctors, first of all, it's not automatically that they're all going to get paid much less, because we have other countries where we can see where this was done and the doctors are doing very well, thank you.

If you don't have to pay a huge staff to do all of the billing, you could earn more money and then you wouldn't have to spend all of your time fighting with insurance companies to get paid. And you could see more patients. It's not automatic that doctors would get paid a whole lot less. The government isn't going to take control of the whole medical system. They are going to do the financing.

Caplan: One proposal might be single-payer, one type of reimbursement agency—kind of like what we see with the VA or with Medicare. Further along the road there is a proposal which says that everyone is going to work for the government. It'll be like the British system, but we're not talking about that. You're not talking about that?

Rosenthal: I'm not talking about that. I'm talking about a single payer that's the government but privately delivered. The system we have now—I agree with Nicole—it's chaotic, it's expensive. There are lots of things that we could do to improve it—not just the financing, the delivering system. The one thing we can do that I think would bring down costs and simplify everything is to have a government single payer like Medicare.

Medicare has worked very well in this country for 50 years. Now there are attempts to privatize it, but it has been working very well. When it was instituted, it was up and running very smoothly within 1 year, with no computers.

Giving the Government Payment Authority

Caplan: Some people worry, and I think Nicole brought up this worry, over handing payment authority to a single agency, particularly a government one. Let's talk about our Congress, for example. They're not in the habit these days of generously funding healthcare. Why wouldn't it inevitably start to ratchet down with people saying, "You know, we're going to pay less, we're going to pay less"?

Rosenthal: We know about that because we have Medicare and we have Medicaid. Their payment schedules are very different. Medicare is given to everybody as soon as they get to be 65 and to people who are disabled who are younger than 65. Rich people get Medicare. People with clout get Medicare.

Caplan: They're the haves of society.

Rosenthal: Exactly. But Medicaid is just the opposite. People who get Medicaid have no political clout, and so the first thing that gets cut all the time is Medicaid. This is going to be Medicare for all. Other countries in the world have done it—this is not reinventing the wheel. We can look all over, at the rich countries, and see how they do it. The fees that doctors get paid are not terribly low. Now, it's possible that some of the highest earners might earn a little less and some of the lowest earners might earn a little more, but nobody's going to go poor.

Caplan: I can't ignore this debate opportunity. Nicole, what about this idea that we can go to single-payer, but physician incomes are pretty much going to be preserved? After all, they won't have to hire 48 people to work the back office to do billing all day long. There will be efficiencies in their own time. Maybe they'll get to see their families once in a while. What do you say to that argument? We don't have to worry; other countries have done it and physicians aren't losing their homes or having their cars repossessed.

Saphier: I do have to agree with Elizabeth. Medicare, as it stands, is a wonderful service. It functions very well. However, it is going bankrupt in its current system because healthcare prices have gone so high. Again, changing the system before addressing the healthcare cost is putting the cart before the horse. If you don't truly focus in on how to lower healthcare costs before you come up with your ideas for coverage, I don't think you're going to get very far. It won't be a Medicare for all. It'll be a Medicaid for all. There will be rationing.

Rosenthal: We have rationing right now.

Saphier: It's just going to continue on.

Rosenthal: In other countries, people get the medical care they need. In this country, you get the medical care you can afford. The only reason to have more than one plan is because you can't afford the good one.

Caplan: Let me jump in on this price issue, because I think it is partly driving some of the difference of opinion here. Is there more incentive to go after why prices are so high? If we have a single payer, wouldn't that lead to more questioning of prices right now? It's off in the private sector, in a certain sense—Congress, political officials. Let the market sort it out, if you will. If they were really footing the bill, wouldn't they try to examine prices more closely? Isn't there more motive to do that in a single-payer system?

Saphier: Sure. There might be more motive. Again, it's just a philosophical debate. If you are wanting the government to come in and take over and do that, then that is one philosophy. I can appreciate the merit in it, but I don't necessarily think that we are at that place where that is our only way out. I believe that some people are advocating Medicare for all right now because they don't see another way, because things have gotten so discombobulated with the Affordable Care Act. Now with the new administration, people are just throwing their hands up in the air. My concern is that they're throwing their hands up in the air because they just haven't seen that there are possibly other options that are not being focused on.

Now, your other question, when you talked about the price differential or the compensation differential between physicians—very true. Some physicians may see more. Your primary care doctors, your pediatricians, they may actually see a little bit of a price increase.

Caplan: Income increase?

Saphier: Thank you. Yes, income increase—not because they're necessarily being reimbursed more but their overhead will potentially be lower. As Elizabeth mentioned, they won't have to do so much billing and it's just going to be streamlined a little bit more.

Our specialists, some of them have about three times more training than our family practitioners or our pediatricians. Their compensation will decrease. I've never heard of a solution being a price cut. My concern is our educators. We encourage them to get MBAs, and what do we do when they get their master's? We reward them with an increase in price compensation because they're bringing value to the system. Our physicians, who do extended training—why are we not going to reward them accordingly because they are bringing value to the system as well?

Rosenthal: I'm a dermatologist, and I visited dermatologists in Canada. They were doing very well. The dermatologist I visited was making more money than I was making, and she had a lot fewer expenses. I don't think it's something that's automatically going to happen, that doctors are going to take these big pay cuts.

Doctors are going to be on the boards that decide, and there'll be negotiations between the government, the doctors, and the different doctor groups to see that they're well paid. Everybody gets it, just like everybody gets Medicare; the prices will be good.

Caplan: Let me push that a little bit.

Rosenthal: The compensation would be good.

Single-Payer and Healthcare Costs

Caplan: Why would the price be better or more controlled in single-payer than they are in the market today? Which isn't to say that they're not controlled today, but what makes you think that single-payer would help drive prices down?

Rosenthal: First of all, you're going to eliminate a very expensive middleman, which is the private health insurance industry. They take anywhere from 20% to 25% of the healthcare dollar and they don't give you anything. They add cost but no value to the system. Eliminating them will definitely save billions—some people estimate $400 or $500 billion. Right away that's going to bring the cost down.

The other thing is, if you have one system, you can much better try to find out what works best and what's most cost-effective. Now if you want to get that kind of information, each insurance company has their own proprietary knowledge and they don't share. You could have one big national computer system. Right now, everybody has their own computer system and they don't talk to each other.

Caplan: I like this point, so let's ask Nicole. Big data,: all the rage these days; everybody wants to collect massive amounts of data about everything. Correlating your hospital admissions with your grocery store shopping habits with who knows what. If we had a single-payer system, some would argue that we would be closer to being able to really squeeze important public health findings out of a single database. What would you say to that?

Saphier: Why do we need a single-payer system to have a cloud-based EMR? As a radiologist, we are already advocating for private sector cloud-based programs such as this because, absolutely, it is inefficient and it's overutilized. We're repeating scans, we're repeating tests, and patients are essentially double-dipping and they're not even trying to. They have no idea that things are having to be duplicated because there's no computer.

Caplan: Then there's some fraud out there too.

Saphier: There is fraud, absolutely, but a lot of it is billing errors. My concern is that we're getting off topic of what insurance really is. Insurance is risk-based. It's not actual. It's not definitive. We're stuck trying to jam these benefit models into insurance. I think we have two broken systems. In my opinion, it is not how to pay for our sick; that is an insurance problem. I think we need to really separate the two: Focus on insuring Americans. I don't think it's acceptable for tens of millions of Americans still to be without insurance. I think we can agree on that. I don't think that should be compiled with how to care for our chronically ill and very expensive population.

Caplan: Elizabeth, let me ask you a question related to this. What are we going to cover? What's the essential plan? Is it what Medicare covers? As you pointed out, Medicaid doesn't cover a lot of what Medicare does. Can we afford it?

Rosenthal: It also covers a lot of things that Medicare doesn't for us.

Caplan: What do you see in your package, is what I'm getting at. Medicare plus?

Rosenthal: What Medicare covers plus vision.

Caplan: Long-term care?

Rosenthal: Long-term care, dental, hearing.

Caplan: Preventive?

Rosenthal: Preventive—absolutely.

Caplan: A lot of insurance these days don't cover some preventive-type interventions.

Health insurance companies are in business to make money. They are not in business to deliver healthcare. They compete against each other by who can most successfully avoid paying for sick people.

Rosenthal: The way insurance works is that you have a very large pool and the healthy people subsidize the sick people. Well, if you have a really large pool, like the entire country, you can do that so much more efficiently. Health insurance companies are in business to make money. They are not in business to deliver healthcare. They compete against each other by who can most successfully avoid paying for sick people.

Speaking of Taxes

Caplan: We got rid of them in your ideal world. How are we paying for this? Are we taxing?

Rosenthal: Yes.

Caplan: We're going to tax. Meaning income?

Rosenthal: Progressive taxes. It hasn't been entirely worked out. There are lots of different possible ways of doing it. There's a New York health act which—one of the economists who did a study on how that would be financed, with taxes, payroll taxes, 80% [from] the employer, 20% [from] the employee. It would be graduated progressively so that people who earn very little money would pay nothing. People who earned a lot would pay a lot more. You'd also have a tax on your earned income.

Caplan: We tried a mandate under Obamacare, much more modest insurance reform. What do they call themselves, the young immortals? The people who are young and healthy, they said, "I'm not paying anything. I don't need it. I don't want to subsidize Art Caplan's rotten health and his crummy health habits. I'm not paying for that." The mandate was attacked constantly. How are you going to get a mandate through to those healthy people?

Rosenthal: It's going to be a tax. You have to pay your taxes; everybody does.

Caplan: They're going to say, "I don't want to be taxed for people who are irresponsible."

Rosenthal: I don't want to be taxed for the army. I don't want to be taxed for the wars that we're fighting. But I have to pay my taxes.

Caplan: We're going to tax. There's no political argument about it. You've got to pay your taxes. This is going to be part of what your tax bill is. Is that viable? Is that politically viable?

Saphier: We're Americans; we pay taxes. However, I don't ascribe to the point that I'm okay with my tax bill going up significantly. We saw the outrage that occurred under the Obama administration with the Affordable Care Act. I can only imagine the backlash that would come if we just went straight to a single payer. That would be, in my opinion, an astronomical increase.

Rosenthal: No, it won't. It wouldn't be—you wouldn't have any healthcare expenses.

Saphier: I did say "in my opinion."

Caplan: Let's stick on that point for a second.

Saphier: It's a subjective term.

Caplan: Tell me: If we went there—you know we can't go once, tomorrow, but could we go gradually?

Saphier: If we were talking about a gradual progression of increased taxes, then at some point, potentially, we could get to the place where we're able to afford said healthcare system. The one that's being described sounds extremely expensive to me and I'm not Oprah. I can't just—"you get a house, you get a house, you get a house." To me it does sound like a reach. Perhaps over decades, America can get there.

Caplan: I just want Medscape to know, by the way, that we're going to that format soon with our guests. You get a house, you get a house. It'll be coming soon.

Saphier: Wonderful. I'll come back every time. Gradually, long term, if that is the way that the country decides to go as a country, then I am not necessarily so opposed to that. However, I think an implementation of such a system now with this shortened cycle, in my opinion, is just not something that's viable and I don't necessarily think I would have gone into medicine.

Rosenthal: First of all, I have to comment on one thing that's been said. We can't afford not to do this. These healthcare costs are bankrupting our country. It brought down General Motors. People cannot afford it. The businesses cannot afford it. If we go on the path that we're going now, pretty soon the average premium from health insurance is going to equal the entire average income. That's the path we're on. It's unsustainable.

It's not that everybody's going to get a house. I mean, you can have a house, you can have a car, whatever. People are going to get the healthcare they need. If their entire medical expenses disappear and their taxes go up half as much as the expenses that disappeared, they'll actually be saving money, and for most people that's what will happen.

I don't feel bad about paying a little more for my health insurance because other people can't afford to pay for them. I can afford to pay a little more on my taxes so that everybody has health insurance. That's fine with me.

'Medical Care Is a Social Need'

Caplan: That would be a kind of solidarity or community value.

Rosenthal: Right. I mean, we have socialized police. We have socialized libraries. We have socialized schools. Everybody gets it and everybody pays for it, and that's what we should have for medical care.

Caplan: You see it as part of a right that Americans ought to have access to basic healthcare?

Rosenthal: I don't like to get into legal language. I think it's a social need. Medical care is a social need, just like you have to have food and water and police protection.

Caplan: Do you agree with that?

Saphier: I do agree with that. I do believe that some level of access should be available to all Americans. I don't necessarily feel that that's an all-inclusive insurance card, but that's why we don't turn away people at the emergency departments.

There's something I want to touch on that you alluded to. You said that you have poor health but that's due to poor behaviors. I want to focus on poor behaviors, because in the United States we're seeing some decline in our life expectancy, which is astonishing for physicians, for everyone. A lot of it has to do with the opioid epidemic and cardiovascular disease, which plays into your self-inflicted behaviors. My concern is that we are not holding Americans accountable for some of their bad behavior. Don't quote me on the statistic, but I believe that over 50% of healthcare outcomes are actually due to patients' choice and behaviors, not necessarily the medical care that they receive.

Caplan: With the obesity rate we have, I'm sure that number's not far off.

Saphier: The American community has more gym memberships than anyone else in the world. We also have more people with metabolic syndrome. Why is that?

Caplan: Do you think the mode of payment would change the approach to prevention or lifestyle change?

Cost-Sharing Considerations

Saphier: If you think healthcare is expensive now, just wait until it's free for everyone and you take away the cost-sharing reductions.

Caplan: Do you agree with that?

Rosenthal: No. What cost-sharing does—and I love whoever called that "cost-sharing," because did anybody ask you if you wanted to share? I don't think so. What cost-sharing does—and there are statistics to show this—rather than avoid, is to bring down the costs and avoid too much care. It serves as a way for people to get the care that they actually need but can't afford. I think the reason for that is this whole skin-in-the-game idea, which is very popular in health policy.

I think the people making these policies do not know, have never known, have never been in the position where the $30 or $40 that they had to pay would stop them from getting something that they really need.

Caplan: That challenge is out there. We both agree that we need to drive prices down. We both agree that we need to do things more aggressively to enhance health by getting after lifestyle change and trying to prevent conditions and chronic ailments. It seems to be a consensus there.

I'm going to utter a word—well, two words, actually—and I want to get your reaction to it: death panel. I can't imagine that this fight will go more than 5 minutes in a public forum without somebody saying, "Well, if the government's doing the insurance, then they're going to decide who's going to live and who dies." What do you say?

Saphier: I do hear people talk about how in Canada, just north of us, there are people who are dying and are on wait lists. Is there some truth to that? People are absolutely on wait lists for specialists up there. I can't quote statistics that people are dying. I do think that when you ration care, people are having to wait longer, they're out of work longer, they're not bringing in income. Ultimately, it could lead to a more long-term disability if they're having to have excessive wait times getting in to see a physician.

Caplan: The government's got its hand on the check-writing. Is that going to make it worse in terms of access?

Rosenthal: We ration care in this country.

Caplan: What do you mean by that?

Rosenthal: It's according to how much money you have.

Caplan: People who pay get their care?

Rosenthal: Like you, I went to NYU Medical School. I was recently at my 50th reunion and we were given a tour. The student said, "This is Bellevue Hospital, where our underserved population goes, and this is University Hospital, where the other people go." I spoke up and I said, "Why should they go to two different places?" That's the way it was 50 years ago, that's the way it is now, but that doesn't mean it's right. We have a vast problem.

Caplan: I should add that there are some cities with no Bellevue.

Rosenthal: Right.

Caplan: Philadelphia, where I was for one time—no public hospital at all.

Rosenthal: Why should you not get healthcare if you're poor? It's not fair, it's not right. Our country's definitely rich enough to give it to everybody. It won't increase the price; it'll lower the price because we'll get rid of the very costly middleman. We'll be able to, as I said, with one unified system.

Caplan: Let me rephrase my provocative death panel idea.

Rosenthal: Let me explain about the death panel. People are made much more afraid of that than [they] really [need] to be. Many people here get too much care in their last days. They get tortured for the last 2 weeks of their life and a huge expense is paid. Other people just don't—they can't afford medicine, they can't afford anything, and they die on waiting lists.

Caplan: Homeless or something.

Rosenthal: They don't die on waiting lists; they never even get on the waiting list. Absolutely not. I see people all the time—I'm a Medicare advisor. They can't afford medical care. They just can't. They have to not take their pills or take them every other day. There are loads of people like that.

Caplan: Let me ask you two final questions. One is, why don't we try this out in a state? There are proposals; I see them fly by every once in a while. I think Vermont was kicking around an idea of going to Medicare for all. If we're nervous, as Nicole is, that if we institute this overnight, so to speak, it might, if you will, fossilize an out-of-control system. Couldn't we test it? Shouldn't we test it in some states? Couldn't we give it a try? Is that a good idea?

Rosenthal: We have tested it. We have Medicare—50 years of Medicare. That's not a small thing. You said that Medicare is going bankrupt, but actually the costs of Medicare are going up more slowly than the cost of private insurance. Medicare is taking care of the sickest people in the country, the old people. Those costs are going up more slowly than they are in the private system. How can you say it's not working?

Caplan: Is that enough of an experiment to make you calm?

Saphier: That's because we've entered Medicare Advantage into the system and we're supplementing with some privatized insurance to offset some of Medicare state by state.

Rosenthal: What we're doing with Medicare Advantage plans is, the private companies could not deliver what Medicare could for the same costs. For each Medicare patient, the government pays 14% more for a patient who has Medicare Advantage, so we're losing money on that. The private insurance company system is not helping that at all. It's not saving money.

Saphier: Implementing it state by state, we have seen that this actually hasn't worked. Vermont's tried it; they've gotten the furthest. California's looked at it, Washington's looked at it. As soon as they get the price tag, it's sticker shock and it's political homicide. They just know that their taxpayers don't want that right now.

As I said, if you put the cart before the horse and you just try to implement this without bringing down the costs of our pharmaceuticals, of our devices, and patient responsibility, people aren't going to go for this. It's way too expensive.

If you're trying to think of other states, think of Georgia; it has the second highest uninsured population. It also has the second highest unemployment. Why aren't we focusing on the economy of Georgia and trying to get some of those unemployed people into the employment pool so they can benefit from employee-sponsored health plans? There are other ways to tackle this problem. Georgia obviously would not be a state in which you could just do Medicare for all because that would be a Medicaid for all—because you don't have a lot of tax-paying citizens there to offset that loss.

Caplan: I'm thinking that the only solution you see is to do it federally because of these states that are poor; some of them probably couldn't do it if we're going state by state.

Rosenthal: I think I want to do it federally, but because I think right now that's not going to happen, it is possible to try it in states. In fact, New York is closer than a lot of other states and New York is a good state to do it; it has a large population and it has a lot of rich people as well. It would be easier to do it. Plus, it has passed a lot of progressive legislation.

Caplan: I should add that it's not short on healthcare providers either.

Rosenthal: Right. Right now, we're closer than you or I could possibly imagine. As far as people who don't want it, in fact when you do polling now, it's just a little bit over 50% of people who are in favor of a single-payer system.

Saphier: I don't think for everyone taxes would go up a little bit. I think for some people, taxes would go up a lot. I do think that if you poll people and you say to them, "Wouldn't you like to just have a healthcare card that covers everything you want? You never have to pay a copay. You never have to worry about that. You should have it come out of some of your taxes." That sounds great. In essence, that's not necessarily the truth for a lot of people. When you really get into the details of it, if you really help people understand, a lot of people aren't for it.

Caplan: Let me end with a little prognostication question. As I said when we began, I've listened to single-payer debates for a long time. I think I've managed to conceal my own views about this pretty well today, so I won't break that shield or wall now, but I am interested in a forecast.

If I'm a proponent of single-payer or I hate it—and I still think we have to leave this to other reforms before we even move towards that—what do you think the odds are of seeing single-payer nationally in the next 5 years?

Saphier: Nationally in the next 5 years? I think it's low. I truly believe the way forward is a combination of private-sector changes to drive down the cost. I think you have to focus on that before you can talk about any sort of health insurance reform.

Rosenthal: I think that within the next 5 years nationally, I agree with you—I don't think that the chances are good, but you never know. In New York State, I think it might come sooner than that because—which I didn't get a chance to say before—there's a single-payer bill, the New York Health Act. It has passed in the Assembly for the past 3 years by a 2-to-1 margin. There are now 31 sponsors in the Senate for this bill. Thirty-two is a majority. We are very close.

Caplan: You think the governor would sign?

Rosenthal: I do. I wasn't sure of that before but—as we were talking before, we didn't ask the governor because we didn't want to hear him say no, and it's not time for him to have to rule on that. Brian Lehrer did [ask the governor] on the radio.

Caplan: A public radio station here in New York, yes.

Rosenthal: He said, "Yes, I think it's a good idea."

Caplan: Well, let me check back in 5 years and we'll see with both of you what has transpired. Maybe we'll have a large state with a lot of diversity running an experiment. Obviously, who's in the White House and what happens in Congress will drive the prediction.

I don't know myself where I'd come down. I'd say the chances seem low, but I do agree that there may be a state or two that might try to model something and move in that direction.

That said, I want to thank both of you for participating in Both Sides Now. Hopefully you found this show to be as engaging, fun, and interesting as I did. We had some great disagreements, some good points of view. A lot to think about here in terms of where our national policy might head with respect to insurance reform and reforming the health system. I took away that both of our guests agreed that the system was broken. The question is, what are we going to do to fix it? I want to thank you both for being here, and thank you for watching Both Sides Now.


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