That the Affordable Care Act ("Obamacare") is a key issue in the 2016 presidential race is not a surprise, since every GOP candidate has made a promise to repeal it.  What's surprising is the fierce debate between the two Democratic candidates on whether to keep and expand the ACA to achieve universal coverage, as former Secretary Hillary Clinton advocates, or replace it with a single payer system ("Medicare for All") as Vermont Senator Bernie Sander proposes.

In one sense, this debate has been going on within the Democratic Party for generations.  Most progressives believe in their heart of hearts that a single payer system—one in which the government is the sole source of payment for healthcare services, thereby eliminating private insurance-- is a more egalitarian, efficient, and less expensive way to provide health care to everyone.

Even so, pragmatic voices in the Democratic Party have long carried the day.  They argue that the current system, under which most Americans get coverage from private insurance offered through their employers, is so entrenched that it would be a Fool's Errand for a Democratic nominee for president to try to replace it with single payer.  A more politically expedient pathway is to keep the current system of multiple payers and have the government help people who fall through the cracks, as Obamacare does.

Senator Sanders has challenged this conventional wisdom, arguing that a "political revolution" can bring about single payer. Secretary Clinton remains firmly planted with her party's pragmatic wing.

On the politics, I'm with the pragmatists, because I see no chance that the next Congress would enact single payer.  But putting political realities aside for a moment, I think it's a very good thing for the public to have a serious discussion of the respective merits of a single payer system compared to our current fragmented system.  History is full of examples where ideas that were once considered to be politically unfeasible become accepted later on.

But first, we would need a much more informed debate than Senator Sanders and Secretary Clinton have served up.  One place to start is to look at the experiences of other countries. In a 2008 policy paper I co-authored for the American College of Physicians, "Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries, "  published in the Annals of Internal Medicine,  we reviewed the healthcare systems of  a dozen industrialized countries, all of which had some form of universal coverage. Some, like Canada, are a true single payer system, with the government paying for all care; others, like France, had the government guarantee a basic level of care while allowing people to buy insurance to cover more services.

While the paper was written before the ACA became law, I think our findings still hold. We found that each approach had pluses and minuses, yet would be better than the U.S. system of leaving tens of millions without coverage:

Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access. They may require a higher tax burden . . . particularly as demographic changes reduce the number of younger workers paying into the system . . . Pluralistic systems . . . can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs.

We also found that single-payer systems typically take aggressive steps to restrain expenditures that may produce shortages of some services and delays in obtaining elective procedures.

Which would you choose?  Or would you prefer the Republican approach of rolling back government's role in healthcare even if that leaves millions more uninsured?  Now that's a debate worth having.

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