To understand the proposals, know the terms. Bear in mind that it's easy to be misled.

John M. Schwarz

Published: July 02, 2007

Michael Moore's film "Sicko" has spurred debate about the U.S. health system and about publicly funded, universal health insurance. Some clarification is in order to better serve this debate.
The most-abused label in health-reform dialogue is "socialism." It's commonly used as an accusation regarding universal coverage and single-payer or other systems that involve publicly funded patient care. Most uses of the label misrepresent the system components being addressed.

The biggest problem stems from ignorance about what socialism is. Socialism is an economic model in which the means of production -- land, labor and capital -- are in the hands of the government, publicly owned and run with workers employed by the state. It includes public financing and the provision of goods and services to all.

"Universal coverage" is a concept that holds merely that all people should have health insurance. As a concept and practice, it does not address an economic model; it can be used with different arrangements of private and public funding and production. It can be used in a socialist system, but is not itself socialist. It can also be used in a market-based patient funding system, but isn't itself a market-based mechanism.

"Single-payer" is an economic model for financing patient expenses. England's system includes single-payer -- with the exception of some private financing -- along with government-run service delivery. That's socialism. Single-payer can also be part of a system in which medical services are delivered mainly by private providers and entities. That describes the Canadian system, which does not involve government-run medicine, merely publicly financed patient care. The production of services rests as much in private hands as it does in the United States.

Yet, single-payer proposals are repeatedly called "socialist" even when that label is not appropriate. The major single-payer proposals, both nationally and on the state level, are based on the Canadian model. Public funding of patient care? Yes. Government-run medicine? No. The plans do not include government production of medical services, the necessary element of a socialist model, beyond what currently occurs.

Claims that American single-payer proposals are socialist often refer to the public financing of patient care. Public financing does not necessitate government production of the goods and services delivered. If that were the case, all publicly financed goods and services would be labeled socialist, including the police, firefighters, the military, schools, higher education, parks, libraries and, in some places, even trash collection and snowplowing.

The misuse of the label stems not merely from ignorance, but also from ideological commitments and from the desire to serve private interests -- namely, those of health insurers. Politicians are notorious for misusing the socialism label, and recent Republican presidential debates provide numerous examples, notably from Rudy Giuliani. He either doesn't know what socialism is and what single-payer and universal coverage are, or he's deliberately distorting. Probably it's some combination thereof.

It's time for health-reform dialogue to move beyond ideological rhetoric -- something that also occurs on the left. Commentators from all walks, including the media, are guilty of misrepresenting what single-payer and universal coverage are. Ideology and commitments to particular kinds of economic models in a belief in the superiority of one system across space and time get us nowhere. The question isn't capitalism or socialism, public sector or private sector. It is: What elements of a health system best serve the needs, interests and preferences of the public? Dismissing universal coverage and single-payer with a demonizing label merely stifles debate on an issue of fundamental importance.


John M. Schwarz is director of United Health System, a health policy nonprofit think tank in St. Paul.

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