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Recently there has been a surge in political attention to Medicare for all, the latest chapter in a long history of conflict over national health insurance in the United States. This essay places the current Medicare for all debate in historical perspective. My aim is to illuminate past struggles over single-payer reform, explore the genesis and evolution of Medicare, and analyze the implications for contemporary health politics of the public and private insurance arrangements developed by the United States over the past century. The history of US health reform provides critical lessons for understanding the enduring appeal of single-payer models as well as the formidable political obstacles to transforming Medicare for all from an aspiration into a legislative reality.

US political debates often refer to the experience of “single-payer” systems such as those of Canada and the United Kingdom. We argue that single payer is not a very useful category in comparative health policy analysis but that the experiences of countries such as Canada, the United Kingdom, Spain, Sweden, and Australia provide useful lessons. In creating universal tax-financed systems, they teach the importance of strong, unified governments at critical junctures—most notably democratization. The United States seems politically hospitable to creating such a system. The process of creation, however, highlights the malleability of interests in the health care system, the opportunities for creative coalition building, and the problems caused by linking health care finance and reform. In maintaining these systems, keeping the middle class supportive is crucial to avoiding universal health care that is essentially a program for the poor. For a technical term from the 1970s, “single-payer health care” has proved to have remarkable political power and persistence. We argue it is not a very useful term but the lessons from such systems can be valuable for those contemplating movement toward universal health coverage in the United States.

The adoption of a single-payer health care system, a recurring dream of progressive American reformers, now enjoys sustained attention in the run-up to the 2020 national elections. Some compelling arguments support the case for single payer, and its political prospects may indeed be on the rise, but myriad obstacles beset it, and a full-throated Democratic endorsement of it carries disquieting risks.

From a public health perspective, single-payer health care financing embodies collective action to secure universal, financially sustainable health care access as a public good and social determinant of health. In the United States, however, health care is financed through a fragmentary mix of public coverage, private coverage, publicly financed but privately administered coverage, and substantial out-of-pocket expenditures. Private insurers assert their interest in prevention, but insurers' incentives are not well aligned with farsighted public health goals.1 Because Americans are segregated into hundreds of plans -with many left out altogether -the population served by any given payer does not reflect the US population as a whole.This editorial focuses on one choice among the many choices that reformers face: what role will states play in financing and administering more universal public health coverage? As a long-term goal, federal reform modeled on the Canada Health Act could enshrine states as administrators of federally financed coverage. In the short term, Democrats would be wise to gather support for state-by-state experimentation with public-option and single-payer reforms rather than focusing exclusively on reforms built on Medicare, in which states play no role.

Current interest in a single-payer approach to universal health care coverage in the United States has also triggered interest in alternative multipayer approaches to the same goal. An analysis of experiences in Germany, the Netherlands, Switzerland, and Israel shows how the founding of each system required a distinctive political settlement and how the subsequent timing, content, and course of the reforms were shaped by political circumstances and adjustments to the founding bargain in each nation. Although none of these systems is directly transferable to the United States, certain parallels with the American context suggest that a multipayer approach might offer a model for universal coverage that is more politically feasible than a single-payer scheme but also that issues associated with risk selection and other potential inequities would remain.

There are formidable institutional obstacles to passing a single-payer health program in the United States. Advocates should consider incremental improvements that may better match legislative realities. There are three potential directions for incremental coverage policy. One possibility is to build on the successes of the Affordable Care Act; this might include rolling back regulatory changes, further incentivizing Medicaid expansion, enhancing coverage in the Affordable Care Act marketplaces, and imposing regulations on private employer-based insurance to ensure that all Americans have access to affordable coverage that provides adequate financial security. A second direction is to offer more publicly sponsored insurance options, which might involve offering a public option to those eligible for marketplace coverage, creating a Medicare or Medicaid buy-in program, lowering the eligibility age for Medicare, or developing a public plan that serves as a default for those who do not choose to buy alternative private coverage. A third direction is to build on federalism, offering states incentives to expand coverage. Federal and state legislators could also consider incremental cost-containment steps, such as rate setting.

Although the focus for most single-payer advocates is in Washington, DC, and on proposals for Medicare for all, there are also efforts in a handful of states to enact a state-based single-payer program. Moreover, the odds of legislative passage are better in a state like New York than at the federal level. Even if enacted, however, state-based single-payer proposals face a distinct set of obstacles, including (1) the need to obtain federal permission (via waivers) to repurpose federal dollars, (2) the federal Employee Retirement Income and Security Act, and (3) the burden of state-only action in an interconnected 50-state economy. The most likely result of the energized single-payer movement will be incremental public insurance expansions at the federal and state levels, including state programs to permit the uninsured to buy into the Medicaid program. Such an outcome is consistent with the most plausible path (incrementalism) to a US version of universal coverage.

Just three Novembers ago, few would have predicted that the expression \"Medicare for All\" would be ringing so passionately today in the national political arena. Donald Trump's slender victory and the returning Republican congressional majorities, the most conservative in modern history, suggested that repealing the Affordable Care Act-along with largely dismantling Medicaid -would be the defining health care policy issue of the current era. Yet here we are, after that failed effort pushing hard to the political Right while the progressive Democratic presidential contenders are stumbling over one another to proclaim their respective fealty to Medicare for All on the Left. Is the United States truly on the cusp of making a historic leap toward universal health coverage and system transformation? This AJPH special section on the history and contexts of single-payer health caretives in in both Washington, DC, and the states- authored by a set of preeminent figures in the field-could not be better timed or more constructive.

Myriad anecdotes—of a Nobel laureate who sold his medal to pay medical bills, or the more than 250 000 GoFundMe medical campaigns last year —attest to the financial toll of illness on American families. National surveys confirm that medical bills frequently cause financial hardship, and the US Consumer Financial Protection Bureau reported that they were by far the most common cause of unpaid bills sent to collection agencies in 2014, accounting for more than half of all such debts. Less evidence is available on the medical causes of bankruptcy, a public and stigmatizing confession of impoverishment. In surveys conducted by researchers with the Consumer Bankruptcy Project in 2001 and 2007, a majority of recently bankrupt debtors implicated medical bills or illness-related work loss as causes of their bankruptcy, findings that President Obama used to argue for passage of the Affordable Care Act (ACA). The ACA both expanded and upgraded health insurance coverage, banning preexisting illness exclusions, imposing a cap on out-of-pocket spending, and mandating coverage for essential benefits. Although these reforms might attenuate the risk of medical bankruptcy, increasing medical costs and stagnant incomes could have the opposite effect.