The botched implementation of Obamacare has created a bittersweet moment for advocates of a universal, single-payer health care system: They saw this coming, but they can't gloat about it.
"We may have an 'I-told-you-so' moment, but it's hard to get any pleasure out of it knowing how many people are actually going to get hurt," said Stephanie Woolhandler, a New York-based doctor who co-founded Physicians for a National Health Program, a group that pushes for universal health care. "You had a bad system, and you're putting a patch on it using the same flawed insurance companies that got us here in the first place," she said.
In the seven weeks since the insurance exchanges created by the Affordable Care Act debuted, Obamacare has been defined by faulty websites, millions of canceled health plans and uncertainty about whether President Barack Obama's administration can set up a new marketplace for private health insurance that protects consumers against industry practices like excluding the sick, while ensuring less-well-off Americans can afford coverage.
Single-payer advocates favor scrapping private health insurance and enrolling everyone in a program akin to Medicare with a comprehensive set of benefits that is financed through taxation, one whose primary focus is providing medical care, not earning profits.
To them, the messiness of Obamacare's infancy was inevitable; the law is built upon a fragmented health care system and a private insurance industry that they believe, by definition, is focused on profit first and the needs of its customers second.
"What you're seeing right now is the kind of compromise that was reached, kind of cobbled together, for the Affordable Care Act," said Sen. Bernie Sanders (I-Vt.) a vocal single-payer supporter who voted for the bill in 2010 after shelving his amendment to create a single-payer plan. "What's happening now just reinforces to me that what we need is a simple system focused on providing health care," he said.
The difficulties of launching insurance exchanges in every state and dealing with dozens of insurance companies are considerably greater than just signing up every American for a Medicare-like program, Woolhandler said. "The single-payer system's simple. They rolled out Medicare less than a year after passage," he said.
"I have always thought that was the most efficient way to deliver quality health care to people, keeping the best of the private enterprise system but, at the same time, making it possible for all Americans to be covered," said Rep. Jim McDermott (D-Wash.), a medical doctor who like Sanders has sponsored several single-payer bills.
When Congress debated health-care reform in 2009 and 2010, the creation of a government-run, single-payer program that would provide health coverage to everyone was never seriously considered. Although Obama and many congressional Democrats say they support the idea, none forced it onto the agenda.
"I didn't talk about single-payer a lot during the run-up because it was clear that was not going to happen, and I didn't want to get people away from looking at what we can get done," McDermott said. "We got a hell of a lot done, and I'm proud to be a part of it."
Democrats focused on preserving and expanding the private health-insurance system, with all its complexities and shortcomings, to minimize disruption for consumers. And in a bid to secure support from insurers, hospitals and other private health care interests, the Senate -- with the White House's blessing -- eliminated the so-called public option, a government-run health plan that would have competed alongside private plans on Obamacare's insurance exchanges.
"When you have a system which is so complex, its main function is to enable insurance companies, drug companies, medical equipment suppliers to be making huge amounts of money off of the system. The more complex it is, the easier it is for them to do that," Sanders said.
Sanders credits the Affordable Care Act with providing coverage to millions and guaranteeing access to health insurance for people with pre-existing conditions. But he rues the missed opportunity to move the United States in the direction other developed nations went decades ago, especially since study after study shows the American system is more expensive but doesn't provide the highest-quality care.
"In this whole health care debate, there's been very little discussion as to why it is that, in America, with 48 million people uninsured, we end up paying almost twice as much as do the people of any other country," Sanders said. "But we can't ask that question because the insurance companies and the drug companies are too powerful."
California Democrat Lee Rogers, a podiatrist from Simi Valley, unsuccessfully challenged Republican Rep. Buck McKeon for Congress in 2012 on a platform emphasizing single-payer, and he plans to run again next year.
To Rogers, the problems with Obamacare's websites pale in comparison to the program's greatest shortcoming: It fails to achieve universal coverage. According to the Congressional Budget Office, even though the Affordable Care Act will reduce the ranks of the uninsured by 25 million over the next decade, 30 million people will still lack health coverage.
"It is not universal coverage. It doesn't even get close to it; it just gets closer. So that's been a disappointment to me looking at the original way that they had gone about the reform," Rogers said.
None of these single-payer advocates has given up hope that their goal will one day be achieved, despite the struggles of Obamacare. Sanders's home state of Vermont is using authority created by the Affordable Care Act to enact its own single-payer program, which is slated to be in place in 2017.
"If Vermont can do it, and do it well, I think it will have a real impact on discussions in other states," Sanders said.
The troubles of getting Obamacare off the ground could hurt or help the single-payer cause, Sanders said. "What many people are going to say is that the federal government can't even run a bloody website," he said. On the other hand, the headaches of the insurance exchanges could generate renewed interest in a more straightforward approach, he said: "We need a system that is not as complicated as this system is."
Obama tried to make his health care reforms as non-disruptive as he and congressional Democrats thought possible. But the outcry from the several million people whose health insurance plans are being canceled underscores the pitfalls of shaking up the health care system -- as throwing out the private insurance industry and enrolling everyone in a single-payer program certainly would.
As McDermott sees it, that's the price of progress. "Whenever you make a big social change, you're going to have some turmoil," he said. "And I don't get put off by turmoil."