Hey America. Canada here. Yes, we’re still friends, though we’re going through a bit of a rough patch. (Tariffs? Really?)

I’m writing to meddle in your election. Why? Health care. It could win it or lose it for the Democrats. I watched the July debates. Every candidate wants every American to have access to care. All agree the system is absurdly expensive, captured by insurers and pharma, and tragically unjust. So do most Americans. But there is no consensus on how to fix it. Many abhor the system as a whole, but like what they have.

That conundrum splits the front-runners into two camps. Transformers (led by Bernie Sanders and Elizabeth Warren) advocate for versions of Medicare for All, a single-payer system under which private insurance would disappear. Reformers (led by Joe Biden and Kamala Harris) advocate a public option (exiled from Obamacare) to compete alongside private insurance. The go-big camp believes the revolutionary moment is here, and Democrats can win by seizing it. The Obamacare 2.0 camp considers single-payer too disruptive, radical and expensive to win over an electorate attached to private insurance plans and hostile to government-run programs.

Who’s right? Who knows? It’s easy to demonize single-payer. Choice — gone! Taxes — up! Government takeover! Rationing! Most people have health insurance. It is the devil they know, and single-payer offers them the devil they don’t.

As I watched the debates, I found myself barking at the TV: “Come on!” “You can do better than that!” “Bring your A game!” The case for incremental improvement rests on hoary myths and bad math. It’s no secret why people are opposed to change or are still on the fence. The Democrats need to deal head-on with concerns like these:

• I like my private insurance plan and want to keep it. Really? I doubt you love your insurer, part of the cabal that skims off hundreds of billions of dollars a year from direct care. You may like your doctor, low copays and deductibles. All around the world, single-payer covers as much or more than your private insurance, often at half the cost.

• Single-payer will raise my taxes. The issue here is not what you pay in taxes; it’s what you keep in your pocket after taxes and (in this case) health-care expenses. Even with so-called good insurance, you fork over for copays and deductibles and about $5,500 per family as your share of the average $19,600 total cost of premiums paid by your employer. Your income will be lower because your employer has to spend $14,000 a year on your health-care insurance.  Single-payer makes most people financially better off.


• Employers should have to provide health care for workers. Health insurance is a huge burden and threat to business. You also shouldn’t have to stay in a job you don’t like just to keep your health insurance. Businesses should compete for workers on the basis of pay, working conditions and opportunity, not health care.

• Under single-payer I won’t be able to choose my doctor or hospital. Big lie. Canadians can go to any family doctor they like, and the family doctor is the gatekeeper to specialists. Most Americans don’t have unrestricted choice without paying a big price for going out of network. Under single-payer, the norm is that people choose their providers. In the U.S., most insurers make the choice for you.

• Single-payer is unaffordable. Compared to what? Health care in the U.S. is twice as expensive as in other wealthy countries. But that doesn’t mean Americans get more health care. Massive amounts of money are siphoned off to the insurance bureaucracy that buries doctors in paperwork and challenged claims, and tells patients where they can and cannot go for care. U.S. consumers pay the highest prices in the world for drugs. Single-payer  has secured far lower drug prices in many other countries.

• Single-payer may not provide everything I get now. That’s right, it may not. No program — private or public — offers everything to everyone in every circumstance. But health care in the U.S. is spectacularly abundant, and many patients get tests and procedures they don’t need. You want the right care, not necessarily the most care.

If how the U.S. organizes and pays for health care were based on dispassionate analysis on the part of fully informed citizens and uncompromised legislators, the status quo would have been shown the door decades ago. Those that stand to lose the most — pharma and insurers — are widely unloved. The monstrosity persists because of money, fear, inertia and deep suspicion of government as an instrument of good.

The anti-single-payer playbook is hardly a mystery. If you can’t win public hearts and minds in a contest with drug-company felons and insurance oligarchs, and if you can’t get business behind a plan that liberates it from a crushing burden, it’s either a hopeless cause, or you’ve been outgunned.

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If the Democrats can sell single-payer, they will likely win in 2020. The new president will have a mandate and the moral authority to get single-payer in place. Single-payer isn’t perfect, but it’s incomparably better than the status quo.

The health-care stakes are enormous. Choose your words carefully, Democratic candidates, and play your hands well.