Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.

Who would have guessed that one of the most right-wing Republicans in the Senate would predict that the American people, sooner rather than later, will see the passage of single-payer, universal health care such as Medicare for All?

I hasten to add that this prediction from Senator Tom Coburn of Oklahoma, would not be to his liking; indeed he’d probably fight to his last breath to prevent such a proposal from becoming law.

Coburn, a physician, is known as “Dr. No” because of all the nominations and legislation he has obstructed with his lone objection, the latest being the emergency aid to the earthquake victims in Haiti. He’s also the M.D. who suggested we pray that the late Senator Robert Byrd (D, WV), would be too ill to cast a crucial vote on health reform, which Coburn opposed. (Byrd voted and the health reforms passed.)

Now that the Affordable Care Act is law, Coburn predicted in a speech earlier this month to the Republican Women’s Club of Tulsa,

“There will be no insurance industry left in three years. That is by design. You’re going to make insurance unaffordable for everyone - which is what they want. Because if there’s no private insurance left, what’s left? Government-centered, government-run. Single-payer health care.”

The reforms, he said, will mean “the beginning of the end of America” unless they are killed by repeal, or the courts.

He didn’t explain who is the “they” who want insurance to be unaffordable. The Obama administration has criticized companies that have sharply raised premiums and asked them to desist. And the law’s requirement that individuals must buy insurance (the so-called individual mandate), subsidized by the government, is expected to add millions of new customers to the insurers’ rolls.

As far as I know, no one in the Obama White House is plotting to extend the health reforms into Medicare for All, which is too bad. But Coburn may be right without knowing why; the greed and stupidity of the insurance and drug industries could kill the reforms and bring on true universal health care if they continue their rapacious conduct.

That’s a strong possibility, according to a more rational and traditional conservative, Professor Paul J. Feldstein, of the University of California and an expert in Health Care Management in the school of business who has written text books on health economics. He was interviewed for the journal, Nursing Economics, by Peter I. Buerhaus, on the faculty of Vanderbilt University.

As Buerhaus wrote, he conducted the interview (may need free registration) because, while the health reforms

“did not include language to transition toward a single-payer system, this does not preclude that over time, and depending on how the legislation is implemented, a single-payer system might eventually be adopted as many people and advocacy groups desire.”

The description “single-payer” can be confusing, and Feldstein defined it:

“When a government is the only payer of health services. It does not mean that the government owns the health provider, like the U.S. owns VA hospitals. An example is Canada, where the government is the only payer for all the basic medical services provided to its citizens.”

Feldstein is not necessarily a fan of such systems; he’s a believer in the market, but he favors some regulation and restraints. When he was asked if the health reforms could lead to the adoption of a single-payer system, Feldstein said,

“I can see a scenario where there is very little cost containment and little pressure to keep insurance premiums from rising substantially. And if there is a weak mandate for individuals to purchase health insurance, then the resulting adverse selection [enrolling too many sick people] is likely to cause insurers to increase their premiums. People will become dissatisfied...and may become more supportive of a government funded public insurance option...

“Eventually, if many individuals purchase public insurance we could end up with a single-payer system or something close to one. We already pay the health care for tens of millions of people with the Medicaid and Medicare programs, and you can just pretty much put a public insurance option together with these programs into one system.”

He acknowledged that a single-payer system would cover more Americans, spend less money per patient and save on the vast administrative costs now spent on the fragmented private health insurance establishment. But Feldstein said a single-payer system would include budget restraints that could retard advances in technology and lead to rationing, inefficiencies and a reduction in preventive care because of the greater demands for acute and urgent care.

Dr. Don McCanne, of Physicians for a National Health Program (PNHP), praised Feldstein for “a more intellectual” and “sincere” discourse on the singe-payer issue. But

“it is distorted by exaggerated potential adverse consequences of single-payers,” he said, “by his failure to include certain inescapable benefits.”

Dr. Quentin Young, Barack Obama’s physician in Chicago before he became president, agrees that the new health reforms could lead to a single-payer system, if it is undermined by its critics, challenges in the courts and “destabilizing pressures” from the insurance industry. Indeed, he adds, “the law may unravel sooner than many suspect.”

Young, a founding member of PHNP, warned that if the Affordable Care Act collapses, “Single-payer Medicare for all needs to be ready to fill the gap...”

And in the meantime, he hoped Obama would reject cuts in Medicare that may be suggested by his deficit commission. “Medicare should be strengthened by improving it and extending it to everyone,” he said.

There are two bills calling for Medicare for All, one (HR 676) that has been introduced by Representative John Conyers (D. Mich), the second longest serving member of the House. Information on his bill may be found at the healthcarenow website.

The second bill, introduced by Senator Bernie Sanders, (I, Vt.), is the American Health Act, S. 703, which calls for state based single-payer systems that combine all current programs such as Medicare and Medicaid. You can study this proposal at govtrack.

When Young was Obama’s doctor, Obama favored Medicare For All, as do many Democratic lawmakers who have co-sponsored the Conyers and Sanders bills. Obama now says he would favor Medicare for All, “if we were starting from scratch.”

Well, why not start? Maybe in the second term, if there is one.

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