Several national advocates of a single-payer system, including Dr. David Himmelstein of Physicians for a National Health Program, sat down with Hillary Clinton in February [1993]. She listened attentively, asked smart questions….It was evident Hillary [was] thinking a lot about politics. Can you realistically tell me, she asked, that there are any big powers that support single-payer and that can take on the insurance industry's lobbying and advertising budget? "I said 'about 70% of the people in the US favor something like a single payer system,'" Himmelstein recalls. "'With presidential leadership that can be an overwhelming force.' She said, 'David, tell me something interesting.'"

—THE NATION, April 26, 1993



by Steffie Woolhandler, MD, and David Himmelstein, MD. 

The New York Times , May 28, 2013

Occupy Wall Street wasn’t born in time for the 2009 health care debate. But that debate was a quintessential display of the power and privilege of the 1 percent.

Drug and insurance firms dictated the terms of reform: “do it our way or do nothing at all.” The result was a lopsided bargain: the American people were allowed to expand Medicaid, ship a few scraps to community health centers and impose feeble insurance regulations. Insurers got hundreds of billions of taxpayer dollars and a mandate ordering the middle class to buy their defective products.

Drug and insurance firms dictated the terms of reform. A reversal should stoke a social movement for real change.

The plan’s demise would offer peril and possibility. The corporate-backed “do nothing at all” option would perpetuate disaster: about 50,000 annual deaths from the lack of insurance; about 800,000 medical bankruptcies each year, mostly among families with coverage; a continuing spiral of rising costs and shrinking coverage; and continuing assaults on Medicare. But we need not meekly acquiesce to the dictates of the 1 percent.


A DECADE AGO THE PRESIDENT AND MRS. CLINTON attempted and failed to introduce health care reforms that would give the American people a national health system providing universal coverage for all. It is a truism worth repeating that the United States, the richest country in history, is the only advanced state that does not provide health care to all its citizens, a hallmark of a civilised society.  In 2013, President Barak Obama introduced the Affordable Heatlhcare Plan. It constituted progress in that it enabled more—though not all—of the uninsured to purchase health insurance on special health exchanges from private insurance companies. However, Obamacare—as it is popularly known—is still not the rational option. It is too cumbersome, too complicated,  does not guarantee coverage to those who deserve it the most—the poor—and is hostage to the obstructionist policies of state governments controlled by the Republican Party. It is a pusillanimous half-step because the Obama administration has also balked at reducing the dominance of the insurance industry, which remains central to the operation and therefore to the inadequacies of Obamacare. 

This work, published as a contribution to the health reform debate in the Clinton era, remains as relevant today as it was then. It presents a detailed description of national health program which every advanced industrial democracy has established in one form or another as an effective means of providing universal health coverage to all citizens. Known as the "single-payer" option, it provides the basis for the health systems in Canada and much of Europe.

In clear, concise language the authors of this work cut through the morass of the health care debate and set forth a rational program which will provide coverage for all of America's uninsured and guarantee freedom of choice in choosing one's physicians. It is a proposal which the Congressional Budget Office described as the most cost effective of all plans capable of covering every American with a comprehensive range of benefits.

The authors, physicians at the Harvard Medical School and founders of Physicians for a National Health Program, take aim at the Clinton Administration's flawed and ineffective approach to health care reform. They are critical of the tactical compromises the administration made to accommodate the opponents of universal coverage by mediating the reform through the private insurance industry. Single-payer advocates were categorically opposed to any compromise with a powerful interest group which—governed by its profit maximisation imperatives—had prevented the introduction of a national health program for Americans for two generations. In their view, an effective political strategy had to confront and defeat such interests in order to secure a rational system for all.  

The Clinton effort in part of history. The Obama effort will be tested and, most likely, found wanting.  For those who ask if another road was, and still is possible, this work is an essential text. The Rational Option is a book for today and for the future.


The Authors

JOHN CANHAM-CLYNE is a journalist who has written and reported for The Progressive, World Policy Journal, Pacifica Radio, and In These Times.

STEFFIE WOOLHANDLER, MD, MPH, and DAVID HIMMELSTEIN, MD, are internists and professors of public health at the City University of New York at Hunter College and visiting professors of medicine at Harvard Medical School. They are co-founders of the Physicians for a National Health Program .


This book presents the best argued case for why the United States should have followed Canada's example in the nations's recent round of health reform. Canada's universal insurance is comprehensive in scope, limited in its budget, straightforward and lean administratively, and modest about whether the quality of care can be usefully improved by those who pay the bill.  For those who want to understand what happened to the Clinton reform, The Rational Option is a hard-hitting critique , unsparing in its assessment of the failed attempt. What's more, this doctor-journalist team provides an extraordinarily up-to-date account of the private re-forming now going on—the unexpected legacy of the legislative stalemate and the American difficulty in learning either from [Canada] our northern neighbor or our own experience with Medicare.

Professor Ted Marmor, Yale University

Author of Understanding Health Care Reform

America's health care and financing problems have not disappeared; they will grow more acute, and the health care reform debate will resume. We are fortunate that this volume will be available to those who want to understand the remarkable opportunity the nation has….The authors outline a strategy for American health care reform, a strategy that we must be certain is part of the debate if we are to have a more equitable, efficacious, and economic health care system.

Dr. Rashi Fein, Harvard University