I think it's important for the discussion of how we get to a single payer system to review how the Canadians got there. They did not have a full single payer system until they passed the Canadian Health Act of 1984 (revising the Medical Care Act of 1966 to prohibit user fees and extra billing from doctors). When did they start the evolution to a single payer system? 1946. It took 38 years of provincial models, legislation, stakeholders fights, doctor strikes, and lots of citizen advocacy to get there.
from wikipedia:
The beginning of coverageIt was not until 1946 that the first Canadian province introduced near universal health coverage. Saskatchewan had long suffered a shortage of doctors, leading to the creation of municipal doctor programs in the early twentieth century in which a town would subsidize a doctor to practice there. Soon after, groups of communities joined to open union hospitals under a similar model. There had thus been a long history of government involvement in Saskatchewan health care, and a significant section of it was already controlled and paid for by the government. In 1946, Tommy Douglas' Co-operative Commonwealth Federation government in Saskatchewan passed the Saskatchewan Hospitalization Act, which guaranteed free hospital care for much of the population. Douglas had hoped to provide universal health care, but the province did not have the money.
In 1950, Alberta created a program similar to Saskatchewan's. Alberta, however, created Medical Services (Alberta) Incorporated (MS(A)I) in 1948 to provide prepaid health services. This scheme eventually provided medical coverage to over 90% of the population.<10>
In 1957, the federal government passed the Hospital Insurance and Diagnostic Services Act to fund 50% of the cost of such programs for any provincial government that adopted them. The HIDS Act outlined five conditions: public administration, comprehensiveness, universality, portability, and accessibility. These remain the pillars of the Canada Health Act.
By 1961, all ten provinces had agreed to start HIDS Act programs. In Saskatchewan, the act meant that half of their current program would now be paid for by the federal government. Premier Woodrow Lloyd decided to use this freed money to extend the health coverage to also include physicians. Despite the sharp disagreement of the Saskatchewan College of Physicians and Surgeons, Lloyd introduced the law in 1962 after defeating the Saskatchewan Doctors' Strike in July.
Medical Care ActThe Saskatchewan program proved a success and the federal government of Lester B. Pearson, pressured by the New Democratic Party (NDP) who held the balance of power, introduced the Medical Care Act in 1966 that extended the HIDS Act cost-sharing to allow each province to establish a universal health care plan. It also set up the Medicare system. In 1984, the Canada Health Act was passed, which prohibited user fees and extra billing by doctors. In 1999, the prime minister and most premiers reaffirmed in the Social Union Framework Agreement that they are committed to health care that has "comprehensiveness, universality, portability, public administration and accessibility"
Given the Canadian's experience, and our more diverse 50 state system (rather than 10 provinces), I think it's unrealistic to think somehow we can enact a national single payer system and eliminate private insurance in one step. The Canadian system's evolution is instructive to understanding the development of a national single payer system. There are realities of the political process, power of stakeholders, divisiveness within a country, that can't be ignored. I believe the president is taking the wise approach by keeping stakeholders at the table, and by introducing a public option as a facet of a comprehensive reform plan. Looking at how long it took Canada to get a single payer system, I think a goal of a public option now is a very encouraging start. If we can get this in place, and it is successful and people see it doesn't kill granny or break the bank, we can work on further expansion.
I also think the president is wise not not focus all the attention on insurance. Private health insurance is not the only reason our costs are more than double most industrialized nations. (read "The Cost Conundrum"
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande ). Canada's development of single payer from the 1946 Saskatchewan model is parralell to state models being developed here now (such as Massachuetts). MA has learned that they can get most citizens covered with universal insurance, but it has become very expensive and they learned they must also find ways to controlled costs and increase the number of primary care physicians. To control costs Obama has proposed models of best practices (such as the Mayo and Cleveland clinic) that have lower costs and better outcomes by not utilizing a "fee for service" model. He's also proposed requirements for preventative care and wellness, and healthier food and exercise in schools to reduce long term costs of childhood diabetes and obesity. Health care reform needs a comprehensive approach, not just insurance reform.
We have islands of excellence in this country such as cancer care and technology that attracts foreigner from all over the world. The Canadian system covers all it's citizens, but does not have the same level of innovation. If we can develop comprehensive reform to cover all our citizens without sacrificing this advantage or breaking the budget, our 37th in the world WHO ranking will shoot up to the top.
This is difficult work, with no silver bullet. I think an open mind, rational/respectful debate, persistence, and patience is our best strategy.
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