WASHINGTON - The YouTube video shows Donna Smith pulling on a white hazmat suit and protective rubber gloves. She's going to work, trying to clean up the nation's health insurance industry.
With a bullhorn in one hand and a picket sign in the other, she leads a group of a dozen or so similarly attired activists in marching outside a Chicago hotel on a windy morning last fall.
The "Health Care Hazard Cleanup Team" has come to protest an industry it sees as toxic to the health of Americans. Today's target is an insurance company trade group that's meeting inside.
"Hey, hey, ho, ho," a chorus erupts. "Private insurance has got to go."
Smith is a cancer survivor whose personal experience with insurance has driven her to lead rallies such as this one. She's a foot soldier in the battle over health care, and hers is the most radical prescription for change.
The idea, which advocates call "single payer," would replace private insurers with a single, tax-funded government program. They envision a national health program in which every American would be guaranteed coverage, regardless of ability to pay or medical history, and all patients would be free to pick their doctors.
Despite its appeal to many, "single payer" is DOA as an option in the debate in Washington. More of its advocates have been arrested on Capitol Hill than have testified at congressional hearings. President Barack Obama, who said years ago that he supported the idea of single payer, now favors bolstering the employer-based insurance system.
Without a seat at the bargaining table, single payer proponents are still looking to influence the process, if only to raise red flags about proposals that they say would make the current system worse. The Leadership Conference for Guaranteed Health Care, a coalition of single-payer advocacy groups, is planning a major rally July 30 in Washington in an effort to demonstrate the widespread support that they say their cause has garnered.
Most political experts say that a single-payer plan isn't feasible in the current environment. Public ambivalence about the role of government combined with the upheaval that would result from dismantling the insurance system make radical change highly unlikely, they say. In addition, there'd be strong opposition from congressional conservatives, who dispute the rosy picture of single-payer benefits that advocates describe.
The decision not to consider a single-payer scheme "speaks to the pragmatism not just of the Obama administration but the Democratic leadership in the House and the Senate," said Jonathan Oberlander, a health policy expert and visiting scholar at the Russell Sage Foundation, a social science research center in New York. For them, a single-payer plan "would be too controversial," especially when they're trying to reassure anxious Americans that they can keep their existing insurance if they like it.
For proponents, however, the failure of a single-payer proposal to advance shows the grip that the health care lobby has on Washington. At best, in their view, the options that are on the table amount to tinkering with a failed system; at worst, they further empower an already entrenched insurance industry.
Smith, who's 54, may seem an unlikely candidate to lead an attack on the health care status quo. She grew up in suburban Chicago in what she describes as "a very Republican family."
Like many single-payer supporters, though, she comes to the fight seeing herself as a victim of the insurance system.
She and her husband landed in bankruptcy court, she said, snowed under by bills when he had a series of heart attacks and she developed uterine cancer. She was a newspaper editor in South Dakota; he was a machinist. Besides jobs, they had plenty of health insurance, or so they thought.
She became a full-throated single-payer advocate after she and her husband were featured in "SiCKO," the 2007 Michael Moore film about the health care crisis.
Attending the New York premiere, she ran into a busload of nurses who saw the event as a vehicle for promoting a single-payer plan. That inspired her to begin speaking to groups around the country about her film role and her personal experience. She even testified before Congress. The California nurses made her an organizer and legislative advocate in their Washington office.
A single-payer system, Smith said, is an elegantly simple solution. Eliminating the tangle of for-profit insurers would save billions of dollars in administrative costs and executive salaries. Those savings, the thinking goes, would be large enough to cover most, if not all, of the nation's uninsured.
Some experts say those savings are vastly overstated and that single-payer advocates don't have a plan for dealing with the rapidly rising cost of health care, which is at the root of the crisis.
"It is nonsense, absolute nonsense," said Stuart H. Altman, a professor of national health policy at Brandeis University. "The reason health care costs are high is that we spend a lot of money on health care. It is not all on the insurance side."
Critics of single-payer plans say they'd concentrate too much power in the government, including decisions on which treatments qualified for coverage.
Robert Book, a senior research fellow at the Heritage Foundation, a conservative research center, put it more strongly. He wrote in an April issue brief that a single-payer system would result in lower payments for physicians and other health care providers, which would lead to "reduced access and lower quality health care for future generations" of Americans.
Countries with national health programs, said Uwe Reinhardt, a health policy expert at Princeton University, have tended to short-change them. "There is a tendency to under-fund them," he said, "and so care ends up falling short of the ideal."
Smith concedes that single payer may not be perfect, but she said it was far superior to any other proposal out there. She's frustrated with the way that Congress has dismissed what she views as the most just and noble option.
"But I still have tremendous hope," she added. Ultimately, she said, paraphrasing words of Martin Luther King Jr., "the long arc of history bends toward justice."
(Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy-research organization that isn't affiliated with Kaiser Permanente.)