A paper by Selden and Sing (2008) reminds us of what was at stake 45 years ago, when Emmett Hall recommended universal public medical insurance over private-public alternatives. While focusing exclusively on the United States, it also helps to explain why universal pharmacare is being diverted into that same private-public dead end through public "catastrophic" coverage. Governments finance, through many different programs, most US health expenditure. Spending programs - Medicaid, Medicare and others - primarily benefit the unhealthy and unwealthy. However, benefits of the largest program, the tax exemption for private insurance, are heavily tilted towards the highest incomes and are essentially unrelated to health. This pattern (also found in Canada) may help explain political support for private insurance, despite its excessive administrative cost and inability to cover those in greatest need.