Wednesday, February 3, 2016

Single Payer Blues

Umm, OK. But I have a few questions.
Bernie Sanders recently released a campaign plan to create a government-funded single payer health care program that would cover everyone and cost nothing at the individual level. While this plan is fraudulent in a number of ways - more about that in a bit - it has at least started a conversation about the next step in health care reform after the ACA. While that conversation is good, and necessary, it is also fraught with myths, wishful thinking and outright falsehoods. While a properly constructed single-payer plan would be a good thing, America has some unique conditions that make it very difficult to get there, and if it wasn't crafted carefully and thoughtfully, it would leave people much worse off than they are today.

What are some of those 'unique conditions'? Well, first there is the current process of employer funded health insurance. Most Americans never pay an insurance premium. So if you tell them you're going to give them health insurance they don't have to pay for, they don't get terribly excited because they already have that. Then, if you tell them you're going to raise their taxes to pay for that health care, they're going to tell you no thanks.

Second, the big difference between the US health care industry and other nations, particularly nations with their own single-payer programs, is cost. In the US we spend about $10,000 per capita annually on health care. This is far and away the highest cost for health care anywhere in the world. Why is that? Because in the US, we have an agreement that whatever procedures the doctor orders, the insurance company pays for. It is an unusually lavish kind of coverage which produces large profits for the health care delivery network. Single payer plans all have one thing in common - stringent cost controls. They won't just pay for everything, and they define HOW MUCH they will pay for procedures that are covered. This is where the Sanders proposal slips into dishonesty - his cost estimates reflect this kind of dynamic cost-control measures, but he promises the same levels of coverage. It can't be both - the same level of coverage would require several trillion dollars in additional taxation - 20-30% tax increases on the middle class - or there would have to be significant new limitations in coverage.

Finally, there is the question of health care delivery - the point where the rubber meets the road. Everyone wants to talk about the additional costs imposed by a private, for-profit insurance industry, but they never seem to get around to addressing a private, for-profit delivery system. If you're going to offer a plan to convert the United States to a government funded health care system, you're going to have to include the hospitals, doctors, ambulances, dentists, urgent care centers and clinics. Who owns them? Who pays the doctors and nurses and specialists? What's their incentive to cooperate? What happens if they limit the number of single-payer patients they'll see? What happens if employers continue to offer private insurance policies to their employees?

You're going to have to figure out what the comprehensive plan is, how you're going to pay for it, and then you're going to have to convince people to accept less coverage at a higher personal cost than they're paying today. In the end it would probably a good thing, but at least you should recognize that there is simply no direct route from where we are today to that point.


  1. And there never will be as long as entrenched moneyed interests control things.

    Step one: Vote for someone who wants to change it.

    1. It's all fun and games until we end up with President Trump.

      I'm not as sanguine as you seem to be about that outcome...