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There Will Be No Single Payer

There Will Be No Single Payer

Image by matsuyuki There Will Be No Single Payer

Danielle Ofri wonders when Americans will come to realize that the only way we can assure that everybody gets health care is single payer. Ofri’s argument is not unusual. In fact, we hear it from many sides with many different implications. Some leftwards often say it with an “the arc of justice is long” intonation, for example. Some rightwards say it with lament, either due to the “arc of justice” bending the wrong way in their view or frustration that this is only inevitable because Republicans are refusing to tackle the issue, which we hear from the broader left as well. Others suggest that it will happen because hospitals and doctors are forcing a break because they will not bend, many of these hospitals have faced a lot of problems lately, a woman was able to get a big compensation from one of them thanks to no win no fee claims experts, the hospital had recently done surgery on the woman and apparently it did more damage that good.

Here is what is missing from Ofri’s piece and related assumptions: Why single-payer is the only available system. Ofri talks about what every other country does, but every other country doesn’t have single payer as we generally understand the term. There are, in fact, multiple ways to deliver health care to the masses. Even if we were to all agree that single payer is the best way, it is empirically not the only way. Which is why I am almost certain we are going to end up with something else.

Now, one source of confusion may simply be a matter of terminology. Ofri (or the headline writer) may simply be using “single-payer” in place for “Government-guaranteed universal coverage.” Which means that the Bismarck model, or Singaporean model, might also qualify. If we’re serious about universal coverage, though, we need to be more specific than that. For this piece, I regard “single-payer” as a system of health care delivery analogous to that of Canada or Medicare/Medicaid for all, where a predominately government-run system pays private providers with the goal that the level of care is not determined by the ability to pay. So Bismarck doesn’t count. The UK’s National Health Service also doesn’t meet that criteria, but I’m not going to really litigate that because a lot of single-payer proponents would love a no-cost system where everybody is employed by the government even more than a Canadian-style system.

A lot of the fixation with single-payer is simply familiarity. Canadians have it and love it, and many Americans have it and many of those who have it love it. While the VA tends to be an argument used against an NHS-style system, Medicare is one used in favor of single-payer. Polling tends to vary, but when phrased the right way you can actually gin up quite a bit of support for single-payer. So it makes sense for the left to view it as a goal, even if it is actually something of a political mirage.

It’s difficult to determine exactly what kind of plan we will end up with. There are a number of possibilities. Ultimately, though, the system we end up with will be almost entirely reactive and almost certainly not revolutionary. Our system has too many veto points and too much in the way of vested interests to abandon it to the degree that a single-payer system would require. Insurance companies will be fighting for their lives. Providers will be fighting for their livelihoods. People with insurance will be fighting to hold on to it. The polling on Medicare-For-All may be good, but it is less deep than the sentiment that required President Obama to disingenuously claim over and over again that if you like your plan you can keep your plan.

The result will almost certainly be a compromise with current stake-holders. It is, unfortunately for reformers, very difficult to please all of them and address the problems and clear a system with an unusually high number of veto points. So going forward, what we’re most likely to see is going to be one reaction after another after another, as we try to plug the holes created before PPACA, by PPACA and possibly the AHCA if it passes. It’s not unreasonable to believe that, as fewer people can afford health insurance, people with pitchforks will make the system adjust, but it will most likely adjust in smaller ways, crisis by crisis, clearly if all the insurance companies would be like Insurance Partnership everything would be so much different and a lot of people would be able to afford an insurance. Pro-active solutions like single-payer, Wyden-Bennett, or a conservative market-friendly program are vanishingly unlikely.

In fact, you could probably have no better a metric for the type of system we end up with than to ask yourself what kind of system we get if we change nothing before we completely have to and change things no more than the immediate crisis demands. So what might the future look like? My guess is that PPACA does provide a blueprint. We have, as Ofri says, accepted the fact that the government is going to be in the business of assuring coverage going forward. That’s something that conservatives are going to have to come to terms with. Liberals, on the other hand, are going to have to come to terms with a system that is decidedly inegalitarian, with two or more tiers.

There is almost certainly no future in American healthcare where the wealthy and poor will be waiting in the same lines. The evolution will be devoted mostly to scooping up the poor and giving them something somewhere without ruining their finances. Non-poor individuals with pre-existing conditions may also end up in that line, as might self-employed people, freelancers, Uber drivers, and so on. It probably won’t be great, it probably won’t be fast, and higher-end employers will probably advertise that a job with them means you don’t have to deal with any of that. But it will be something available.

I have little idea what it will look like specifically, and it may look like 51 different things depending on where you live. Some liberal states may come down on Catholic hospitals with both feet, take over the ones the church abandons, and run their own VA for those without private insurance. Others might try an idea Montana floated for setting up government-run clinics. Democrats might be wise to focus on Medicaid buy-in, throwing in subsidy schedules. Insurance may end up being built on top of a more aggressive Medicaid and Medicare program.

There is a lot for liberals to like in comparison to the current system, even if it doesn’t match the dream of a grand single-payer system. We probably won’t see the sorts of savings that single-payer advocates tout, and it probably won’t be as egalitarian as they might prefer. But I do believe they will solve the most pressing issue of a lack of coverage or a fear of lack of coverage.

Glass half-full or glass half-empty, but there’s your glass.

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Will Truman is a former professional gearhead who is presently a stay-at-home father in the Mountain East. He has moved around frequently, having lived in six places since 2003, ranging from rural outposts to major metropolitan areas. He also writes fiction, when he finds the time. ...more →

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156 thoughts on “There Will Be No Single Payer

  1. I’m surprised you haven’t included anything about Ezra Klein’s radicalization on the issue and his observations that if the GOP wrecks havoc with the AHCA, it makes it easier for even centerist Democrats to support Medicare-for-All:

    Democrats have long been divided between two camps on health reform. There are the incrementalists who think, for reasons of both policy and politics, that Democrats need to build on the existing health care system and work with private insurers. And then there are the transformationalists, who think Democrats need to push the United States toward something approximating a single-payer system as closely as possible.

    The crucial fact about this divide, however, is that many of the pragmatic incrementalists are philosophical transformationalists: They would prefer a Medicare-for-all system, but they haven’t thought it’s politically possible. Barack Obama is a good example. “If I was starting from scratch, I would have supported a single-payer system, because it’s easier for people to understand and manage,” he told Vox in 2016. But in 2009, after a campaign built on hope and change, he was trying to build bipartisan support for his plan, and if that failed, he needed swing Democratic votes like Nebraska’s Ben Nelson and Connecticut’s Joe Lieberman — and they weren’t going to go for single-payer.

    Obamacare was the test of the incrementalist theory, and, politically, at least, it’s failed. Democrats built a law to appeal to moderate Republicans that incorporated key ideas from Mitt Romney’s Massachusetts reforms, and it nevertheless became the single most polarizing initiative of Obama’s presidency. All the work Democrats did to build support from the health care industry has proven to be worth precious little as Republicans push their repeal plan forward. And the complex public-private design of the Affordable Care Act left the system dependent on the business decisions of private insurers and left Democrats trying to explain away premium increases they don’t control. The result is a Democratic Party moving left, and fast, on health care.

    An interesting thing about the rise of Trump and Trumpism is that we are seeing the radicalization of the Vox set. Vox was always Democratic-supporting but they were the kind of wonkish and earnest Democrats who truly believed in creating systems that “nudged” people towards better decision making. They were also the most Pollyannaish about returning to the age of bi-partisan consensus.

    Despite what people say, the ACA was not a Republican-lite plan or the Heritage Plan but it was designed to be market-friendly, not mess with employer-based insurance (which would have caused a revolt), and encourage people to act in ways that only a Vox-wonk or an economist could love (shop for a new plan every year on the exchanges). But none of this got any Republicans on board and they are determined to keep their promise of repealing and replacing Obamacare. Everything we hear about the AHCA in the news makes it sound worse and worse including that the GOP might be messing with employer-based health insurance and anything else they can do to get a massive tax cut through in 2018.


    • While I do think the likelihood that I am wrong goes up if AHCA passes, I think it goes from one shade of Unlikely to another shade of Unlikely. Politically, I think single-payer is and was always going to be easier in theory in reality. I fell victim to this myself after the election, thinking that maybe the Democrats should have just flipped that switch in 2009/10. But I am back to thinking that they didn’t because they couldn’t, and they still won’t be able to.

      I think the next move they are likely to be able to get consensus on is some sort of Public Option, just like it was before the election.


        • I am referring strictly to the politics here. Administratively, single-payer is easier than a lot of the alternatives. Only an NHS-style system is maybe easier. Politically, getting from Point A to Point B is a different matter.

          It’s true that getting from Point A to Point B with any grand system change is going to be as hard or harder… which is why I don’t think there will be a system change at all.


        • I think both you and Will are right.

          People really like their employer based health plans and more than half the nation receives insurance from their health plan. One of the goals of the ACA was to keep this because ripping down the private insurance market would have been political suicide. Even people who support “universal’ healthcare say that they don’t want to give up their employer-based healthcare.

          But the AHCA looks like it just might wreck havoc on employer-based healthcare as well so if that goes down then it might be more possible to get a Medicare for All kind of thing. Plus it looks like the Senate rules might change enough that Democrats don’t need to appease the Joe Liebermans anymore and they are soured on bipartisan consensus.


          • People really like their employer-provided health insurance because of the quite reasonable fear that they can’t get anything that’s even useful, let alone “as much coverage for as low a price”, on their own.

            If you said “you get exactly the same thing you have now, only it’s a Medicare card instead of Blue Cross / Blue Shield” then you’d get a lot more support for abandoning employer-provided healthcare.


            • Right? Like, I have a wide range of options in employer health insurance, and I haven’t even signed up for most of the options, because why bother?

              Almost anything catastrophic – the sort of thing for which one insures – is already covered by the public system. All that’s left for employer health packages to even cover is the bits that fall outside Canada’s public coverage. Prescription drugs and dental care are the big ones, and I chose the basic packages for those. The other packages cover things like massage therapy, glasses, crutches, wheelchairs, etc. I figure those are sufficiently small ticket items I’m better off saving the money I’d be putting into the employee-contribution part for that stuff.


            • “as much coverage for as low a price”

              Because we decided (short-sightedly and when healthcare was cheap) during WWII to heavily subsidize employer-provided insurance. The coverage isn’t actually cheap, it’s just being paid for by tax deductions and employer payments so you don’t see the full cost.


  2. One thing is for damn sure, regardless of single payer, defined however, I’m gonna get shafted and have to pay more.


      • Yes, we’ve already “discussed” this. But I’ll say it again.

        Point me to the contract document. Point me to the terms I agreed to and where I signed affirmatively to those terms.


        • The next time someone comes by, knocks you on the head, steals your car, defaces your property, or rapes you: don’t expect justice then.

          Honestly, your response, Damon, is infantile; we are not born in a web of social relationships and obligations of our choosing. If you don’t believe that, go talk to someone not living in your basement.


  3. One thing is for damn sure, regardless of single payer, defined however, I’m gonna get shafted and have to pay more.

    Take this with the utmost respect, and in the spirit of productive dialogue, please. Truly.

    What part of “Repeal and Replace” you didn’t understand?”


    • Please.

      I had to pay more with the implementation of the ACA and my benefits decreased. It has nothing to do with that. It has to do where the money is….the vast middle class. That’s who pays. Neither the rich, who are smart enough to pay guys to find loopholes, nor the poor who have no money, pay for this vast F up of gov’t.


      • It’s not that the rich are “smart enough” to pay people to find loopholes, it’s that they have the money to pay people to find loopholes. And the loopholes often work because the cash needs to be parked somewhere, rather than flowing through and paying for stuff. Rich people generally aren’t rich because they are smart. There are exceptions, of course.

        I think that if we got rid of the differential rate on long-term capital gains, it would make a big difference, and that difference would almost all land on the rich. Yes, some of the merely well-to-do would be hit, too.

        I don’t think the growth justification for the lower capital gains rate exists any more. I don’t think we have any trouble finding capital for investment. I think we are awash in cash, which is constantly being thrown at iffy propositions.


  4. You’ve skimmed over one important aspect of single payer, or alternatives that are regulated to resemble it. In addition to guaranteed issue of insurance, all of them have guaranteed acceptance of that insurance by the care providers. Insurance is worth zero if the docs won’t take it.

    Next year my wife and I will transition from my retiree coverage to Medicare. The medical practice we currently use sent her a letter the other day — she’s six months older than I am, so my letter won’t come for a while — saying that they do not accept traditional Medicare. They do accept a subset of the Medicare Advantage plans in our area.

    Colorado has entire rural counties where there are no providers that will accept either Medicare or Medicaid. Also areas within the Front Range urban corridor. A few years back Loveland was put near the top of a list of best places to retire in some financial magazine. The writers added a caveat: if you have private health insurance, as there were no GPs in Loveland that were accepting new Medicare patients.


    • Medicare vs Advantage is the sort of dynamic I could see for the two-tiered system I think is ultimately going to happen.

      It seems me as likely that telling rural providers that they’re going to have to accept the (lower) M/M rates has potential outcomes other than the providers staying in ruralia and taking a pay cut. And the solutions to that within single-payer are largely available outside of single-payer, too. (Such as they are.)


  5. Your understanding of this topic is too low to possibly characterize the situation in a useful manner.

    ACA has dramatically decreased the profitability of insurance companies. When you say that they’re fighting for their lives? They are — by jumping into the Providing Health Care business.

    You need to understand that the stakeholders are radically reorganizing their profit models, before you stand a chance at saying “We’re going to make a patchwork solution that everyone sort of likes.”

    Because when your stakeholders are nigh unrecognizable compared to four years ago, you can’t possibly expect them to be totally conservative about what they push for.


        • I don’t think what we get will really even qualify as a “plan” so much as an outcome, or a series of outcomes until we get to an outcome where there is not enough will for further substantive change.


        • Kimmi, I’m kind of curious about something. Have you seen ‘traffic shaping’ occurring in the trenches yet? Not the normal traffic shaping, but the delay for no good reason type.


              • Joe,
                Me? No, the places to watch are those where the new Medicare reimbursement rules are really hitting them hard. There was a spate of people being allowed to die, which was a bit more extreme than traffic shaping, no?
                Last I checked they were considering how to rewrite the rules to make sure that doesn’t happen any more.


                • I was expecting traffic shaping leading to people dying. What your looking for is a facility with plenty of capacity and equipment under staffed. The scheduling should start looking hinky and not logical, almost detrimental to service.

                  Basically artificial scarcity. Should see something in legislature that allows it.


                  • Joe,
                    A MRI scanner that’s not in use isn’t earning any money. You can require that anyone getting an MRI can afford it (unless it’s an absolute emergency, which MRIs are generally not). So, there’s no need to create artificial scarcity.

                    Where you see understaffed equipment, it’s for Private Doctors to be flown in to man. (which isn’t to say there aren’t techs, just that there’s a market for “I want MY doctor, who’s the best!”)


                      • MRIs, like a lot of big infrastructure things, are basically all fixed costs. Once you brought it in from the store, the short term marginal cost of running another scan is just the cost of the electricity (*)

                        Any owner of an idle MRI machine is better off doing an extra scan for 10 dollars that to let it sit idle, waiting for a patient willing to pay $300.

                        (*) The long-term marginal cost, the price that justifies buying the second MRI machine is a different story.


                        • There are a lot of factors in utilization, OEE I think the kids are calling it these days. With your background, I’m sure you have seen it where a machine is running around the clock to shorten the payoff period.

                          The problem with just running another scan for X amount of dollars is that most machines have a quantum of lifetime cycles. I have worked with some mechanical devices that only have a 2000 cycle life expectancy so every cycle counts.

                          But I don’t think that cuts to some of the subtlety Kim was getting at up above. How all those things parse in supply and demand and what’s left idle and what is or isn’t supplied. It’s complicated.


    • People blame insurers, but it is providers that hold the most leverage in setting costs.

      Most of what is wrong in health care, and frankly the good ol’ US of A, is an imbalance of leverage. Leverage between big businesses and small (read entrepreneurs here to make good capitalists cry), leverage between employers and employees (see: to make leftist beards wag), to where the rich have the coin to spread misinformation to serve their interests. Its not that I want people not to earn the fruit of their labor; i’m all for entrepreneurship. But a society without a social contract that redistributes leverage to level the field is one that cannot be but unjust, corrupt, and poor.


  6. Scott Lemieux of LGM would agree with you. One problem he notes with single payer advocates is a confusion of terms. Canada’s single payer isn’t exactly like Medicare for All. There are some big differences between them.

    Another problem that very few people talk about is the issue of doctor pay. American doctors tend to make more than all other doctors in the world even if they are general practitioners but especially if they are specialists. Imposing any sort of affordable health care would require doctors to take a huge pay cut. Naturally, doctors are going to oppose this. Other universal healthcare programs got doctors on board by offering them a better deal in terms of money when they were implemented. Swedish doctors didn’t voice much opposition to universal healthcare because there was a long history of most of their salary being paid by the Swedish government anyway. NHS increased doctor pay. The United States is going to need to do the reverse, get doctors to go along with a salary reduction. Good luck with that.


    • The United States is going to need to do the reverse, get doctors to go along with a salary reduction. Good luck with that.

      Reducing the money in a system isn’t the same as giving everyone in it a haircut of equal proportions.

      Our system has multiple massive bureaucracies whose only purpose is to deal with each other. Fire half of the administrators and pass the money saved to the patients.


      • This would be a benefit of single payer. Lots of that bureaucracy is insurance related, both on the “how to submit / defend claims at 100 different companies” end and on the “how to deny as many claims as possible” end.


  7. My prediction of US future healthcare:
    Travel longer distances, wait for a ridiculous amount of time, bribe heavily, expect subpar results.


  8. Remember a million years ago when we were arguing about Deamonte Driver?

    Oh, jeez. We were so young.

    The story of Deamonte Driver was somewhat muddled by a lot of the rhetoric at the time but it seems like it was a combination of there being a shortage of dentists willing to take Medicaid as well as some confusion as to whether Deamonte was actually in the program (not due to eligibility but due to paperwork problems).

    It seems most likely to me that we’re going to have a system with Medicaid for All, Medicare for Some, and a surprising amount of doctors who aren’t accepting new patients. Unless they’re paying with supplemental insurance of some kind. Maybe they’ll be able to squeeze you in under those circumstances.

    Which, at the end of the day, will end up looking a hell of a lot like what we have now, only with more black markets.


    • And for those of you keeping score at home, I happened to find a prediction I made back in 2010 (!) about something that would happen by 2025 and since we’re halfway (!) between back then and coming up, I figure it’s fair to see where we are now.

      This bill does not create health care as much as it creates health care access and “coverage”. This tells me that it is going to create more demand without doing a darned thing about supply and, as such, the price will go up. As the price goes up, markets will spring up to meet the unmet demand (and there will be unmet demand).

      The cartels in charge of writing this legislation in the first place will create barriers to entry for other providers. Rules, licensing laws, zoning, whatever.

      And a black market will be created to circumvent this.

      That’s what I see happening.


      But I see all of the ingredients for a black market. It will require a complete rewriting of my axioms if one doesn’t show up by, oh, 2025.

      Since then, I’ve heard a handful of stories similar to this one which is representative.

      While I have rewritten a number of my axioms since 2010, I am not yet thinking that I’m going to have to rewrite the ones in this category quite yet. Hey, I might… we’ll see. We’re halfway there, after all.


      • What’s amusing is seeing exactly the same arguments in that eight-year-old thread that we saw here just recently, and the same argument style of “disagree with Jaybird, do it again ONLY LOUDER THIS TIME”.

        Oh, a fun one from Jaybird:
        “I’ve no doubt that this monstrosity [the PPACA] will be with us until it can no longer be sustained… mostly due to arguments about the number of dead we’ll have in the streets if we go back to the system we had in 2009.”

        And guess what arguments we’re getting about the AHCA!

        there is some fun stuff in these old threads!
        “The problem is going over the list of the names the Republicans are most likely to run come [2012], I don’t see a decent top-of-the-ticket name on there and the ones that are there range from “threaten to move to (other country)” to cringeworthy to, at their absolute best, “maybe not an awful choice for VP, maybe”.”



        • And guess what arguments we’re getting about the AHCA!

          Well, primarily, “what the heck is in the Senate’s version of the AHCA?!? And why are they afraid to share it?!?”


      • The cartels in charge of writing this legislation in the first place will create barriers to entry for other providers. Rules, licensing laws, zoning, whatever.

        Since then, I’ve heard a handful of stories similar to this one which is representative.

        You realize that story doesn’t have anything to with the ACA, though, right? In fact, most of that story happened pre-ACA, and most of the rest happened before any part of it went into effect.

        It is entirely reasonable to assert there is a cartel of medical entities that have created barriers to entry for both medication, and, to some extent, for doctors. That is a perfectly valid argument, and I even agree with it.

        That seems a rather dubious reason to oppose the ACA, either then or now. The ACA had nothing to do with that.

        And claiming that ‘that cartel’ helped write the ACA and thus we should have opposed it is bogus…the ACA was mostly written by insurance companies and large medical providers, whereas the ‘cartels’ are pharma companies and doctor groups that control education. I’m sure there is some overlap, but it’s not a lot. In fact, insurance companies really do not like some of the cartel-like qualities, and would be happier if there was more competition in both doctors and drugs!

        There is, of course, an argument to make that insurance companies also behave in cartel-like ways, but that cartel isn’t what’s reducing up the doctor supply in this country. It is, if anything, reducing the doctor demand.


        • David,
          Which would be FINE if there were any insurance companies left!
          Instead, you’re seeing vertical monopolies, which behave far differently from insurance companies.


        • And claiming that ‘that cartel’ helped write the ACA and thus we should have opposed it is bogus…the ACA was mostly written by insurance companies and large medical providers, whereas the ‘cartels’ are pharma companies and doctor groups that control education. I’m sure there is some overlap, but it’s not a lot. In fact, insurance companies really do not like some of the cartel-like qualities, and would be happier if there was more competition in both doctors and drugs!

          A very good point.

          I completely got the mechanism of the law creation incorrect there. Well, there was some overlap, but not much.

          Here’s what I’m seeing when it comes to insurance providers, though:

          For the First Time, 45 Counties Could Have No Insurer in the Obamacare Marketplaces.

          I thought that barriers to entry would prevent doctors from providing health care proper.

          As it is, we’re starting to see situations where insurance companies are leaving the market.

          And that’s happening at the same time as the thing that I was talking about is happening.


          • As it is, we’re starting to see situations where insurance companies are leaving the market.

            There are basically three reasons for that.

            One is uncertainty on whether or not the Republicans will continue fighting the reinsurance that insurance companies get, which they have fought from the very start.

            The other reason is those things aren’t working well in some ways, and need to be tweaked, and the Republicans are not doing that.

            And, three, this happened every year under Obamacare anyway! In the past, the Federal government has done outreach to insurance companies and gotten them to extend coverage. The Federal government is not doing that this year.

            The insurance market constantly changes, and that means the Federal government has to be constantly interacting with insurance companies and making sure that things stay on track. It has been crippled in this from the very start, with lawsuits about every possible thing, and a complete unwillingness to fix anything in the ACA, and it’s only gotten worse under Trump.

            That’s not really an indictment of the ACA. It just means that the ACA is not as automatic as people might wish, and it turns out to actually needs a constant balancing act from the government to continue to function.


            • David,
              Of course it’s an indictment of the ACA. It’s also blatantly not true.
              The ACA as originally constructed would have given insurance companies some lump sums to buffer them until they got their actuarial tables straight. Republicans didn’t like that.
              So, yes, the “we DID predict that” stuff happens. I know who to blame.

              No governmental work should need constant monitoring from the Legislative Branch!


              • No governmental work should need constant monitoring from the Legislative Branch!

                I didn’t say it did.

                The ACA, like all the executive functions, and especially those that interact with the business world, need constant monitoring from the Executive. Which the ACA used to have, and thus worked, and now does not have, and thus parts of it are floundering

                And also do not need to be constantly meddled with by the Legislative, which the Republicans in Congress did, with constant lawsuits about nonsense.

                The ACA also, like all new laws, needs some fixes from the Legislative. This not ‘constant monitoring’.


                • David,
                  Fixing the law to be BACK to the original draft isn’t actually fixing the law. It’s fixing the legislature.

                  The ACA wasn’t working under Obama, it was actively not-working by saving people’s lives and driving non-profit insurers out of business.


                  • The ACA wasn’t working under Obama, it was actively not-working by saving people’s lives and driving non-profit insurers out of business.

                    I can’t figure out if you made a typo there, but asserting it’s not working by saving people’s lives is a bit weird.

                    The reason that all those non-profits failed is that the Republicans screwed up the risk corridors payments. Large insurance companies could live without those payments for the time, or ever, but the small non-profits that got set up to provide insurance went out of business.

                    Seems sorta absurd in blaming the ACA for ‘driving out of business’ entities that were only created to operate as part of the ACA, though.


                    • “The risk corridor payments” not being in the bill is tantamount to creating a Broken Bill That Won’t Work.

                      Yes, I know it’s weird. That’s why i did it. You see after they got done breaking the non-profits, they moved on to the insurance companies, many of whom were already dancing on the bleeding edge of profitability (see Highmark grabbing for hospitals in the worst possible way).

                      If you pass a bill that you know is broken, as the Democrats (certainly Baucus) knew, well, then you’re just as culpable as the Republicans.

                      I blame the ACA for not finding any way to make anything profitable. I mean, if you were going to do THAT, why not just have it be single payer and be done with it?

                      I don’t believe Obama knowingly and willingly signed a poison pill, but DUDE, you got an argument for it.


  9. “We’ll never get single-payer! But Democrats might be wise to focus on Medicaid buy-in, throwing in subsidy schedules.”

    “Isn’t ‘Medicare buy-in with a subsidy’ what most people imagine when they think of ‘single-payer’?”

    “Yeah but that’s not what I think it means!”

    You’re right that arguing over terms and definitions is a pretty big part of this whole thing–like, even “provide healthcare to everyone!” can get an argument about the meaning of “provide”, “health”, “care”, “everyone”, and “to”–but it’s a bit clickbaity to title your post “There Will Be No Single Payer” and then follow it with “(because the thing you think is single payer isn’t actually single payer)”.


    • I don’t know if that’s what they mean or not. I do know that the term has a meaning, and people buying their way into Medicaid isn’t it. That is more akin to the Public Option, which has been discussed and evaluated separately of Single-Payer. There are some borderline cases (What if people have to do copays? What about the NHS? Do those count?), which is the main reason I decided to talk about definitions.


      • The distinctions have meaning to a lot of us wonky people who argue this stuff for free/for fun online. I’m not sure how representative we are.

        Among those who aren’t like us, there seem to be a handful of groups:

        1. The people who want much better healthcare than they have now. They want to go to good doctors in a reasonable amount of time to deal with the usual maladies and spend only a small amount out of pocket. (See: Medicaid patients, some Medicare, some VA patients, some Blue Collar Workers)

        2. The people who remember 10-20 years ago when they had better insurance plans than they have now and they want to go back to something like that again. Maybe they got on the wrong side of liking/keeping their doctor. Maybe they’re merely irritated at the rate of increase in their insurance plans. (See: Some White Collar Workers, Some Blue Collar Workers)

        3. The people who just don’t want things to get worse. They’ve got a good thing going, they don’t mind how much they pay, really, they don’t mind paying a little more to help others, really (but I’m talking 2% and not 20%)… but they are apprehensive as heck about things changing because they like things the way they are now. (See: The rest of the White Collar Workers, Some Blue Collar Workers)

        There doesn’t seem to me to be a fourth group that would be willing to experience significant reduction in the amount of benefits they get or a significant increase in the money they pay in order to get the same thing.

        It is not possible to make a plan that addresses the hopes and aspirations of all three of these groups. One, or two, or even all three of these groups will be gravely disappointed.

        We’d love a NHS system that improves things for the #1s, reduces costs for the #2s, and maintains the status quo for the #3s.

        Hell, I’d *LOVE* for there to be an NHS system that does that! That would be freaking awesome!

        But we’re not going to get one. So we’re stuck hoping to limiting the groups we’re going to screw over to just one of those three groups and figuring out which one it will be.


        • Well they are quite a few uninsured people and those who now fear being uninsured and those with pre-exsisting conditions who might again be at risk of losing HC. That is actually a lot of people.


        • I think it’s simpler than that, JB: a really big group of people want something like NHS because it provides better HC at lower total cost and another really big group of people oppose that type of centralization for ideological and pragmatic reasons. The first group denies political reality and the second group denies policy reality. The mushy middle is comprised of people nodding in agreement at valid points made for and against each view and remain unmoved.

          I mean, ask yourself why the US is so resistant to an NHS or Canadian-style two-tier system. Seems to me it’s not because the model doesn’t deliver the goods. It’s due to a fundamental skepticism of and resistance to Big Gummint. For better or worse and irrespective of why.

          Add: Actually the “why” does matter, because some of the arguments against Big Gummint, especially as it applies to the US, are quite valid.


          • I think a big thing about a Canadian-style system that American liberals misunderstand is that the Canadian system is the federal government sending a block of money to the regional governments on the condition that the public health systems they set up meet a fairly short and broad list of conditions. The federal government acknowledges that it isn’t well positioned to set up a big universal system that addresses everyone’s problems, its just the level with the broadest tax base and best credit rating so its best positioned to subsidize the thing.

            I think this can be very much applied to the American system. Your federal government doesn’t at all look competent to micro-manage health care but is necessary to the process because it has the deepest pockets.

            So I think a big part of the problem for American liberals is their excessive focus on Federal politics and the Federal government.


            • Maybe, but to be fair there’s no regional government in Canada that would be dumb enough to, for example, refuse to expand medicaid.

              Federalism is great, except liberals also care about the citizens of Mississippi.


              • If Mississippi doesn’t like the deal, they shouldn’t have to take it. If their dumb by doing so that’s their problem to address internally.

                It does help for this kind of thing though if the regional government has broad discretion for how they do things so long as it meets the goals of the program broadly stated. Like I said, federal governments are bad micro-managers.


              • I know that there are some state-level Republicans who opposed expansion who are now saying, “See? We told you that the risk was that the feds would cut off the expansion money, leaving us to either come up with the 90% on our own or kick a lot of people out of the program.” Most states are already in some sort of budgetary pain these days, caught between rapid growth in the cost of their traditional major programs and the political limits on state/local taxes — the CBO’s model assumes states will kick people off rather than raise taxes, which I think is accurate.

                I admit to being surprised by how rapidly the attitude of “Liberals can have things they think are nice in their state/region, or they can be part of a country with lots of Mississippis, but not both” seems to have taken root.


                • About that last bit, it’s similar to arguments for a national minimum wage: all or nothing. The problem isn’t with the minimum wage part as much as the national part. Liberals, and Democrats, need to figure how to bring localness back into their politics.


            • Yes! Excellent points and I agree. Especially that last bit.

              If the Canadian model is a potential liberal policy goal the mechanisms and evolution of that system should be instructive. From what I understand it began with the provinces and administrative control resides in the provinces.


              • Exactly. The basic story is that one province forced it through, found it worked well so everyone agreed to do it so long as the federal government picked up a part of the tab.

                The extent the Feds are actually involved comes from an authorizing statutue that’s about 7 pages long that sets out 5 goals for Provincial systems to meet, and if they do meet them for the Federal government to cut them a check. It doesn’t need to be any more complicated than that at the national level.



          • I think it’s simpler than that, JB: a really big group of people want something like NHS because it provides better HC at lower total cost and another really big group of people oppose that type of centralization for ideological and pragmatic reasons. The first group denies political reality and the second group denies policy reality.

            “Policy reality” means looking at whether you’re increasing demand/supply/whatever and seeing what the expected outcome of that. It’s NOT bringing in one component of someone else’s system out of their context and claiming we’re going to get the same outcome.

            For example,California is thinking of going with a single payer, they need eye watering tax increases to even try it.


            • For example,California is thinking of going with a single payer, they need eye watering tax increases to even try it.

              Sure they have to raise taxes. That’s what single payer entails. I don’t see how that’s an argument against, tho, since right now all the consumed healthcare and insurance is about $10K/person (the national average). The question is whether you get better HC for that cost, or same healthcare for less, etc. The calculus runs in a different direction.


            • Yes and no. Employer-based healthcare would vanish, so the money not going to that health care system would be available to be captured by the state.

              My own view is that it’s more productive to focus on the payment side. The legislature thinks that it can provide the same aggregate volume of care at a lower cost, largely due to pricing power, as is currently provided within the state by the various existing, fractured systems.

              That’s not a bad bet, but things get technical and really complicated in a hurry. Per David Anderson over at Balloon Juice (here) the State will need a half-dozen major waivers from federal agencies, not to mention a major revision to the tax code, to allow it to operate essentially as its own country for purposes of delivering health care.

              That’s a very heavy lift, but it’s also precisely what’s being discussed above.


              • What they’re proposing seems like an overly ambitious recipe for disaster:

                Under the proposal, which was announced in February, the state would cover all medical expenses for every resident regardless of their income or immigration status, including inpatient, outpatient, emergency services, dental, vision, mental health and nursing home care.

                Insurers would be prohibited from offering benefits that cover the same services as the state.

                The program would eliminate co-pays and deductibles, and patients would not need to get referrals to see eligible providers. The system would be administered by an unpaid nine-person board appointed by the governor and the Legislature.

                This proposal strikes me as unnecessarily risky. Why not start with something more modest, work out the kinks, expand over time to the limits of realistic success?

                I do like the idea administrative power residing in non-elected officials appointed by the Gubna, tho.


                • Why not start with something more modest …

                  A. This is a trial balloon that is intended to show what is needed for complete state-based single payer.

                  B. The legislature has too many morons in it who have been protected from self-harm by Jerry Brown. This is what happens when one of the two parties in a state has been reduced to a parody.

                  C. Other


              • Employer-based healthcare would vanish, so the money not going to that health care system would be available to be captured by the state. …The legislature thinks that it can provide the same aggregate volume of care at a lower cost, largely due to pricing power…

                Let’s take a look, big picture, at what “success” would look like. Assume (:handwave:) a quarter of all HC spending is wasted via insurance/bureaucratic systems fighting with each other.

                The legislature capturing that money means hundreds of thousands of highly paid, highly intelligent bureaucrats/insurance people/medical coders are unemployed, to the tune of 4% of CA’s GDP. They’re going to scream to high heaven, as will their allies and their various organizations. So we’re looking at the AMC, the doctors, nurses, etc all making TV ads claiming that the politicians are killing people.

                These groups are heavy donors of the Dems, but California’s wonderful politicians will stand up to them and the political pressure and do what’s best for the patients. This frees up amazing amounts of money which can be used to give the uninsured sick care and keep good care for the people who currently have employer insurance.

                And I don’t believe that for a second. FAR more likely imho is we keep all of these groups alive, don’t ruffle too many feathers, and add another layer of bureaucracy. (This reality is why I like market solutions)

                And since they’re not saving any serious amount of money, they need, and will continue to need, massive tax increases for NEW money into the system to cover everyone who wins in the new system.

                Or alternatively, they can have serious losers, say, everyone who currently has employer insurance (which is probably another political non-starter).


        • I think it’s absolutely true that a lot of normies haven’t through through the difference between an NHS model and a single-payer model. They just want access to health care without spending.as much money. So all they hear when they hear is “single payer” is that one person is paying, and it’s not them (though do understand something about higher taxes in lieu of insurance premiums). The flipside of this is that if single payer ever starts to get a push through congress, there will be a whole lot of money spent towards defining the concept – and how it will work in practice – in a really negative way.

          That’s why, in my mind, it would be sort of ideal if California did get something like it through. It would provide better counterarguments than Canada or France. (The realiziation of how difficult it would be for a state to pull it off is one of the things that turned me towards skepticism of the political viability.)


          • My views on political viability changed a lot when I learned you can write the bill with zero hearings and pass it with 50 votes in the senate.

            But the filibuster! Nope a Democratic Party that has full control in 2020 isn’t going to bother with that after this and Gorsuch.

            And after the fallout from the complicated and attempting to accommodate everyone they will keep it super simple.

            Subsidies and you can just freaking buy Medicaid/Medicare.

            Because then they don’t have to deal with the frakking market raising premiums/copays.


  10. Everything we hear about the AHCA in the news makes it sound worse and worse including that the GOP might be messing with employer-based health insurance and anything else they can do to get a massive tax cut through in 2018.

    What is happening with the Senate right now is, quite possibly, the most absurd thing I’ve ever seen. I can’t even start to comprehend how they think it will work out for them.

    They seem to think that if they get their vote out of the way before the American people see the bill, they win. If they can just get it passed before the July recess, they never have to deal with opposition to it.

    First of all, that’s not how politics works, and considering that Republicans spent 7 years attacking the Democrats for a vote they Previously made, you’d think they know that.

    Secondly…they do all remember how passing legislation works, right? That the Senate bill will go to committee to work out differences between it and the House AHCA, and then changes have to be voted on in both houses? They’re going to have to vote again. They know this, right?

    I’m with Erza Klein, as mentioned above. I can’t see how this is any sort of intelligent plan. What this is actually going to accomplish is the Democrats pushing, hard, for single payer at the midterm. The insurance rates get set in June and July, a year from now, and people realize what, exactly happened.

    I keep making jokes about how the Republicans have actually forgotten how to legislative, but it’s slowly starting to dawn on me they really truly have.


    • I think, if you squint, there is a plan in there. The plan is to pass something that isn’t going to go anywhere then let it vanish into committee and die. Then the conserva-media wing and the GOP politicritters gets to truthfully spin that all the GOP politicians passed a “repeal and replace” of Obamacare but none of the dreadful consequences of them actually fiddling with the ACA come to pass. I’m presuming the idea is if they can spin hard enough then they won’t get primaried and since nothing actually gets changed their Trumpkin supporters won’t get shafted and thus won’t turn on the party.


      • You don’t think they’ll pass it? I do. I think the plan is to pass it, spin it (Mitch “The Most Cynical Man in Washington” McConnell will take the lead, natch), and move on to the second round of tax cuts betting that anti-Dem sentiment, Trump-based confusion, and Dem Party incompetence carry them thru the midterms. If not, they still got their tax cuts.


        • Yes, I see what you’re outlining as their best case scenario and what I’m describing as the more likely and for them Plan B scenario. Knowing the wily Majority Leader from Turtle Town Plan B is also highly palatable to him which is why they’re doing it that way.


          • I read an interesting comment somewhere on the internets but can’t remember where: “The GOP understands the shifting political dynamics right now better than Democrats do.” I think that’s right. I think they’re more confident in their prospects than you or I would think justified, but our presumption is that things will “return to normal” soon. Personally, I don’t think it will.

            Add: McConnell’s process re: the AHCA bill is just one example of that.


          • Another reason why I think they’ll pass it: Dem proposals to fix things will now require a) raising taxes and b) re-introducing “failed Obamacare policies”, both of which are political losers. So by slashing and burning right now the GOP is in a position of political strength for future election cycles. Or at least as much strength as they can wring out of a tax cut masquerading as healthcare reform anyway.


            • If they can spin a tax cut for the wealthy and a literal direct shot to the groin for Trumps voters into electoral victories or a tie in 2018 then they probably deserve to win on political merits (or the Dems deserve to loose). That’s a big gamble for their various Congress Critters to be taking tho. Those DC jobs are cushy. It’ll be interesting to see if they can wrangle it.


  11. I agree with the premise that the jump to single-payer (i.e. medicare-for-all) from where we are now is too big. It won’t happen first nationally because it would require large tax increases (though, from a policy perspective, likely offset by savings on healthcare expenditures). Vermont proved that a small liberal state with the best of intentions can’t find a way to make it pencil out on its own. I suspect California is going to rapidly prove that the same is true for a big liberal state.

    To me, the obvious path (and what a democratic government would surely be trying right now to strengthen the exchanges–assuming their current weaknesses aren’t purely Trump-related) is to allow a public option onto the exchanges, then provide suitable incentives to allow employees to choose between employer-provided and exchange-based plans, and see whether the public option destroys its private competition. If it does, then a formal move to single-payer is a much smaller and more palatable jump (“Save unnecessary administrative overhead managing exchanges, just give folks what they’re already choosing!”). If it doesn’t, then the argument for single payer loses some credibility anyway.


    • I think your proposed path makes a lot of sense. It really seems like either a Public Option (was was considered for PPACA) or Medicaid buy-in is the next step. Whether that’s successful or not will likely depend on particulars. I am (obviously) skeptical that it would mostly displace private insurance, but it could. And if it doesn’t, that at least helps get the left a lot closer to where it wants to go.


      • Right. We really should have gotten a public option, and the nutjob Democratic senators who killed it should live in infamy, but I suspect the tide will turn again and provide another chance to give it a shot. Certainly the post-2016 elections are indicative of a possibility that things will turn fast.

        If private insurers can beat the public option, then I’d gladly switch from advocating single payer to just robust exchanges for everyone. I think it’s a pipe dream (government overhead is ~2%, private is 10-20%), but the public option would offer a low-risk test environment.


  12. The best plan to fight against the “the Democrats are going to take away your good health care” attack on single payer is something like Pete Stark’s Americare plan, which was originally brought up in the halycon days of 2006.

    Here’s a description from Vox –

    “You can think of the AmeriCare approach as a public option on steroids. It would create a new single-payer program called AmeriCare that would take on everyone ensured by Medicaid and SCHIP, and would automatically enroll all children at birth. It would pay the same rates to providers as Medicare, meaning it’d be considerably less generous to doctors and hospitals than private insurers.

    AmeriCare involves cost sharing very similar to what you’d find in a private plan, but more affordable. There are deductibles ($350 for individuals, $500 for families), co-insurance (20 percent of spending above the deductible), an out-of-pocket spending cap ($2,500 for individuals, $4,000 for families), and premiums.

    However, cost sharing would be sharply limited for low-income families. Individuals and families living on less than twice the poverty line ($48,500 for a family of four in 2015) wouldn’t have to pay premiums, deductibles, or co-insurance, and there would be premium subsidies and lower deductibles for people between two and three times the poverty line.

    Here’s the kicker: Employers could buy into the plan. They’d have to pay 80 percent of the premium, leaving 20 percent to employees, but it’d be an alternative every company got to their existing private plan.”

    Basically, it’s single payer without being single payer, because if your company or union has an amazing health care plan, you can keep it.


  13. All of this is smoke and mirrors. It doesn’t matter whether we’ve got “single payer” or “whatever”. As long as the HC system itself is broken, costs aren’t going to go down.

    I had surgery two or three years ago, my doctor couldn’t tell me how much it would cost because he didn’t know. All costs in the system are opaque and hidden from view. If they want to charge me $1000 for an aspirin, they can and I wouldn’t be able to even notice without an absurd amount of research on my part. The insurance companies have massive bureaucracies set up to prevent that kind of nonsense, hospitals have the same set up to do it.

    Who pays is besides the point. Moving to single payer isn’t going to get rid of the hospitals’ bureaucracies, nor remove their strong incentive to play these games.

    We need medical cost reform, not medical insurance reform.


    • “Moving to single payer isn’t going to get rid of the hospitals’ bureaucracies, nor remove their strong incentive to play these games.”

      What it will do is give the same negotiator to every American.

      The reason that cost negotiation works is that the insurer can say to the provider “look, if you accept us paying you less than you ask for, we’ll throw business your way, and you can make it up in volume”. Obviously, this works better for insurers that have more patients to send to the provider. So imagine that you have three hundred fifty million patients; that’s a pretty big volume to make it up from!


      • The reason that cost negotiation works is that the insurer can say to the provider “look, if you accept us paying you less than you ask for, we’ll throw business your way, and you can make it up in volume”. Obviously, this works better for insurers that have more patients to send to the provider. So imagine that you have three hundred fifty million patients; that’s a pretty big volume to make it up from!

        The underlying assumption here is we’re going to build a massive bureaucracy which will deal with the hospital’s massive bureaucracy and it’s going to be much more successful than the current massive bureaucracies.

        I’d feel a lot better if we just forced all HC providers to publish their prices so people could compare.


          • I’d feel a lot better if we just forced all HC providers to publish their prices so people could compare.

            You think that will fix our healthcare problems? Seriously?

            Everything? No. But I think that would open the door to other things at least being possible. Without that we’re stuck with the overhead of dueling bureaucracies, say like the “Pentagon”.


          • They really believe that healthcare is like any other commodity and that having open prices that people can compare would lead to people going for the best price so hospitals and doctors would have to compete.

            Its the rightest equivalent of why Saul thinks that the Vox set likes the market exchanges, it nudges people into the proper direction. Most people do not want to think that deeply about health care, they just want to get cured. Depending on the injury or sickness, they might not even be in a place to look around. If you’ve been in an accident, your going to need help immediately rather than latter. Same with sudden weird symptoms that happen at times. Healthcare is not like furniture shopping.


            • Lee,
              Two miles, same insurance system. An MRI at one hospital costs DOUBLE what it does at the other.

              are you so CERTAIN that Healthcare shouldn’t be like furniture shopping?

              Plus, you apparently haven’t had anything seriously wrong with you. Seriously wrong with you crap means you’re better off not hitting the first hospital nearest to you. [Not “I have a heart attack” — try “My blood is contaminated and blackflagged. Please do not spill on pregnant ladies.”]


              • If there was a way to munge the data to protect privacy, it would be really interesting to see all of the prices charged for every item published for every medical center. Just a table of billing code:number performed:price(mean, stdev) for everything everywhere.

                Or a voluntary glassdoor.com type system.

                Sure, there will be variations due to the types of patients different providers take, but I’d kill to have that data problem rather than the one we have now.


                • tf,
                  The data exists, but it’s indexed as well by insurance company (as each hospital has a different price for each insurance).

                  … yes, it’s still illegal to collate together. Don’t pretend that it being illegal means that someone hasn’t done it.


                • Even then, though, what the patient ends up actually paying isn’t necessarily related to the cost of the procedure itself.

                  Like, you have what the surgeon charged–but also the anesthesiologist, the nurses, anyone called in for a consult. And then the hospital adds charges for the bed, for food, for consumable items, for whatever else they want to slam in there.

                  And the insurance company has its own ideas about all this–not just the rates for service, but whether the hospital is allowed to charge patients at all for some things. And sometimes they’ll let you get balance-billed for what they didn’t pay, and sometimes they won’t. (And sometimes whether they’ll cover the balance-bill or not is dependent on which customer service rep you get when you call the insurance company.)

                  And considering that the doctor might be an independent contractor who gets paid by the hospital, and not by the insurer, so what he charges to do a surgery might not even be remotely related to what you get charged for it.

                  So, sure, they could publish the rates, but that won’t tell you a whole lot about what you’ll actually *pay* to have something done.


                  • I think that settling for what the individual was actually billed for each line item would do the trick, especially if it’s binned by which insurance provider the patient has. The rest is internal forces that are the hospital’s problem, frankly.


                  • So, sure, they could publish the rates, but that won’t tell you a whole lot about what you’ll actually *pay* to have something done.

                    Good products push bad ones off the market.

                    And normally if you enter into a contract to buy a product and they give you another, then that’s a breach of contract. For that matter when buying a car you’re not forced to buy the tires, steering wheel, etc, separately.


                      • if you get a hospital acquired infection, you’re paying more.

                        Thank you, I’d forgotten about “hai”. While we’re forcing HC providers to publish their prices we should also be forcing them to publish their other relevant stats, including infection rates.

                        There are HC providers that are wonderful, others that are horrible, and there’s no way to tell the difference. That’s a great example where lack of any market feedback is killing people.


                  • Absolutely true. And if patients started submitting their itemized bills to MedicalGlassDoor.com, it would take about a week before every provider and insurance company added a pricing NDA to its terms and stomped that little uprising flat.


                  • Stillwater,
                    Not at all! Don’t you think Someone pays to get this shit?
                    All it takes is a clever hacker (and people clever enough to not make it Incredibly Obvious that they have their competitors numbers).


            • Depending on the injury or sickness, they might not even be in a place to look around. If you’ve been in an accident, your going to need help immediately rather than latter.

              True, but how relevant is this? What percentage of HC fits this? I think it’s in the single digits percentage-wise but let’s call it 10%.

              Hopefully sweating down the price of 90% of the system will also reduce costs for the other 10%. Hopefully the hospital won’t charge you 10x for an emergency MRI, and if that’s actually a thing then maybe it needs a legal remedy.

              And published prices also lets non-patients evaluate and force competition on the system. The job of Insurance companies, in terms of keeping their own prices down, gets much easier if they can eval prices and not medical codes designed to obfuscate things.


              • Dark,
                An MRI costs double at one hospital than another, 2 miles away. I think, even if the difference was $100 versus $50, people would still choose the more expensive hospital. (Now, make it $1000 versus $500, and people MIGHT choose the less expensive place. But that’s not the regime you’re talking about).

                … also, the rates I’m quoting are for the hospital’s OWN insurance.

                Ain’t no margin in “keeping your prices down” if you’re cutting your own throat. (and the Profit Center for health care is NOT insurance companies. Its Actually Providing Care. Which is why Highmark is running so quickly to get new hospitals.)


        • We already have a bureaucracy to operate Medicare/Medicaid claims (and great enforcement by DOJ). They’re WAY better at it from an efficiency perspective than private insurers.

          If you think adding volume would reduce efficiency, I’d like to hear why.


              • The quick summary is that Medicare [Administrative Costs] overhead is 2%. Private is high-teens.

                Yes, but at what cost? Efficiency of the total system is not measured by lack of administration, especially when most actors are deliberately inflating their fees.

                In theory you could reduce admin costs to near zero by just mailing a blank check to every HC provider every time they ask.


                  • Compared to more than 1% of our Fucking GDP? … Medicare ain’t wasting that much, that’s for sure!

                    This is a program spending percentage points of the GDP, which is growing exponentially and threatens to break the budget.

                    It had better be wasting 1% or more of the GDP. If it isn’t wasting money then at some point we get to choose between breaking the budget and people dying on the streets.


                      • Waste is a technical term. Waste is not about people dying on the streets. Antibiotics are not waste.

                        IMHO an army of bureaucrats fighting with another army of bureaucrats fits the definition of waste very nicely; And that’s even before you deal with the mismanagement of resources which this generates.

                        Do it enough and yes, you end up with people dying on the streets (communist countries have repeated proven that, especially when applied to agriculture).


                • I don’t understand the question.

                  Government healthcare pays negotiated rates that are nearly always lower than private insurance rates (which makes sense, because bigger groups have better leverage). And, while there are certainly cases where people try to bilk the system, the DOJ is quite good at catching them (and excellent at enforcing the law against those caught). Is your argument that government healthcare is more frequently cheated that private healtcare? If so, cite?


                  • Fairly regularly you see stories in the news about medical practices caught in various sorts of largish scale fraud on Medicare or Medicaid fee-for-service payments. (Granted, the ones you hear about are the ones that got caught. When I worked for the state government, it was a given that there was a certain amount of Medicaid fraud, but not enough to justify the software to do pattern matching and catch the providers out.) I don’t recall ever reading about fraud on that scale against private insurers.


                    • With Medicare people do fraud. With insurance companies, we merely stack the deck, so that we get all the moneyz without it being blatantly against the contract. (which codes do you code something as to get the most money? making sure docs don’t forget a code… etc)


                    • I bet if you counted up all the Medicare & Medicaid fraud in the past decade, it wouldn’t add up or even be close to the compensation given to top level health insurance executives in the same time period.


                  • …while there are certainly cases where people try to bilk the system…

                    The problem is what’s legal. Medicare pays negotiated rates on particular procedures, i.e. “health codes”. However many procedures can legitimately be put under various codes, and/or can changed from one code to a much higher costing code with some trivial change.

                    Ergo “testing facilities” which are in the same building “separated” by some door holding a big sign saying “you’re leaving this facility” (presumably legally they’re different buildings as well). In-the-same-facility medical tests are billed at one rate. Extern-to-this-facility tests are billed at another. And it’s legal… although it certainly doesn’t add value.

                    I don’t understand the question.

                    My question is, is Medicare paying more per patient than the privates are? Efficiency of a system is average(patient-cost+admin-cost), not average(admin-cost).

                    Private companies can’t run administration that tight without becoming unprofitable, which suggests their administration (i.e. their own medical code warriors) adds value by keeping prices down. Part of that isn’t “reducing the cost of a code”, it’s “claiming three codes are actually one”.

                    Medicare doesn’t run administration that tight but also doesn’t have to earn a profit and thus doesn’t have to keep prices down. I wasn’t able to find numbers this subject which normally doesn’t mean good things.


                    • Private insurance runs on codes too.

                      As to your second question, check the same link. The question is a little bit apples/oranges because Medicare only covers elderly patients while private insurance mostly covers younger patients. But if you limit your focus to Medicare Advantage (private companies’ old-person coverage), you see they cost 12 percent more (the “So-called “competition” in the private health care market has driven costs up” heading). Likewise, cost growth overall at private companies is higher than Medicare by a subtantial margin (the “Medicare Has Controlled Costs Better Than Private Insurance” heading).

                      What’s more, none of that should be surprising unless your prior is that the government sucks at everything because it is the government. Insurance is not an innovative space, it’s an actuarial and administrative function. Which the government can do WAY cheaper than private companies who pay CEOs eight figure salaries. Not only that, the best way to save money in the field is to maximize your bargaining position against providers, and Medicare has near-infinite leverage while individual private companies do not.


                        • It reads to me like simple market economics. Medicare has WAY MORE market power than any individual private insurer, and cartels are illegal, so it it gets the best prices.

                          I’m sure doctors would say they couldn’t survive without the private payments, and they’d get a lot of public cred in saying it, but I also bet few would hang up their stethoscopes if we did single-payer at Medicare rates.


                          • To be fair, your numbers clearly show this to be a much more viable plan than I’d originally thought.

                            Medicare has done a better job controlling costs.

                            The problem is “Better” isn’t the same as “Good”. In other threads I’ve argued Medicare/Medicaid’s out of control growth is on course to break the bank.


                            • If that’s true, it’s only because medicine has gotten dramatically more expensive (and because all medical services in the US cost WAY more than anywhere else in the world).

                              There are good reasons (yes we have to pay for MRIs, but it’s pretty great technology to have when you need it) and bad reasons (we don’t do enough ounces of prevention and do too many pounds of cure). But that’s a major problem that will be very difficult to solve entirely given that attacks on doctors’ comp by DC politicians would be a political firestorm. Single payer, though, would at least help with the issue.


                              • Single payer, though, would at least help with the issue.

                                Single payer is medical insurance reform as opposed to medical cost reform.

                                There are aspects of SP which help (eliminating private administration), there are aspects which hurt (increasing demand on the system by adding people who were previously excluded). I’m not sure whether the net would be positive or negative.

                                Medicare is already on a course to break the budget. Medicare is politically insulated. Medicare is 3rd party pays with the people insulated from all cost decisions. Moving to single payer doubles down on all of that. If we get a 10% (or even 20%) savings then we’re just buying a year or two… and that’s in the context of not being sure if SP won’t increase actual spending.

                                We don’t need single payer to have medical cost reform, single payer is FAR more about expanding access.


                                • I’m envisioning single-payer as Medicare-for-all. So you immediately get the 50% cost reduction vs. private, and immediately get the 10-15% overhead savings. Plus you now have a system with near-infinite leverage to fight price increases.

                                  It’s certainly more about increasing access, but it would be a positive step on cost control too. (keep in mind, I support a public option as a test case, because a sudden shift to single payer would be hugely disruptive).


                                  • …you immediately get the 50% cost reduction vs. private, and immediately get the 10-15% overhead savings. Plus you now have a system with near-infinite leverage to fight price increases.

                                    This seems too good to be true. Assuming the math is right (and if it’s right then I don’t understand why it doesn’t work at a state level), we’re talking about the firing of 4% or more of the GDP worth of well paid bureaucrats. I find it hard to believe our political system could implement this in the face of the kind of pushback we’d get.

                                    I’d like to see this at a state level before it goes federal.


                  • These arguments you’re making for health care could apply to any product. Are you in favor of a command economy in general? If not, I’m (genuinely) curious to hear what you think are the drawbacks of a single payer system and why in the case of health care it makes sense to accept them, whereas it doesn’t for, say, toothpaste or detergent.


                    • Sure thing. First, no. I do not favor a “command economy” in general.

                      The difference is that I don’t believe health care is fairly understood as a generic good like toothpaste. Instead, I view it as a necessary service in a modern economy (and at some level that position has been universally and controversially accepted for at least thirty years, since we mandate provision of health care but not toothpaste). The problem with health care, though, is that it’s needed only sporadically–in many cases unpredictably and, critically, unavoidably–but when needed is so astronomically expensive that it would often be expected to bankrupt the recipients.

                      The first-order solution to problems like that is insurance, where you pay a manageable amount of money regularly so you aren’t bankrupted by a $500,000 medical bill because your doctor finds a lump at your checkup (or whatever else happens). But we can’t naively stop there for a few reasons. First, the high cost events are frequent/expensive enough that even spreading risk leaves regular payments that are too expensive for lots of people (and, unlike auto/home/other forms of insurance, you can’t just structure your life to avoid consuming health care). Second, back before that was the case, and in trying times, the country created an irrational system whereby people with full time jobs nearly always get their insurance from their employer, leaving people without such jobs to fend for themselves. Third, private insurers then had decades to come up with creative ways to maximize their profits by both maximizing upfront income AND minimizing payments to their insured, making may policies (especially in the individual market) unreliable and low-value. Fourth, the health care providers (doctors, hospitals, etc) are extremely popular institutions (after all, few sectors of the economy get tens of billions of dollars in private donations).

                      So now we have a mess. People need and are entitled to health care. But many of them can’t afford (or rely on) insurance. That sucks for those people, but it also sucks for everyone else (since we agree that, at minimum, they can get treatment at ERs even if they can’t afford to pay for that treatment, and we would presumably prefer to have the same people healthy at their jobs so they aren’t infecting others). These concerns simply don’t apply to toothpaste/detergent/generic consumer goods.

                      You also asked about drawbacks. For single payer, those are pretty clear: (1) government spending goes way up, because it is now paying the nation’s health insurance, which means it needs to collect a lot more revenue (though, in my view, those taxes will go up less than the amount paid to private insurers, even the distribution isn’t matched); (2) the change would be disruptive (health insurance is a big industry, so a lot of people would find themselves out of jobs, and the government wouldn’t be hiring all of them); and (3) there would be inevitable growing pains as providers and the government fight to set a playing field with huge amounts of money at stake (and, of course, people will always trust their doctor over their government).

                      That’s why Obama decided to incorporate a good republican idea (from back when they had those) and do the ACA. And its why if I were god-emperor of the USA, I’d likely choose to add a public option to the exchanges, and make it easier for employers (or even individual employees) to choose that option if they preferred it to employer-provided HC. That way (as I said above) you’d have a competitive period for the government to figure out Medicare-for-all, with choices so no one is overly harmed by growing pains, a major industry isn’t gone in an instant, and if I’m wrong about the superiority of public insurance, we find out with the lowest possible stakes.


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