Why can't states run single payer systems?

Ezra's speech on state health care programs comes out against them, but neatly avoids the obvious: the reason that they all failed was that they were incredibly expensive. Moreover, they were vastly more expensive than the planners had anticipated, which knocked budgets out of whack. This in spite of the fact that the programs were very well positioned to take advantage of all of the collective bargaining, administrative, and preventative medicine efficiencies that advocates of national health care keep promising us will shave the cost of such a system. Whatever those savings are, the evidence seems to be that they are outweighed by the fact that if you make health care free, and don't ration it, people use a whole lot more than you were expecting them to. Your costs, accordingly, shoot through the roof.

TennCare didn't get into trouble because there was a recession; it got into trouble because it was godawful expensive and getting more so by the minute. Costs were projected to rise by about 75% over the next five years, and even though the federal government would have picked up almost half the tab, Tennessee couldn't afford to pay it. The failure of the various state initiatives is an instructive look at our future.

Comments

The claim that the sole reason for the failure of those plans is moral hazard on the part of covered individuals is a very strong claim. Is there any evidence that the state health care plans failed because people who were covered by those state initiatives actually consumed more health care goods and services than policymakers expected?

(As opposed to: expected savings didn't materialize, the costs of providing health care goods and services went up more than expected, more people sought coverage under those plans than expected, etc., etc.)

Posted by alkali | October 18, 2007 4:15 PM

alkali,

Yes, but if the savings didn't appear and they are just as costly or more, why switch?

BTW, will illegal aliens get healthcards under Hillarycare? How without getting deported?

Just wondering...

Posted by buffpilot | October 18, 2007 4:19 PM

What, didn't Israel generate enough heat for you?

Posted by Dan Miller | October 18, 2007 4:31 PM

Yes, but if the savings didn't appear and they are just as costly or more, why switch?

Why the plan failed is important.

If the plan failed because there is no way to provide health care to the uninsured without massive overconsumption of medical services, then that might be a good reason not to try to do that.

If the plan failed because too many uninsured people moved in from out of state, that might be a reason to try such a plan at the federal level and not at the state level.

If the plan failed because states with balanced budget restrictions couldn't play for the plan in the trough of the business cycle, that suggests that states might be able to carry out such a plan if they weren't subject to such restrictions.

Etc., etc.

Posted by alkali | October 18, 2007 4:41 PM

If we are going to do some type of major health care reform I would much rather see it at the state level. Of course there are some changes at the federal level that could help this process.

The main reason I think this is that there are many unknowns with all of the proposals. Everyone has a theory of how each would work but no one really knows. Better IMO to try multiple test cases in multiple states of different programs and see which ones perform best.

The experience I have is with electricity deregualtion, Initially reformers wanted deregulation based on the California model nation wide. The model was good in theory and had worked in Europe (Britian, Scandinavia).

What we got instead was multiple state/regional programs. Some states deregulated on the California model, some deregulated based on another model in the NE, and others did nothing.

Well in retrospect the California model was a disaster, the NE model worked pretty well and was adopted by other states, and the old model turned out not to be that bad after all.

Since there are many unknowns and we have a large diverse country seems better to try a few state experiments and see how they work, then other states can adopt them if they look promising.

Additionally competion between states will provide an important check and balance on any program. No state can get too generouse or too stingy or it will loose people/businesses. The federal govt. on the other hand is one giant monopoly.

Posted by Eccdogg | October 18, 2007 5:09 PM

Universal coverage plans are not necessarily single payer systems.

The Dutch national health plan is not a single payer system.
Neither is the German system.
Neither is the Swiss system.
Neither is the Massachusetts system.
Neither is Schwarznegger's plan.
Neither is Hillary's.

I keep on reading this blog to find out if Megan understands the difference between single payer systems and other methods for providing universal medical insurance. So far, the answer is no.

Posted by Stan | October 18, 2007 5:10 PM

the reason that they all failed was that they were incredibly expensive. Moreover, they were vastly more expensive than the planners had anticipated, which knocked budgets out of whack. This in spite of the fact that the programs were very well positioned to take advantage of all of the collective bargaining, administrative, and preventative medicine efficiencies that advocates of national health care keep promising us will shave the cost of such a system. Whatever those savings are, the evidence seems to be that they are outweighed by the fact that if you make health care free, and don't ration it, people use a whole lot more than you were expecting them to. Your costs, accordingly, shoot through the roof.

Your costs would be shooting through the roof regardless of how many people are taking advantage. Costs are skyrocketing EVERYWHERE, universally, throughout the country, regardless of whether there is a state single-payer program or not. They may skyrocket MORE where more people are consuming more health care; but to imply that costs are NOT skyrocketing in the absence of single-payer plans is unfounded and, in my opinion, misleading.

As far as the state plans being "very well positioned to take advantage of all of the collective bargaining, administrative, and preventative medicine efficiencies," I think you're off-base there as well. Those efficiencies will only be significant in the absence of competition to the single payer; why should a hospital in Tennessee charge less for its care than a hospital in Arkansas, just because there is single-payer in Tennessee? Pharmaceutical companies and medical supply companies are not going to lower their prices to accommodate Tennessee, when there are plenty of markets for their products in neighboring states that will pay the higher prices. I mean, HMOs pool patients from DOZENS of states and can't seem to negotiate lower prices; how can a single state be expected to do so?

That's why single payer MUST be a nationwide system. There must be NO alternative to negotiating with the single payer. And the federal government is the only organization we can trust with monopoly power in a marketplace; the temptations of monopoly power in private hands are simply too great.

The failure of the various state initiatives is an instructive look at our future.

No, they aren't. They are apples and oranges in terms of scale.

Posted by liberalrob | October 18, 2007 5:22 PM

More of this, please, Megan. Good points.

"If the plan failed because too many uninsured people moved in from out of state, that might be a reason to try such a plan at the federal level and not at the state level."

What if too many uninsured people move in from out of country? Another reason to enforce the laws on the books against illegal immigration before adding another entitlement to the welfare state.

LiberalRob,

Do you think your argument for nationalizing health care seems more compelling when you use all-caps?

Posted by Fred | October 18, 2007 5:39 PM

Do you think your argument for nationalizing health care seems more compelling when you use all-caps?

YES. Especially when I am trying to EMPHASIZE something, because it's hard to indicate emphasis in a text box. That's NOT all-caps, BTW. Go check the definition:

http://en.wikipedia.org/wiki/All_caps

Posted by liberalrob | October 18, 2007 6:20 PM

liberalrob wrote: That's why single payer MUST be a nationwide system. There must be NO alternative to negotiating with the single payer. And the federal government is the only organization we can trust with monopoly power in a marketplace; the temptations of monopoly power in private hands are simply too great.

Talk like this is precisely why you're not going to get a single-payer system. The US might be ready to slouch into a national health model along the lines of continental Europe, seeing as how we've already got a lot of socialized healthcare by different names, with disproportionate benefits to the elderly. But too many US citizens have seen the Canadian and UK healthcare systems, and the DMV, to believe that the Guv'mint is trustworthy with monopoly power in the services marketplace.

Posted by anony-mouse | October 18, 2007 6:27 PM

Now, I have my doubts about socialized medicine. But I'm a fair man, and I'm willing to give it a shot. Since much of the argument in favor of socialized medicine is predicated on the "amazing" cost savings achieved in other countries, I propose this as a compromise:

In 2003, the U.S. spent $5,711 per person on health care. That same year, Canada spent $2,998 and the United Kingdom spent $2,317. And according to the Alliance, $.45 out of every dollar in health care spending comes from the government (primarily the federal government). That works out to $2,570 per person. Here's my plan. I propose we appoint Ezra National Health Care Commissar and him full discretion over those health care dollars spent by the government. He can remake the system however he likes. For that kind of money, we might not be up to Canadian standards, but we should at least be able to bring NHS quality and excellence state side. No need for additional spending (like those pesky Democrats in Congress would like). Remember, we'll get the full benefit of those fabulous cost savings Ezra promised.

Posted by Alejandro Gonzalez | October 18, 2007 6:44 PM

Talk like this is precisely why you're not going to get a single-payer system.

Not at all. The reason we're not going to get a single-payer system is that (to borrow a term from economics) the opportunity cost to the people satisfied with their health care is perceived to be too high. That's because they've been continually lied to about how "the Canadian and UK healthcare systems" are hopeless disasters, when in fact they are known to be more efficient and cost-effective by far than the ridiculous profit-driven system we have in place in this country. And since people generally satisfied with their health care are currently running the country, and millions upon millions of lobbyist dollars are flowing to them in support of the status quo, nothing will happen.

Posted by liberalrob | October 18, 2007 7:07 PM

Has anyone ever done a good study comparing the single payer universal health plan we do have (Medicare) to the Eurotopian health plans we hear so much about (obviously adjusting for age) in terms of cost and effectiveness of care? That might be the closest we can come to an apples to apples comparison. I'll go out on a limb and guess Medicare costs more but where do the higher costs come from?

Posted by dix | October 18, 2007 7:14 PM

I don't think the problem for state-run universal healthcare plans is so much that the states can't afford them. Even relatively poor American states are pretty rich places by world standards. I think the problem, rather, is one of political will and political infeasibility. A state needs to raise taxes more than the voters are willing to go in order to maintain truly universal health care coverage over the long term, and so far no state has been able to pull this off (the jury is still out on Massachusetts). One problem related to feasibility, of course, is the simple fact that economic resources can move across state lines if a given state's tax regime becomes too onerous in an effort to cover all its citizens with health insurance.

Still, I have wondered about the possibility of, at long last, attaining universal health care access in the US via those laboratories of democracy, the states. If every state were required by the federal government to enact UHC, some of the problems alluded to above would disappear. Why, for instance, couldn't Washington make Medicare/Medicaid transfer dollars contingent upon the successful adoption and implementation of a valid universal healthcare plan by every state, and then stand back and let the fifty "laboratories" do their thing. The federal government could set some basic standards to insure such plains were meaningful, and then give the states, say, five years to get the plans up and running. Don't want to participate? Washington wouldn't force you, but I seriously doubt any state government could afford to go without federal healthcare transfers. I don't see why such an approach couldn't work in theory. And under such a scheme the mistakes made in St. Paul or Tallahassee wouldn't screw up the whole country, and the innovated, highly effective ideas hatched in Boise or Columbus might be adopted far and wide.

Posted by Jasper | October 18, 2007 7:36 PM

If government-run health care is so much more expensive, then how come Americans spend 15% of our GDP on health care, while the countries with national health care generally spend 8-10%?

Posted by Avram | October 18, 2007 7:49 PM

The federal government could set some basic standards to insure such plains were meaningful, and then give the states, say, five years to get the plans up and running. Don't want to participate? Washington wouldn't force you, but I seriously doubt any state government could afford to go without federal healthcare transfers.

I’d gladly accept your proposal so long as any State that wanted to refrain from participating in this scheme would be exempt from all federal payroll, income and excise taxes that go for Medicare, Medicaid and SCHIPs. They won’t receive “federal healthcare transfers” but nor will they be paying for them either.

Posted by Thorley Winston | October 18, 2007 7:51 PM

IN all universal health care plans there is one universal question:

What will you NOT pay for?

In other words what will you let poor granny die for and let rich grandma, who can write a check, live another 6 months?

If you can't answer that question, your not ready for universal health care. In the case of all the countries mentioned the rich come here, to America, to write the check. Where will we go?

I doubt any proponent of single payer can answer my first question and that is why you won't get the savings promised.

Posted by buffpilot | October 18, 2007 8:24 PM

In other words what will you let poor granny die for and let rich grandma, who can write a check, live another 6 months? If you can't answer that question, your not ready for universal health care.

Your question presents an obviously false choice. There's no reason to ration care based on ability to pay, that's one of the main benefits of single-payer. Both grannies get saved.

In the case of all the countries mentioned the rich come here, to America, to write the check.

What percentage of those cases are simply not wanting to wait for a non-critical procedure, versus being denied life-saving care? And what do you have to say about the increasing phenomenon of "medical tourism" to places like Singapore and Malaysia, not to mention Cuba, for life-saving procedures that are simply unaffordable to have done in this country with our wonderful profit-driven system? Somehow those countries manage to afford being able to provide that service...

Posted by liberalrob | October 18, 2007 8:42 PM

USA citizens have a per capita of $45,000/yr. Europeans have c$32,000/yr. Mexico, Brazil, Russia etc. have c $12,000. What should we spend the extra $13,000 (or $33,000) on? Right now we spend a lot of it on medical stuff. Doesn't seem unreasonable that the superrich here could spare a chunk and we hoi polloi could all pitch in and fund care for those who have not. Problem comes then at drawing a line beyond which we will not pay. Right now we have trouble doing that. Medicare pays for kidney dialysis for any and all who can reach an American hospital in kidney failure, citizen or not, legal immigrant or not. We dialyze prisoners on death row for years while they go thru appeals.

Posted by jay | October 18, 2007 10:53 PM

I think I'll let Ezra respond.

Posted by Justin | October 18, 2007 11:21 PM

"There's no reason to ration care based on ability to pay, that's one of the main benefits of single-payer. Both grannies get saved."

LiberalRob, if you believe this, you are either ignorant of the facts or you are seriously deluding yourself. That's not how it works in the real world in countries that have single-payer systems. That's one reason I doubt we'll ever have one here: our elderly like the health care coverage (Medicare Parts A, B, and D + private health insurance or Medicaid if they're poor) and high level of care they get now, and they vote.

Posted by Juan | October 19, 2007 12:23 AM

Accepting that the US currently spends 2x more on health care than any other country and a large number of people do not receive care, how can more people receive services at a lower total cost? More people receiving services with lower total expenditures has to translate into less services for at least some people.

I don't believe that there is that much overhead in the current system (one dollar wasted for every dollar spent? 100% waste? Really?), nor do I accept that a single payer system will be 100% efficient. I can believe that there are some savings that could be realized, but nothing approaching the order of magnitude required to bring spending in line with other countries without also some reduction in services. Alternatively, if everyone is to receive the current level of service, health care is going to cost a lot more than it does now.

I'm not necessarily arguing against single payer. I agree that the current system is highly flawed. I can't agree that single payer is a silver bullet that will make everyone healthier and wealthier. There are no silver bullets. Any change to a system as complex as our nation's health care is going to have some losers. Who do single payer advocates think would be losers under their proposed system?

Posted by SG | October 19, 2007 2:11 AM

Nations with state-provided health care accomplish their cost objectives by rationing. Life threatening conditions get treated pretty well, but elective conditions, including those where the patient may be suffering intense pain, are more problematic. Britain's NHS is a constant electoral issue & Canadians flock to the US for medical care. Just go to any hospital close to the border and look at the license plates in the hospitals' parking lots. Every approach to health care has rationing - it's just a matter of who does it and with what criteria. Your choices are rationing by politicians, rationing by insurance companies, or rationing by ability to pay.

Posted by Jim Dew | October 19, 2007 7:11 AM

I continue to be bewildered by the discussion of single payer health systems in this forum. None of the Republican presidential candidates favor any national health plan at all. Only one Democrat, Kucinich, favors single payer. The plan in effect in Massachusetts and the one proposed in California are not single payer plans. Even Paul Krugman favors a Massachusetts type plan rather than single payer. Why the discussion about single payer?

Posted by Stan | October 19, 2007 8:02 AM

"The failure of the various state initiatives is an instructive look at our future."

"No, they aren't. They are apples and oranges in terms of scale."

I know that this is not the case for all states but many states are of similar size to European countries. California, Texas, New York are of similar size to several big European Countries and mid size states are similar in size to countries like Austria, Sweden, Denmark, Finland, Switzerland, Belgiium, Ireland (4-10mm). Half of the US states have populations bigger than 4MM (bigger than Ireland) and all but like 7 are 1MM+

Shouldn't these states have the economies of scale to do what their similarly sized European counterparts can do? And smaller states could group together for economies of scale.

Posted by Eccdogg | October 19, 2007 8:19 AM

"The failure of the various state initiatives is an instructive look at our future."

They aren't all failing. Check out this report.

www.heritage.org/Research/HealthCare/wm1414.cfm

Posted by Stan | October 19, 2007 9:15 AM

You can say "Tennessee couldn't afford it," but note that Tennessee has among the lowest rates of taxation in the country by any measure, and has no income tax. It's regularly in the bottom 5 along with New Hampshire, Texas, and South Dakota.

Tennessee made a political choice not to spend the money on a growing TennCare, but they could have afforded it if they'd decided they could handle the tax burden of, say, a Kentucky, Georgia, or Missouri.

Posted by Brittain33 | October 19, 2007 9:27 AM

Liberalrob,

You dodged the question. If the rich grannie is rich enough, she will be able to afford care the poor grannie will not unless, of course, the state restricts the rich grannies rights to buy healthcare to that offerred by the state.

In other words, at what point are you willing to let poor grannie die from some ailment that rich grannie will be able to buy treatment?

Posted by Yancey Ward | October 19, 2007 9:47 AM

Thanks for the link Stan.

Looks like in most respects the Mass plan is working pretty well.

With some tweaking it is something I could get behind at the state level.

I just don't see the need for one giant national plan.

Posted by Eccdogg | October 19, 2007 9:52 AM

LiberalRob, if you believe this, you are either ignorant of the facts or you are seriously deluding yourself. That's not how it works in the real world in countries that have single-payer systems.

How does it work then? Why is the life expectancy in those countries longer than ours? Are you just lying and making shit up?

That's one reason I doubt we'll ever have one here: our elderly like the health care coverage (Medicare Parts A, B, and D + private health insurance or Medicaid if they're poor) and high level of care they get now, and they vote.

Considering that many people's idea of fixing our healthcare is Medicare (minus the deliberately flawed Part D) for all, your argument carries very little weight.

Posted by slippytoad | October 19, 2007 11:46 AM

When you compare life expectancy, be sure you are not including infant mortality, which is measured different in different countries. The US includes a lot more births under "live births" than most other countries. So we get a lot more 0's added into our average...

EI

Posted by Earnest Iconoclast | October 19, 2007 11:50 AM

You dodged the question.

No I didn't.

In other words, at what point are you willing to let poor grannie die from some ailment that rich grannie will be able to buy treatment?

None. At no point. Ability to pay will not be a factor, because by definition the government will be able to pay. Either they both die, which the people won't support, or they both are saved and we figure out how to pay for it.

All the doomsaying about how it'll be too expensive and we'll bankrupt the government and scary stories about rationing care are silly. We run huge deficits now and it doesn't seem to be a problem ("deficits don't matter," remember?); and there's every reason to believe that costs will be controlled better by the single-payer system to the point where expensive procedures might turn out to not be so expensive after all. As far as rationing care, that goes on right now based on ability to pay, and it's uniformly the poor who get the short end of that rationing.

Posted by liberalrob | October 19, 2007 12:27 PM

slippytoad wrote: How does it work then? Why is the life expectancy in those countries longer than ours? Are you just lying and making $#!% up?

Hooookaaayyyy...one more time:

1. "Life expectancy" is not measured uniformly across all countries, notably in the area of infant mortality, and for countries outside of the "West" (including, for this argument, Japan), many of the official statistics are not well-vetted.

2. Actual lifespan can be dominated by lifestyle choice factors not related to the quality of healthcare. The US, in particular, enjoys inactivity and fattening foods, with corresponding problems in diabetes and obesity.

Posted by anony-mouse | October 19, 2007 12:27 PM

Here is how you fix EVERYTHING that's wrong with this country:

1. De-fund the military industrial complex.
2. Institute a parliamentary system of government, at both the state and national level.
3. Get assassinated for even contemplating doing steps 1 and/or 2.

.

Posted by ManOnBlog | October 19, 2007 12:38 PM

"How does it work then? Why is the life expectancy in those countries longer than ours? Are you just lying and making shit up?"

Because proper medical care adds only 2-3 years onto life expectancy. Other countries have higher life expectancies because they are generally healthier than the US. Proper diet and exercise are huge contributors to their additional life expectancy. Their medical care probably is only a small part of the picture.

Anyways, back to LiberalRob:
Many of the European countries allow the rich to purchase additional health care beyond what the state provides. In France 80+% have purchased additional insurance over the state. The rich in those countries receive better medical care, but why is that a problem? Medical procedures are hardly a binary live/die situation. It could be 20% chance to survive for 3 more months if you get a procedure. However, the procedure costs $200,000 and you're already 80 years old. At what point does the cost, chance to live and length of survival make you say no?

Posted by JordanT | October 19, 2007 12:39 PM

liberaldodger,

Nicely done, once again!

Posted by Yancey Ward | October 19, 2007 1:31 PM

If the plan failed because too many uninsured people moved in from out of state, that might be a reason to try such a plan at the federal level and not at the state level.

Actually, plans at the state level tend to fail because insurers, having alternate markets in other states, leave, not because sick people arrive. See what happened in Washington when it tried to implement community rating/guaranteed issue. Within two years, there were no insurers writing health policies in the state. They simply took their business elsewhere. A program implemented at the federal level would thwart this.

Posted by Jaye | October 19, 2007 1:31 PM

Jaye,

They left, if they did, because the funding was too little to make a profit. A program at the federal level wouldn't thwart anything other than the insurance companies surviving as business entities, unless the funding level is actually raised. In any case, nothing was preventing the states like Tennessee from bypassing insurance companies altogether- the doctors, hospitals, and pharmacies didn't relocate, did they? That the states unable to find politically acceptable funding to do even this should tell us something.

Posted by Yancey Ward | October 19, 2007 1:58 PM

Jaye I do not believe a similar program at the federal level would be any different.

If regulations become too onerous companies will leave the US or more likely just go out of business. Companies need to earn a return on thier capital investment, if they cannot earn a reasonable return and there are no other markets they can simply return that capital to their investors and close up shop.

Posted by eccdogg | October 19, 2007 2:10 PM

How does it work then? Why is the life expectancy in those countries longer than ours? Are you just lying and making shit up?

Others have already addressed the lifestyle issues and differences in the way things like infant mortality are measured, but here's how it works in countries with nationalized health care: the health care is rationed. Your poor granny has to wait three months before seeing an oncologist, and at that point her cancer may have spread to the point where it is no longer treatable, so she's sent home for hospice care; or, she simply gets turned down for a procedure because she is too old and it's too expensive. If you don't think that's what happens, do some research and familiarize yourself.

Considering that many people's idea of fixing our healthcare is Medicare (minus the deliberately flawed Part D) for all, your argument carries very little weight.

Let's examine this from the perspective of an intelligent senior citizen. She's got great coverage with the combination of her Blue Cross/Blue Shield private insurance and her Medicare Parts A, B and D. She knows that Medicare is one of the most expensive and fastest-growing programs in the federal budget, and that the payroll tax that's supposed to pay for it only covers about half the costs not covered by premiums. She also knows that Medicare doesn't cover a lot of stuff -- that's why she's got her Blue Cross/Blue Shield too. Now some young lefty suggests expanding Medicare to everyone -- what would she think?

Well, she knows that Medicare is a budget-buster as is, and she knows that it would cost even more to expand it to everyone below age 65, and she knows that, since it doesn't cover a lot of stuff, it would have to be expanded to do so, for it approach liberal ideas about "free" health care. So she knows that if a budget-busting program that gives her very good benefits is going to be expanded and offered to everyone, something has got to give. What's more likely, that working people will have their Medicare taxes doubled or tripled or that expensive care for old people will get curtailed? Why should she risk it? Better to vote against any nationalized health care scheme.

Posted by Juan | October 19, 2007 3:22 PM

"...here's how it works in countries with nationalized health care: the health care is rationed. Your poor granny has to wait three months before seeing an oncologist, and at that point her cancer may have spread to the point where it is no longer treatable, so she's sent home for hospice care; or, she simply gets turned down for a procedure because she is too old and it's too expensive. If you don't think that's what happens, do some research and familiarize yourself."

Where does this nugget of wisdom come from? From John Stossel? The ghost of Barry Goldwater? The tooth fairy? Where do you right wing types do your research?

Posted by Stan | October 19, 2007 3:34 PM

"he simply gets turned down for a procedure because she is too old and it's too expensive. If you don't think that's what happens, do some research and familiarize yourself."

Yes with a national system, the state will ration the health care, but this doesn't mean people can't:

A)Purchase private insurance that covers what the government doesn't, and reduce their wait times.
B)Pay for things out of pocket to see the doctor now, or pay for things the state doesn't cover.

Lastly, you don't think people with insurance die because insurance companies refuse to approve necessary procedures? Ones that they are supposed to cover but call "optional"

Posted by JordanT | October 19, 2007 3:45 PM

liberaldodger,

Nicely done, once again!

I assume that was directed at me. I answered the friggin' question, doofus. At length. Just because you want to force me to make a false choice is not my problem.

Moving on.

Let's examine this from the perspective of an intelligent senior citizen. She's got great coverage

Stop right there. I've already said one of the obstacles to implementing single-payer health care is the perceptions of those who already have coverage that they have nothing to gain and lots to lose.

And here again we see the Republican mindset that I've referred to time and again: "I've got mine, to heck with you!" It's apparently unfathomable that someone might consider others having the same benefits they themselves have. Would this "intelligent senior citizen" really object to national health care that would cover 45 million uninsured Americans, just because some guy tells scare stories about rationing care?

Nice use of language there, too: "budget-busting" and "scheme" are great ways to negatively characterize whatever government program you're trying to shut down. Medicare's only "budget-busting" in that the budget hasn't been set up to cover its increased costs; you should also talk about the budget-busting Iraq occupation and the budget-busting Defense appropriation bill while you're at it. And let's talk about the Bush administration's domestic surveillance schemes and their tax cut schemes too.

A quick Google search turned up Physicians For a National Health Program's FAQ on single-payer:

http://www.pnhp.org/facts/singlepayer_faq.php

Here's a group of 14,000 doctors advocating a national single-payer system. They must all be daft.

Posted by liberalrob | October 19, 2007 5:22 PM

Would this "intelligent senior citizen" really object to national health care that would cover 45 million uninsured Americans, just because some guy tells scare stories about rationing care?

Only someone who's never even heard of the AARP would think to ask such a question.

Posted by Paul Zrimsek | October 19, 2007 5:38 PM

liberalrob,

Your arguments and claims are so naive and uninformed it's hard to take you seriously at all. Take this absurdity:

Ability to pay will not be a factor, because by definition the government will be able to pay. Either they both die, which the people won't support, or they both are saved and we figure out how to pay for it.

So under your proposal, there is literally no price limit on the health care services the government will pay for. If the treatment is only available at an expensive private clinic in Switzerland, the government will still pay for it for anyone who wants it. Either that, or the government will make it a crime to purchase the treatment privately. Because we must ruthlessly enforce equal access for all, and prevent anyone from getting any kind of superior health care as a result of private wealth. Is that it?

Here's a group of 14,000 doctors advocating a national single-payer system. They must all be daft.

And here's a group of 250,000 doctors that opposes a national single-payer system.

Posted by Mixner | October 19, 2007 5:50 PM

AARP is an organization, not an individual. And yes, I have heard of it, yet I did think to ask the question; so your statement is plainly false. Only someone trying to insult rather than discuss would make such a statement.

Posted by liberalrob | October 19, 2007 6:00 PM

"And here's a group of 250,000 doctors that opposes a national single-payer system."

Because in a broad group like the AMA every doctor in it agrees with every position the AMA has?

Posted by JordanT | October 19, 2007 6:25 PM

Because in a broad group like the AMA every doctor in it agrees with every position the AMA has?

No, probably not. But then, I also somehow doubt that every doctor in PNHP agrees with liberalrob's absurd policy proposals.

Posted by Mixner | October 19, 2007 6:35 PM

JordanT,

Yes with a national system, the state will ration the health care, but this doesn't mean people can't: A)Purchase private insurance that covers what the government doesn't, and reduce their wait times. B)Pay for things out of pocket to see the doctor now, or pay for things the state doesn't cover.

But if they cannot afford or choose not to purchase insurance, and they cannot afford to pay for treatment out of pocket, then they are at the mercy of the government system, as Juan pointed out. Rationing and waiting lists are routine in single-payer systems.

Posted by Mixner | October 19, 2007 6:40 PM

Your arguments and claims are so naive and uninformed it's hard to take you seriously at all.

So don't. No one's holding a gun to your head. And it's not like you'd be the only one.

If the treatment is only available at an expensive private clinic in Switzerland,

I thought we had "the best health care in the world," how could Switzerland be ahead of us?

the government will still pay for it for anyone who wants it.

NEEDS, not WANTS. Yes, the idea is the government pays for the needed care.

or the government will make it a crime to purchase the treatment privately.

Which would not happen, because it's already paid for by the government.

Because we must ruthlessly enforce equal access for all, and prevent anyone from getting any kind of superior health care as a result of private wealth. Is that it?

If everyone has the best possible care, there is no "superior health care" to be had. If conversely there IS superior health care but it is rationed on the basis of ability to pay, then you can't say that everyone has the best possible care. Which means you can't go around scoffing at initiatives to provide health care to those who can't afford it and constructing lady or the tiger gotcha scenarios based on false choices. Well, you can, but it becomes very clear just how compassionate you are.

And here's a group of 250,000 doctors that opposes a national single-payer system.

And here's a group of 45 million American citizens who aren't getting health care, and who the AMA's misguided tax-credit plan (scheme! I forgot to use the right word!) won't help because it tries to shore up the rotten, useless private insurance system rather than dispensing with it altogether. Any solution that continues to try to harness market forces to provide health care is doomed to failure. The market is not a compassionate deliverer of health care. I think we've adequately determined that.

Posted by liberalrob | October 19, 2007 6:56 PM

No, probably not. But then, I also somehow doubt that every doctor in PNHP agrees with liberalrob's absurd policy proposals.

PNHP is a single-issue advocacy organization. Everyone in it advocates single-payer health care, because that's its only issue.

Absurdity loves company.

I freely admit my conception of single-payer is probably more expansive than theirs. I am, after all, absurdly liberal.

Posted by liberalrob | October 19, 2007 7:03 PM

"Rationing and waiting lists are routine in single-payer systems."

Rationing is routine in our system as well. My dermatologist is an excellent doctor, last time I checked she was three months out on appointments. Waiting list. At the time I had a gold-plated insurance plan, now I couldn't afford her at all, I don't have health insurance and specialists aren't cheap. Rationing.

The odd presumption that everyone in this country gets immediate access to medical care on demand kind of fails in light of the fact that they call them "waiting rooms" rather than "reception areas". I had some non-threatening cancer surgery that required coordination between the Seattle specialist who did the cutting and the Everett plastic surgeon who did the repair. Well there was at least a month gap between diagnosis and surgery. Waiting list right there. You can spend hours waiting to be seen in an Emergency Room and not everything is covered. Rationing again with a Waiting list.

The President of the United States can have medical care on demand. The rest of us hear "the doctor will see you soon" with 'soon' carefully not defined.

It's like people haven't heard of the concept of 'medical appointment' which builds rationing and waiting lines into one device.

Posted by Bruce Webb | October 19, 2007 7:16 PM

Rationing and waiting lists are routine in single-payer systems.

For which procedures? Is there rationing and waiting lists for emergency cardiac care? If I show up in the emergency room with a severed arm, spurting blood all over the room, am I going to be told to have a seat in section B because we're rationing health care today under our single-payer system?

I mean, really. Fear, fear, fear! That's all you guys seem to have. Single-payer, ooga booga! Rationing! Hey, if that means 45 million people get a ration instead of nothing, I'm in favor of it! Waiting lists! If 9600 people want to get liposuction at a single hospital, it isn't going to kill them to wait! There's rationing and waiting lists for a new Prius, too, horrors! Can't have that, rationing and waiting lists, eeevul!

Do you consider that just maybe, the rationing and waiting lists might be done by doctors in such a way that the greatest good is done for the greatest number? And is it not possible that if shortages develop, and the need is clear, that adjustments might not be made in order to reduce the rationing and waiting lists? No, of course not. It's simply dismissed as OMG TEH SOCIALIZM EEEVUL DO NOT WANT.

I've had it. Bye. Have a nice weekend.

Posted by liberalrob | October 19, 2007 7:18 PM

liberalrob wrote: And here's a group of 45 million American citizens who aren't getting health care

Aren't getting healthcare, or don't have health insurance? There's a difference. Also, how many of the 45 million don't have insurance but want it, and how many don't have it because it isn't necessary in their present life? (Many young males fall into that latter category.)

But okay, let's work with those numbers. Subtract 45 million from 300 million and that means there are 255 million American citizens who do have health insurance of some form or another. That's a 5.7:1 ratio, which means that for every person whose lot you theoretically improve under a universal system (setting aside the various outlier cases and assuming anything is usually better than nothing), there are 5 or 6 persons whose lot could be potentially made worse if your universal solution turns out to be less effective than whatever it replaced.

Most of us are smart enough to do that math, which is why we're not rushing to embrace your preferred solution set. It's always nice to help out the sixth or seventh guy who can't afford something helpful, but there are ways of doing that which don't inherently specify scrapping out a large chunk of what we've already got. What we've got is imperfect but reasonably certain, while the alternative is both unknown and uncertain, with a high probability of being imperfect.

And your dodging of the issue by citing goods and services that are luxuries with acceptable substitutes for the overwhelming majority of cases is pretty much a graceless admission that you're running out of valid arguments. But then, given your insistence that the system will work fine because the public treasury represents an unlimited source of largess for all takers, I think that suspicion was already being confirmed several hours ago.

Posted by anony-mouse | October 19, 2007 8:02 PM

"Yes with a national system, the state will ration the health care, but this doesn't mean people can't:

A)Purchase private insurance that covers what the government doesn't, and reduce their wait times.

B)Pay for things out of pocket to see the doctor now, or pay for things the state doesn't cover."

This depends on local laws. I believe A) was the subject of a recent Canadian legal case, because Canada actually made private health insurance illegal. I'm not sure if paying physicians directly is explicitly illegal there, but I wouldn't be surprised if desperate patients in ostensibly single-payer systems tried to grease the skids occasionally with their own cash.

Posted by Juan | October 19, 2007 10:36 PM

A program at the federal level wouldn't thwart anything other than the insurance companies surviving as business entities, unless the funding level is actually raised.

Actually, there was no "funding" involved. There was simply a requirement that they use community rating and provide guaranteed issue. The insurance companies objected to not being able to cherry pick healthy (i.e. profitable) customers in the individual market, and left.

If regulations become too onerous companies will leave the US or more likely just go out of business.

You can't be seriously suggesting that Aetna, UHC and all of the Blues will simply close up shop if universal health care is implemented. I'm not convinced it would be that great of a tragedy (except to their employees) if they did, actually. As far as taking their business overseas, where, exactly would they go? We're the only first world country without universal system.

Posted by jaye | October 20, 2007 12:49 AM

I again point out that the discussion in this thread has a curiously dream-like quality. None of the leading candidates for president are proposing a single payer system. Tennessee did not have a single payer system, Massachusetts does not have a single payer system, and California will not have a single payer system if Schwarznegger's plan is implemented. Can't anybody here play this game?

Posted by Stan | October 20, 2007 7:58 AM

liberaldodger,

Yes, you continuously dodge the question, either out of dishonesty, or simple, perplexing stupidity. Unless you restrict people's access to healthcare to an upper limit of what the government will pay for, there will always be inequality in the level received by those in the government system and those who can afford to buy extra healthcare above and beyond the government system. You refused repeatedly to acknowledge this fundamental truth by simply asserting that government could supply whatever is required- an impossibility.

Posted by Yancey Ward | October 20, 2007 2:35 PM

Jaye,

It doesn't matter what the particulars were for why they refused to deal with the state programs, but the decision to refuse was based on what they could profitably do with their capital. In other words, it was related to the state's setting certain levels of care for which the states were unwilling to pay enough to keep the insurance companies involved.

Once the return to capital falls to a certain point, yes, companies will close up shop and deploy their remaining capital in some other business if they have no other options for continuing in the present one. This happens all the time, but is usually the result of one's competitors driving them from the playing the field.

I am continuously amazed by people who think businesses will continue to operate in an area even if the government restricts their profitability to an arbitrary level, even if the level is less than zero.

Posted by Yancey Ward | October 20, 2007 2:46 PM

gvt run health care is a disaster in the making. I am an American living in Kemi Finland. Guess what, more than 2 months ago the city laid off the Dr's along with allot of other city employees. They don't know when they will be able to pay the Drs and bring them back. They still can do private practice and the ER and hospitals still have docs. But beware, you might just get what you ask for.

I can't go to any nearby cities for care either. it is the law here you must live in the area of service.

it sucks big time!

Posted by Pamela | October 21, 2007 10:24 AM

There should be a two-tier system:

- A single-payer system that covers all people for a basic set of health issues; and

- Private systems that people who want can use for "queue jumping".

This is what happens, in effect, in Canada: People who want to spend the extra money can go private for elective procedures, either in Canada or across the borders (to the U.S. or to India), if they don't want to wait until their place in line comes up. Poorer people will wait - but at least they will get the treatment eventually. In the U.S., they would just be out-of-luck.

However, everybody is covered for basic & urgent services.

What's wrong with this approach?

Posted by Neal J. King | October 21, 2007 10:34 AM

Look, any system we choose has trade-offs. Can we at least agree on what we're trading off, so that we can then argue whether the trade-offs are worth it?

As a supporter of no-second-tier single-payer (being Canadian), the biggest benefits are:
1) Guaranteed access to adequate health care (not super-wonderful healthcare, *adequate*.)
2) Cost savings due to healthcare rationing.
3) Not having to worry about health insurance when changing jobs, declining conditions, etc.
4) Not being allowed to make difficult choices (mortgage the house for a 20% of saving Grandma?)
5) Social solidarity from the theory that we all have equal right to life (being richer gets you more toys, it doesn't get you more life)

Note that 3 out of 5 of these benefits are *psychological* benefits, which, for the most part, makes them *more* important than actual health outcomes.

Biggest down sides:
1) Single payer is essentially a giant HMO. If you're getting better health care than that currently, then your quality of health-care will go *down*.
2) Without people spending gazillions on near useless healthcare, there will be far fewer really useful and affordable healthcare advances.
3) Loss of freedom to make individual choices on healthcare.

Having said that, I'm not anxious to see the USA go single payer for fairly selfish reasons.
(1)The USA acts as a near invisible second tier. This reduces the demand by the few (accent on few, there aren't hundreds of thousands of Canadians pouring across the border for American care) who could afford the cost of American health and would be willing to pay for better outcomes. (2) The Americans pay for health research that will eventually filter down to our medical system. (3) The American system provides a useful benchmark both positive and negative for our system.

And, to be honest, for psychological reasons, I don't think the USA could do away with a second tier, which reduces much of the benefit of single-payer. There's an enormous advantage to being able to believe "there's nothing more that can be done" when you're losing a loved one. That's much harder to accept when the person across the aisle is getting a shot at recovery for a few million dollars. Suddenly it becomes clear that in the eyes of society, the life of your parent/child/spouse just simply isn't worth it. Far better to never become acquainted with that particular truth.

Lastly, could we please note that having different values for these costs and benefits doesn't make one evil. Some people value freedom a lot more than I do. Some people value access to the highest level of medical care they can afford a lot more than I do. I fully expect them to support a medical system that will fulfill *their* needs best. Likewise, they should not be surprised that I support a medical system that fulfills my needs. No need for evil, stupid, or evil and stupid anywhere.

Posted by Tom West | October 21, 2007 10:50 AM

In Canada a physician can opt-out of participation from getting public health money. But they usually cannot charge more than what they would receive under the public plan. A few provinces passed exceptions (notably Alberta and Manitoba) but the federal government takes back from the province dollar for dollar any extra amount charged privately by doctors.

The upshot is that as a practical matter only doctors who practice non-funded procedures (like cosmetic surgery) will take private money in Canada.

Posted by Gideon | October 21, 2007 11:15 AM

Debating various government health plans is, to me, like the fleas arguing over who owns the dog.

The basic problem is what does the federal or state government do better, or more efficiently than the private sector?

As a Katrina survivor, and witness to government "help", I have major doubts as to the ability of dislocated bureaucrats to do the right thing.

Hell, it took me 18 months and finally getting a congressman's personal assistance to convince the US Post Office that I hadn't moved and to stop telling everybody that I had.

If they can't even deliver the mail, why would I trust them to deliver my healthcare?

Posted by thenakedemperor | October 21, 2007 11:45 AM

This is a very interesting, very long article. My take on it is that socialized medicine will kill the pharmaceutical industry and limit us to what we have now.

http://www.city-journal.org/html/17_4_medicine.html

Posted by George | October 21, 2007 11:45 AM

Tom West,

the biggest benefits are... 4) Not being allowed to make difficult choices

You have got to be kidding me! I do understand, as you say in your closing, that people can place different values on "freedom", but regardless of where you fall on that spectrum, do you really think it's going to be better for someone else to make the hard decisions for you?

Posted by Kirk Parker | October 21, 2007 12:02 PM

Of course these single-payer systems are, on a per capita basis, less costly. They achieve that by rationing care. It doesn't cost anything to provide nothing.

Let's at least be honest about what we're talking about here: trading one set of problems for another.

I think we'd do better to follow Michael Porter's advice about reforming healthcare. His book "Redefining Healthcare" is the best treatise on healthcare reform I've ever read. It's not ideologically driven, for one. But it recognizes the problems in our current system, the problems in systems like the ones we might emulate for universal coverage, and suggests ways we might avoid all of them...while driving down costs and increasing access to coverage.

Taxpayer-financed healthcare should be kept for the elderly and poor.

Posted by contrarian_libertarian | October 21, 2007 12:10 PM

We already have a federally administered health care program. It is administered by the Veteran's Administration. IF you are happy with that model then you are going to love Single Payer.

Posted by jreid | October 21, 2007 12:27 PM

regardless of where you fall on that spectrum, do you really think it's going to be better for someone else to make the hard decisions for you?

Which of one your two children will you save, and which one will you allow to burn to death?

Okay, that's the most extreme example I can think of, but the only person I know who had to make that choice (and it was a false choice, thank God), is haunted by it every day (as are her children).

In terms of sacrificing my children's future for my parents or spouse (a far more likely situation): No, in the end, I'd probably make the same decision that the current system does, but I'd be damaged by the decision forever. I'd probably have a different opinion about delegating that decision-making to the system if I thought the decision made by the system would deviate from mine, but the system pretty much embodies the main-stream Canadian values in terms of the worth of human life.

Note, if called upon to make such a decision, of course I'll make it. But I'd prefer a system where my choice feels less like a choice (there are *always* options, but making them remote enough decreases the guilt.) It really helps to believe "we've done everything we could", even when logically it can never be true.

Posted by Tom West | October 21, 2007 12:38 PM

John Edwards made $20 million in 4 years suing doctors. Without Tort reform all universal coverage or single payer systems will cost way more than the figures given. My father was a doctor, and because of that I have watched what has happen to American health care since the early 1970's. The lawyers ruined the last system, and they will ruin this system. Actually, the lawsuit industry has hurt almost everything in America. Watch for the discussions on the impact of the lawsuit industry during the high dive completions during the next summer Olympics. Tens of thousands of pools have had their diving boards removed in the last 40 years. The next time you are at a public pool or a pool at a hotel that actually has a deep end, look for the holes in the concrete where the diving board used to be. Forced wealth redistribution plans hurt, and they unusually hurt in ways that are different than intended. Anyone who claims to know what they are talking about in regards to health care costs who doesn't discuss the impact the overlawyering, is talking about the wrong solution.

Posted by tyree | October 21, 2007 12:39 PM

Liberals are fond of saying that "healthcare is a right".

If this is true then everyone in America has the right to healthcare on the same terms as everyone else. You cannot restrict the "rights" of some because they don't have enough money or they live in an area with fewer healthcare choices.

Everyone in America has to receive the same level of care whether they live in the Upper West Side of Manhattan or an Indian reservation in Oklahoma.

This is not going to set well with the denizens of the Upper West Side. They like to talk the talk but when it comes to paying the price they look to others to do that.

Posted by John D | October 21, 2007 12:44 PM

Bruce Webb said:
"Rationing is routine in our system as well. My dermatologist is an excellent doctor, last time I checked she was three months out on appointments. Waiting list. At the time I had a gold-plated insurance plan, now I couldn't afford her at all, I don't have health insurance and specialists aren't cheap. Rationing"

Who sets the limit on how many hours a doctor can work? Who sets the limit on how many doctors we can have?

The problem you describe is more complicated than "rationing" which is the wrong word to use. One of the reasons there are not enough doctors are lawyers. We will never know how many thousands of young men and women chose different careers because of lawsuits, but the just the fear of legal action has kept a large number out of the profession. That is not "rationing".

Posted by tyree | October 21, 2007 12:49 PM

Americans need to look at the Australian system which has a good public system backed up by a thriving private system. By some good fortune we have developed a system where the two systems complement each other in an effective way. The inevitable Public system waiting lists and whatever other weaknesses appear in the public system push people into the private system. The Private system is constrained in what it can charge over the public system and attract business. Both systems keep each other more honest. In the US and Canada you get refugees from, both systems - some going north, some south. The free market doesn't work because expensive illness or injury strike uncorrelated with the ability to pay or even pay insurance.Both national health and insurance systems can mitigate this problem. I see single payer as the government taking a monopoly and that is unlikely to result in good service.Better to have a private alternative and the right to take you business to the private medial system. Designed correctly the private system would be motivated to control costs in order to compete with the government care. It really works pretty well here in Australia. Liberal Rob above seem to me to lack the experience of seeing various socialised medicine systems in action that try to produce fair results. Single payer type national health schemes have limited amounts of money and they try to produce the best results with that budget. I have private cover for things that can be planned ahead and I feel may benefit from selecting my own doctor. I had a heart emergency and got quickly to the public hospital were damage was minimized and everything was done that should have been done. The US can be better, but there is a real danger you will do worse if you destroy the private system rather than reform it and if you create a single payer monopoly rather than a new public system that will first get a safety net installed and then try to find the natural balance point with the private system.

Posted by lgude | October 21, 2007 12:50 PM