On The Merits
Greg Anrig does us all a service by making a merits-oriented case for a premium-support mixed approach to universal health care rather than a single-payer one. I politely disagree.
Taking his points in order, I don't see how a premium-support strategy resolves the first issue. American choose in a variety of ways to be very lavish about the standard of care we expect and, as a result, spend way more money per capita than do Europeans. My preference would be for a more European-style allocation of social priorities, but my fellow citizens disagree with me and I'm not sure there's a clear sense in which this question has a right or wrong answer. Essentially the same issue would arise under the premium support model -- there's a tradeoff between how convenient you want to make it be to acquire non-critical, non-routine services and how much money you want to spend. In addition, it's not as if we don't have waiting times here in America.
On innovation, Greg says "a universal system built on premium subsidies for insurance that covers demonstrably effective advances, while leaving it to individuals to pay on their own for unproven treatments" will balance equity with a need to create incentives for innovation. I agree, but so would a single-payer system that covers demonstrably effective advances, while leaving it to individuals to ay on their own for unproven treatments. This is an issue about scope of coverage, not method of payment. More hardcore egalitarians will disagree with Greg and me about this scope issue, but that dispute cross-cuts the premium-support versus single-payer question.
On the public attitudes toward government point, my reply is "Medicare." This is a single-payer health insurance program that covers older Americans, and it's very popular. Medicaid is also quite popular. I don't think "Medicare for all" perfectly captures what should be done policywise, but it nicely expresses the basic point that single-payer is hardly alien to the American way of life, and that there's no need to go in for a ban on add-on private insurance the way Canada does.
If forced to point to a country whose health policies offer an attractive model, I suppose I would offer either France, or the Canadian system that will emerge if a recent court ruling requiring Qu
Here is a report on different countries mortality amenable to healthcare, years lost that could have been saved with good healthcare intervention. The US doesn't do very well. The UK system absolutely sucks.
June 14, 2005 2:43 PM | Reply | Permalink
He said "France."
June 14, 2005 2:58 PM | Reply | Permalink
I'm liking the "Medicare for All" idea myself, at least as a nice starting point for the discussion. When I've looked more closely at Medicare, however, I do not envy the 85-year-old who has to try to decipher its complexities. Congress has treated Medicare like a Christmas tree on which it has strung many colored lights and fancy garlands.
Some of those garlands include a significant role for private insurance. Medigap--supplemental insurance--is the most widely known. But there are other programs that allow for consumers to purchase alternative coverage and even set up medical savings accounts. Simple, it's not, but Medicare does take into account a range of choices in how the individual receives health care and add-on insurance is one of those choices.
June 14, 2005 3:20 PM | Reply | Permalink
"On the public attitudes toward government point, my reply is "Medicare." This is a single-payer health insurance program that covers older Americans, and it's very popular."
And when it's time to sell the plan...
You simply contrast Medicare to HMO's. Medicare is popular. Everyone hates HMO's.
- "Wouldn't you rather have Medicare than your current expensive, hardhearted HMO?"
- "And since you've got choice, if you do like your HMO, you can just keep it on top of Medicare for much less money?"
How wouldn't that sell?June 14, 2005 3:30 PM | Reply | Permalink
Wow. Keep it up Matt, and you'll be kicked out of DLC TPM Cafe.
June 14, 2005 4:14 PM | Reply | Permalink
I don't know where this "Medicare is popular" meme comes from, but it might be good to nip it early, before someone is delusional enough to actually think that's going to work. Medicare is "popular" in the sense that when asked "would you rather have Medicare or nothing?" old people tend to answer "Medicare." I suppose "Would you rather be electrocuted or watch Paris Hilton proves Paris Hilton is popular, too.
Look, as someone else noted, Medicare is complicated. It's coverage policies are rather obtuse and there is much fraud, waste and abuse in the system because of its complexity. In situations where old people have been offered HMO service as a complement or replacement to traditional Medicare, it turns out not that they don't prefer it - they do, because HMO coverage is much more straightforward - but that HMO structures can't sustain themselves on less than generous reimbursement rates (compared to the services required for many seniors, who can require considerable levels of care).
When you're the only game in town - which is what Medicare is - because (and this too is instructive) employers push their senior age employees out of company insurance when they qualify, it's easy to mistake that for "popular." But it's not proof of popularity, by a long shot. And Democrats can't have it both ways - the program they ridiculed when Bush's prescription drug plan added yet another layer of insane complexity is now suddenly the "popular" program everyone will embrace for its simplicity. Uh-huh. That selling line is as gift to the GOP, which can run an ad just of old people reading Medicare reguloations out loud to show how "simple," "fair," and "understandable" Medicare is. "Medicare for Everyone" is a terrible idea. A terrible, terrible idea. May it drop off before anyone actually notices it has been proposed.
June 14, 2005 7:04 PM | Reply | Permalink
I do think Medicare for everyone might sell better than Medicaid for everyone or VA healthcare for everyone. (And I think Medicaid is good and VA healthcare is better). But when working on this sort of thing, people usually sell it on "the same healthcare the governor has" or the same healthcare as Congress....
June 14, 2005 7:46 PM | Reply | Permalink
I doubt that this "meme" is very widespread, but that doesn't mean that it can't be quite a useful starting point for discussions of singlepayer healthcare in the U.S. It is, after all, a U.S. program that provides a defined range of healthcare services to a defined population (the elderly and the disabled).
Its first point of utility is the discussion, then, is that it is homegrown and thriving. I'm thinking that that will be useful when tackling the inevitable opposition that will argue that "We don't want the government providing our healthcare."
Its second point of utility is the degree to which it has been used all along to include the pet healthcare solutions of every free market, self-reliant pol who wanted to get a piece of the pie for himself or his buddies. Are the insurance companies afraid that they will be left out of the plan? Not to worry. They are not forgotten. Do you want something more than what the basic plan has to offer? Well, here are some of the ways that you can get more and not get too badly ripped off in the process. And, BTW, if that's not enough choice, we'd never get in the way of your going outside of the system to get what you want.
Yet another point of utility is that we know, to a large extent, where all the warts are. If there are problems, we can work on solving them.
This is not to say that Medicare as it stands now is what the final product would look like, but it makes an interesting starting point.
As for popularity, yes, yes, "Medicare is better than having nothing." It's also better than some of the other insurance products available (or, mostly, not) to the aged and disabled. I am still a few years away from being Medicare-eligible, but I am holding my breath (more or less) until I make that milestone. I am lucky enough to have insurance now through my retired husband's former employer. If he should die before me, I will lose that insurance. My only other choice, aside from no insurance at all, would be the Texas High Risk Insurance Pool. That's a really fine program for those who can afford it, but $800 a month for insurance that wouldn't cover a pre-existing condition for the first twelve months is more than I can afford. Medicare surely is better than having nothing.
June 14, 2005 9:50 PM | Reply | Permalink
"Medicare is "popular" in the sense that when asked "would you rather have Medicare or nothing?" old people tend to answer "Medicare."
No. Medicare is popular is the sense that when asked, "would you rather have Medicare or a private HMO?" old people tend to answer "Medicare".
That choice is the same one we should be offering to all Americans. Medicare is popular in comparison to the existing alternative, and that's all that politically matters.
It's not Medicare vs Paradise.
It's Medicare vs private HMO's.
June 15, 2005 3:48 AM | Reply | Permalink
Can Democrats beat Republicans? Here is an interesting interview at Salon.com
Link from my site
http://satire.myblog...
June 15, 2005 8:09 AM | Reply | Permalink
Hearing "Medicare" makes me a little nervous. When I was in school, I worked as a secretary at an agency that referred people seeking mental health care services to psychologists that would be a good match and took their insurance. Everything was fine for patients of HMOs but when we got a Medicare patient we had to beg people to take those cases. The reimbursement rates were so bad that providers would pass on the patients even if it meant having an incomplete caseload. We even had a special filing system -- case files for HMO members were created in manila folders but cases for Medicare patients were in bright red folders and (just in case you missed it) we had to write MEDICARE in thick black marker across the folders and all sheets in the case.
I would hope that if "Medicare for all" became the prevalent insurance system this would be less of the case and more providers would be willing to accept that insurance. Until then, "Medicare" conjures images for me of, if not a scarlet letter, at least a scarlet folder.
June 15, 2005 8:41 AM | Reply | Permalink
As Matthew Yglesias rightly points out, a hybrid public-private health system like that of France, Germany, the Netherlands, or (in the not too distant future?) Canada could be quite desirable, if it could somehow acquire political traction. In many ways there is a much more natural convergence between this approach and some version of a premium support plan for universal coverage (which I and others have recently proposed) than with full-fledged single-payer plans like those in Canada or Great Britain, where overlapping private delivery of services is prohibited or discouraged.
But at least a couple of cautions (apart from political viability) should be noted: (1) it's important that the coverage offered by private insurers is truly separate and doesn't drive up public costs-- as, for example, Medigap coverage of Medicare's cost-sharing has done so significantly in Medicare; (2) The underfunding of public systems is related in some degree to the spread of conservative market doctrines but it is much more centrally related to the dilemma of rising medical costs, and public awareness of options and their expectations more generally. The French, along with everyone else, are struggling mightily with this. On the whole, I think a premium support approach (with federal oversight and strong regulation of insurers) could be a better mechanism than single-payer for striking a balance among the unavoidable choices over who pays for which medical services.
June 15, 2005 12:49 PM | Reply | Permalink
I think Anons ought a.) stop spamming these boards with links to their blogs and b.) stop trying to make good points before signing up with a real name.
I think the Anon above that said Medicare might not necessarily be more popular than HMOs could be making a valid point. But how could we trust anonymous? Are we sure its not Al?
I'd also like to see the Medicare v.s. HMO polls, also broken down my age group as it might not be popular with young people who don't use it but see that chunk being taken out of their paycheck every week. I hear complaints from seniors about Medicare, Medicaid, and the Prescription drug cards. Then again, some seniors complain about everything.
June 15, 2005 1:05 PM | Reply | Permalink