The "best health care system in the world" is not accessible to the 40+ milliion of us without health insurance.

I'm all for single payer/universal access, but there will be a transition and it will be present some thorny issues. Investor-owned insurance companies are the "repository" for a significant amount of invested capital. If we put in place a system that drives most of them out of business, which single payer would do even if private insurance were not banned, I can see how there would be major difficulties for pension funds, mutual funds, etc. Somehow we would have to work out some kind of "buyout" (for want of better term) of the insurance companies.

The big obstacle is the [Est] $1.8 trillion/year in premiums that flow through the insurance companies to banks, Wall Street, etc. 
Also, giving even half that to the government for health care is also problematic.  Would the Bush Administration just use it to justify even more tax cuts for his friends?

Any ideas on what to do with that pool of money?

Teddy Kennedy is out there saying "Medicare for everybody". That makes sense to me. So I can go to the VA for coverage and my son can go to Medicare. If the insurance companies want to sell us better coverage, or expanded coverage, or coverage for plastic surgery well, more power to them. there's no reason for overwhelming government interference. Medicare is background noise. What's important is everybody gets to see the Doctor and the Dentist.

I really do agree with Matt.  We shouldn't sweat all the details right now.  We need to really push hard for health care reform in any reasonable form it takes.  Once something is in place it can be tweaked and improved.  Getting some thing in the works would be win-win.  The US would be starting the process of ensuring everybody had access to good health care.  And it is a cause we on the left has championed for a long time and rightfully could take credit for it. 

What an insightful and concise argument.

I have to say, I agree 100%. This, despite the fact that I'm one of the guilty mudslinging parties.

I was <gulp> wrong. We should push for single-payer, as a powerful bargaining stance. If we get it, great. If not, we'll be in a much better position to get a favorable competition-based plan.

And we shouldn't be too attached to one plan over the other. Even if one is better than the other, both are solid improvements on the current situation.

<<repeat three times>>

OK, I think I got it now. 

Still, my main qualm is the '08 election. From a congressional viewpoint, pushing for single-payer is the best move; Congress is the place where the most bargaining occurs. But should that translate to single-payer as a primary plank on the Democratic presidential platform?

I keep hearing the notion that since the GOP will defame anything we do, we shouldn't pay heed to the obvious smears to come - in this case, 'Commie health care' and the like. But I don't consider the general public to be that gullible; people can and do make distinctions. Take one look at the President's Social Security disaster, and you'll see that Americans know when the BS pedal is to the floor.

(Yes, Iraq is the big exception, but c'mon - 9-11 made a lot of people very angry, and the Bushies have manipulated that to the Nth. And people are now finally starting to smell the BS there, too) 

Most Americans don't know jack about the currently-discussed alternatives to the current healthcare system, and won't until they become election issues. If at that time a competition-based plan is rolled out by the Dem candidate, will people believe the French-socialist-pigdog comparisons? I don't think they'll bite, because the insurance companies will be a major part of the system. It'll sound like typical Republican hot air, just like it did in '92.

However, if the plan under attack is single-payer, then Republicans will have some red meat mixed in the swill: the concomitant destruction of the health insurance industry, with all its 'socialist' connotations. It's not hard to imagine the haughty arrogance by Limbaugh, O'Reilly, etc. as they hoist yet more 'proof' that the Dems want to turn America into France with hot dogs. And people will bite - not everyone, but perhaps enough to lose another close election.

It was this concern that led me to embrace competition-based plans in the first place - not as a final solution, but as a 'strategic initiative' to warm Americans up to the concept of universal, tax-financed health care. But I'll be more open to other possibilities in the future, I swear.

Hopefully more people will read this thread and put away the screaming tendencies. Thank you again, Matt. 

Didn't Social Security and personal bankruptcy laws disrupt the flophouse industry?

Re Jim Texan,

Good post and good for you for being big enough to say "I was wrong." 

You cite the SS debate as an example of the public's usually fairly good ability to detect BS and make distinctions as one reason to believe the public would actually distinguish between single payer vs. other proposals in a health care debate.

I'm inclined to disagree.  In the case of SS we are talking about a benefit and system that has been in place for a long time.  Americans know about it.  So when benefit cuts are put out as a consequence of Bush's concept that's relatively easy to grasp.

Debates over competing health care reforms, by contrast, are debates over alternative proposals that do not yet exist, over abstractions.  They are played out in what to most Americans is inaccessible policy wonkese.  So it is far easier in such a context to get away with gross distortions or lies and say up is down with impunity.  As Rovebush surely knew when he characterized Kerry's proposal as essentially a government takeover of the health care industry.

If we come out in favor of a harder-to-explain regulatory reform it will be attacked anyway as a government takeover of the health care sector by the Limbaughs et al.  But it will be harder to defend against those charges simply because it is harder to convey what it is as opposed to what it is not. 

I have policywonk-type questions about how Medicare expansion would work but from a strategic standpoint this concept seems best to combine the advantages of a better policy approach (above all by severing the widespread linkage between employment and health insurance; the advantages of doing so I think are very easy to explain and intuitively very easy for the public to grasp) with ease of explanation and broad gut level appeal to the public.  If we go that route we go a long ways towards short circuiting the "government takeover" charges because of the comfort level most people have with Medicare.  The debate over whether we go with single payer or something else might largely fall away as a kind of bugaboo or hangup that gets in the way of universal health insurance supporters coalescing and organizing around and fighting for something vastly superior to what we have now.   

But amen to Matt on his point about staying flexible and not being overly wedded to any particular approach.   

Re '08 each candidate will make his and her own decision on what they want to say on this issue.  It will be interesting to see what they decide to do.  One of my concerns about Hillary is that she might feel overly hamstrung, more so than, say Edwards, in the scope of what she proposes because of her '94 experience.

Re '06 I am intrigued by the possible virtues of a Democratic variant on the '94 Republican Contract With (On) America, as a way to make it easier for candidates who want to insert national issues into their campaigns in addition to the local issues that are always present.  Opening up Medicare might be one of the planks.  

I'm not familiar with Hacker's work, but the problem with the 5% deal is that ALL employers that currently provide health insurance as a benefit probably pay more than 5% of payroll for the health insurance.  My employer, a municipality, pays about 15% of payroll for me and my family, they would pay less if I were single, of course (I pay about 3% of my payroll as my contribution, the city pays the rest).  A 5% payroll tax would cause a mass exodus of employers from private plans to the national plan, probably as soon as it was enacted.  So as for the employer plans withering away - I think not!

Of course, this would solve the selection problem that has caused this mess in the first place, as all people would be in the same risk pool.  What would then explode would be the market for secondary plans, ala Medicare, that would cover the deductibles and copays in the government-sponsered plans.

This plan has a lot to recommend it, however.  Of course, that means it will never happen.......

Marc

As someone who's been working on this issue since the late 70's, I don't understand why there's even a question here. To my mind, with the possible exception of supplemental coverage which is problematic itself, single-payer means the end of private health insurance.

• If we allow supplemental coverage as Medicare does today, then we will still have significant inequities and extra complexity. The most recent data I've seen showed that about half of Medicare beneficiaries had private supplemental coverage. Perhaps 25 percent had Medicaid as an equivalent supplement. The other 25 percent had nothing other than Medicare and they were precisely who you'd expect: near poor. Not poor enough for Medicaid, but not comfortable enough to be able to buy private coverage. And certainly offering private plans the ability to write supplemental coverage would only be a minor sop when their core business would be eliminated.
  
• Medicare today offers beneficiaries the option of enrolling in private managed care plans. Do single-payer advocates expect that option to be maintained and, if so, how does it differ from other voucher plans?
  

Perhaps the single-payer advocates have not been held to the same explanatory standard as everyone else. 

For a number of reasons that go beyond the politics, I prefer universal coverage without single payer (www.signalhealth.com). But on the politics of it, choosing another option is not giving up at the front end. It's recognizing:

• That single-payer is a fundamental threat to the survival of private plans. They have no choice but to fight to the death because single-payer means their death. Alternatively, they could be allies because a new market of 45 million people would open up.
  
• Most people prefer to have multiple choices. Individuals confronting large systems only have two means of influence, voice and exit. The voice of individuals in a national single-payer system would simply not be heard. And there would be no exit. That's not the case with voucher systems. Health plans might behave in ways we don't like, but at least there would be an option for individuals to choose another plan. And the summation of many individuals choosing one plan over another would be leverage in itself.
  
• American history and political culture, our sense of ourselves puts great stock in individualism and freedom. Yes, much of this is overblown myth and much of it includes troublesome baggage, but advocates of universal coverage are asking for trouble if they ignore this.
  

As I understand Matt's post, the transition problem is one involving insurance companies suddenly finding themselves bankrupt, and their employees out of work. My solution would be for a single payer system to be used, with the funding provided by a progressive payroll tax, but with the insurance companies competing to administer the program in various regions of the country. That keeps the element of competition, prevents the need for a massive new federal bureaucracy, and keeps many insurance companies in business.

I argue that the Democratic Party should wrap its identity around a health care system that provides the best incentives.

For a detailed explanation of what I'm talking about, go here.

James Kroeger

...than countries with national health insurance do. I'm not sure, but I think we spend something like 13% of GDP, while the Europeans something on the order of 7-9%. That's partly because administrative costs for things like patient screening to weed out sick people, millionaire executive salaries and returns to shareholders account for abut 30% of U.S. healthcare costs. I think it was Paul Krugman who pointed out that 2-3 million people in the U.S. are employed just to pass medical bills off on someone else.

So the U.S. can actually have a system that makes us all healthier for less of our GDP, not more. I find that amazing, but it's evidently true. As a side note, I now live in Sweden, where my wife just had a baby. Top-flight medical care and the bill from Karolinska Hospital  was just over ten bucks. No additional cost for pre-natal and post-natal care, since it's pre-paid in our taxes.

Yes, I think our businesses would be more competitive if they didn't provid health insurance.

Because single payer has so many efficiencies that it would be much, much cheaper, as shown in every country in the world that has it.

...would at least have health insurance.