I'm also bothered by these things being touted as steps toward universal health care. It's not about idealists opposing small gains; it's about realists fearing proposals that make gains less likely.

We must insure everyone. You can believe in a single payer or some managed care system that puts everyone in the hands of HMOs, but either way, the key is that the funding and risk alike are spread over the entire population. That's an efficiency that controls costs, and without it, the plan is a recipe for assaults on higher taxes, a cry that always wins. It's also a way of demanding that the plan apply to all voters, forging a shared interest between those comfortable enough to rely on health care but realize uncertainties exist and empathize with others, the vast majority who struggle and sacrifice to afford health care, and those who can't, people who suffer egregiously for that and whose costs also burden us all. And without this shared interest, the plan amounts to another welfare program, and we know that caring for those in need is essential to the philosophy of government that many of us have, but is vulnerable to GOP class warfare.

Tell me:  do you seriously think we'd have a program as successful as social security if it had been designed to cover only the poor? Would it even have passed? You might call it a step toward coverage for all, but call it what it would be:  a political (and economic) disaster.

John 

http://www.haberarts.com/

You know, everybody seems to make the point that it is just astoundingly difficult to make the transition to single payer.

Well, how difficult was it to do so with Medicare? What was the history here? Is the difference really just a matter of scope? Is it mainly that special interest are just going to dig in their heels like mad on this one, because it will put them out of business entirely? Based on history, what might one reasonably expect?

If you won't address those obvious questions, I wonder how seriously one should take you and your analysis. 

Medicare or some version of it was proposed by Truman. It passed inthe Johnson Administration 25 years later. It was opposed by the AMA as "socialized medicine."

Daniel A. Greenbaum

I am not sure, but I think we have more people in our own public  health care systems than there are people in Canada.  Not many folks opting out of Medicare, the DOD or VA systems. Hummm. Maybe we should look at our home grown models and let the Canadians deal with their own issues.

Ron Byers

That's funny Gettysburg, I didn't know Bush ever formally came out with a plan.  I could be wrong. Now I agree he did float a few proposals, one of which you summarize, but one of his big problems was his unwillingness to actually push a single plan. That lack of leadership contributed to his inability to change social security.  

Ron Byers

I think that your comment "I can't think of anything that makes it easier today, except for the implications of unsustainable cost growth" starts to get at the real political case for single payer nowadays, but doesn't really capture it fully.

Look, nowadays EVERYONE knows that health care costs are going out of control, and in the most telling of ways -- in the dent it puts in their pocketbook. Even as compared to 1994, the time of Hillary's aborted health care reform, the employee contribution today for a family plan is nearly twice as much, over $220/month. That HURTS. Where there's pain, there's room for effective politics.

And while it's certainly true that the era was different back then with regard to expanding the public sector, it's also true that the smear "socialized medicine" has lost much of its bite since the disappearance of the Red Menace. I think the American people are much more in a mood to think over the case for single payer based on its merits, as opposed to its ideology. If a government solution promises to be cheaper or more secure then people will pay good attention.

And we now have before us, in the form of the Medicare prescription plan, an excruciating example of the sort of confusion non-single player plans might induce into people's lives.

In short, there's a lot going on nowadays that makes the case for single payer a much easier sell than it's been in the past.

And it all starts with the pain of paying for medical insurance, and the worries of losing it altogether if you get laid off. 

Words, words, words.  Somebody show me the numbers.

How much would premiums i.e. taxes be for a single-payer plan?  Have any acturaries run the numbers?  How do they compare with private premiums now being paid?

And why think that there will be no place for private insurers to supplement a single-payer system?   Personally I'm not expecting single-payer to cover everything.  Realistically it can't.  I just don't want to lose everything  I've worked for if I get sick and maybe some help deciding between competing panaceas.

--Emma

The experiences of other countries (i.e., UK, Italy) that have moved from failing private healthcare systems to NHSs has shown that you need 3 political factors in place simultaneously to pull off a dramatic reform: (1) a system whose failings are clear and painfully obvious to a large portion of the public; (2)  weak political organization on the part of physicians; and (3) a pro-reform party in clear control of the government at the time. Right now in the US, it's arguable whether we have (1), we have (2), and we definitely don't have (3).

I'm always skeptical of policy reports or commentaries on the US healthcare system that bemoan its problems without offering any concrete proposal for an alternative. This is, of course, tricky, but it's absolutely essential for reform-minded people to think very carefully about what can work and what can't. For one thing, I'm not at all convinced that an NHS like Canada or Britian has would work here. An unstated principle behind any healthcare system is that it rations care in some way: in our system, we ration care by price (or ability to pay for coverage); in the above NHSs, they ration care by making people wait in line for it. In the US, however, rationing by queue isn't likely to work: because the healthcare sector expanded so dramatically with federal funds after WWII, most every small town in America has a large hospital nearby, which is not the case in Canada; giving universal coverage to people who have such easy access to physicians might be even more exorbitantly expensive than our current system.

Again, these are all details that need to be thought through. I'm no fan of the Bush ideas for "reform", but at least those are ideas that can be discussed.

How was Social Security sold back in the '30s?  What campaigns did the European countries use to sell their single payer programs?  We have a plethora of role models; it reallly isn't necessary to re-invent the wheel. (If you want an unbiased account of the Canadian system, don't count on getting one from the pages of the Wall Street Journal.)

That isn't what people were objecting to in the "plan," Gettysburg. The objection was that there was no way proposed to fund the private accounts.  This would have made sense if the general fund was flush with cash, but that just isn't where we were by the time Bush proposed the "plan." If he had tried it in 2001, he might have gotten the thing through. Using the budget surplus to fund personal SS investments would have been hard for Democrats to oppose.

This is great stuff!  Starting with Max and going straight through the comments.  It takes us through the nay-saying yes-butters to a place where an actually strategy can be formed.

I'd only add that we need to keep in mind the cost-savings as the pork is cut out of the services provided by healthcare insurance (delaying payments to hospitals, huge administrative costs to medical practices,e tc.) and pharmaceuticals (arbitrary price-hiking of over 15% a year on many drugs, extensions of rights preventing marketing of generics, etc.).   Meanwhile (unlike Canada, for example) we have the infrastructure in place, the rural hospitals, the labs, etc.

For someone who's self-employed, my experience with both private industries has been disillusioning in the extreme.  Ending their gouging of healthcare institutions, practitioners, and consumers would make a huge difference.

Rationing by price?  Or rather by a cat-and-mouse game between HMO-like service providers and customers?  The providers introduce co-payments -- e.g. my provider introduced co-payments for X-rays -- and deny permission for some procedures and drugs, only to relent when someone bitches a lot.

What is amazing is that providers do not try to run studies about effectiveness of drugs, operations, devices etc.  Recently the government had such a study about an increasingly popular (and expensive) operation for emphysema sufferers, and as a result, pulmunologists basically stopped recommending it.  One could think that consortia of insurers could do the same, but it is just not done. 

I estimated that we can cut 30% of the costs.  Surely, providing health care to currently uninsured and liberalizing the access to some benefits would work in the other direction, but that 30% would provide a lot of cushion. 

My perception is that the current system is falling apart.  Some states are cutting madicaid enrolments by hundreds of thousands (per state)  and HSAs may demolish parts of the system that still work reasonably well.

Alan

Bush's refusal to increase taxes (even nominally) was a problem.  But the program he was touting did have a great deal of merit.  It goes without saying that some alternative source of revenue will be needed to sustain Social Security in the coming decades.  Whether or not it is private accounts we obviously cannot say at this point.  Aside from Bush refusing to raise taxes, however, many slammed his proposal because they say it put people at risk when much of their social security was going into the stock market and that people would have to be cognizant of their investments.  Being that the portfolios are limited in number and secured by the treasury, a lot of this rhetoric was misleading or altogether false. 

The Wall Street Journal article is unpersuasive, to say the least. While it cites different political issues (provinces moving ahead with supplementary health care program, for example), it provides no statistics indicating problems. Not one.

 And it is replete with careful qualifiers like "While most Canadians would never change their system, people like Josephine....."

Finally, the Canadian health care system covers everybody, at 33% less than the cost of American health care! 

There is much less to the Contract on America than meets the eye, especially in retrospect.  Can you name three big changes in policy (not politics; we can't settle the argument about whether the CoA made the difference in the '94 elections) that resulted from it?

vorkosigan1

You're right that the article was not necessarily an attack on the Canadian system as much as it was a piece designed to highlight the primary problem with the single payer system.  I've read articles before in the Wall Street Journal which were far more convincing.  One in particular featured a man who needed bypass surgery to ease blocked arteries but was placed on a ubiquitous waiting list.  He ended up getting the procedure done in the U.S. because he feared he would have a heart attack before his scheduled surgery at home in Canada.

Getting back on topic, however, the issue is not whether some will receive adequate care while others will not.  Certainly if the U.S. ever adopts this system that would be an interesting aspect to keep an eye on.  Under a single payer system, everyone will get the medical care that they need, the problem, of course, being the dreaded waiting lists for the procedures.  I don't want to be a pessimist and perhaps our healthcare industry could work together to ensure such problems won't happen in the U.S. (as they do in Canada), but it will take a mighty effort to convince American insurance companies to go for a deal like this.

Sawicky: "If you're not forcing people out of current health insurance arrangements they find satisfactory and you're creating a new public system, taxing everyone to pay for a new system implies a burden for those already paying for their own insurance."

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This is one big reason why I think we would benefit from an entirely new line of argument in our push for Universal Health Care.  Don't say we need it as a way to control the high cost of health care; don't say we need it in order to expand coverage.  Let's tell the American people that we need UHC in order to fix the incentives of health care providers, especially those of physicians.

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Prior to the arrival of Managed Care (HMO’s), America’s health care system gave doctors a financial incentive to over-prescribe treatment. With the growing use of private insurance, physicians were seldom discouraged from over-prescribing care. Recommending more tests and procedures tended to increase their incomes. The insurance companies didn’t ultimately worry about this so much because they could always shift their increasing costs onto the backs of policy holders. The result? Skyrocketing increases in health care costs over several decades.

Then came Managed Care. Suddenly, the incentives for doctors were reversed. Now doctors received a fixed amount of income through their HMO contracts for services in a given time period. Under these constraints, doctors now had a financial incentive to under-prescribe treatment at a certain point. Yes, this approach did manage to slow down the growth of health care costs, but then we started to hear patients complain about receiving inadequate treatment and physicians complaining about the restrictions that were being placed on them by HMO numbers crunchers.

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If a physician gets paid a generous salary for “just being a doctor”, for “doing what a doctor does” [a certain number of hours per day] then she will not receive any extra revenue if she prescribes extra tests & procedures. Nor will she be rewarded financially for under- prescribing care. When physicians are on salary, they are freed from their concerns about financial matters and are able to fully invest themselves in the most idealistic inspirations of their calling. They can simply focus on healing people and not worry about all of the administrative headaches.  (More on Fixing Health Care Incentives)

Max is focusing on the need for policy incrementalism; I'm focusing on the need for political incrementalism.  If we could win over a significant majority of doctors over to the idea of salaried physician careers in America, we'd be in a much better position to take on the insurance industry and the Phamaceutical Monopolies.  Divide and conquer.  My impression of Britain's National Health Service is that doctors there have a very large voice in how the provision of health care services is organized.   It could be that way in America.

I say that Democrats need to present themselves as the friends of doctors.  We don't want to take anything away from [the vast majority of] them; we just want to free them from many of the headaches of being a physician in American today and allow them to more fully invest themselves in the most idealistic inspirations of their calling. 

Max-

1. Can you name three politicians who lost because of their support for health care reform? Still no response on this point?

2.  If I can adopt your "causation is hard to show," here are the points which I think have flowed from the Contract on America and the absence of effective Democratic opposition:

A. Welfare "reform."