Why is Single Payer So Unpopular?
With all the controversy over healthcare reform, and the unpopularity of the present plans in congress and dissatisfaction with the status quo, why is no one talking Single-Payer? A single-payer system, a/k/a "Medicare for All", would solve any number of problems with both the existing and proposed systems:
Yet no serious politician dares mention it - it's only support comes from the likes of John Conyers and Dennis Kucinich. Though some polls have found favor among the public (here's a pro-single payer site that lists a number of them), over the past year Rasmussen has found only dismal support for the idea. Being that health-care reform has been in the news the past year, I'm guessing these results are more informed (i.e., the respondents actually understand what's being asked).
As someone who works for a large corporation and thus has fairly decent coverage, I'd be disinclined to change the status quo. But a single-payer systems seems preferable to me than the proposals now being discussed, which is basically keeping things as they are now but making me pay more for it. Now I can understand the young left-wing bloggers favoring it, but who listens to them? How about all the young conservative bloggers (or even not so young without employer-provided benefits) - aren't they concerned about the expense of health insurance? Wouldn't single-payer be an obvious benefit to them?
Update: Commenter Vercingetorix had the gall to lay out the conservative case against single payer. These are my fears as well, though I must admit I seldom here any such negatives from the expatriates I know from these single-payer countries, but this is his take:
- Pre-existing conditions become moot
- Multiple pricing schemes are out the window
- Claim-refusals for petty violations are history
- Self-employed and small businesses can now kiss their health-care worries goodbye
- American businesses no longer have the health-care albatross around their necks when competing with foreign producers
- Significant underwriting and claim processing expenses associated with private insurance are a thing of the past
- Labor-market distortions caused by the unequal availability of insurance across occupations and employers disappear
- No one will be unable to afford health care
- The total cost of the system shouldn't be significantly greater than the total cost of healthcare today (due to the savings associated with eliminating underwriting expenses)
Yet no serious politician dares mention it - it's only support comes from the likes of John Conyers and Dennis Kucinich. Though some polls have found favor among the public (here's a pro-single payer site that lists a number of them), over the past year Rasmussen has found only dismal support for the idea. Being that health-care reform has been in the news the past year, I'm guessing these results are more informed (i.e., the respondents actually understand what's being asked).
As someone who works for a large corporation and thus has fairly decent coverage, I'd be disinclined to change the status quo. But a single-payer systems seems preferable to me than the proposals now being discussed, which is basically keeping things as they are now but making me pay more for it. Now I can understand the young left-wing bloggers favoring it, but who listens to them? How about all the young conservative bloggers (or even not so young without employer-provided benefits) - aren't they concerned about the expense of health insurance? Wouldn't single-payer be an obvious benefit to them?
Update: Commenter Vercingetorix had the gall to lay out the conservative case against single payer. These are my fears as well, though I must admit I seldom here any such negatives from the expatriates I know from these single-payer countries, but this is his take:
Don't talk to me about single payer. I've met too many of those refugees, like my niece's father-in-law, told to go home and promptly die by Finland's single-payer system, he got very effective, not exotic treatment here in the USA thanks to his son's foresightedly marrying an American.See his full comment below.
I realize mere anecdotes do not a policy justify, but the fact is that single-payer means a virtual end to medical innovation, which is the only real hope for extending our pleasant lives.
Single payer necessarily means political budgeting, which means rationing and cost-shaving, which means staff will unionize to push cost-savings onto infrastructure and research rather than salaries, producing an exaggerated case of Baumol's cost disease for the system, such as we see with unionized labor in all goverment agencies and government-monopsonist markets. The same forces which give us innumerate yet tenured schoolteachers making $40/hour to preach homilies to Gaea in dirty schoolhouses with libraries that haven't been updated since the Carter Administration, while asking for parent volunteers to prepare assignments, score homework, and coach the kids would rapidly give us well-paid but unfireable and careless hospital workers in dirty decrepit hospitals where patients would only get fed or bathed if their relatives sat beside them to do the work while the paid staff watched TV in the lounge.
posted by ziel | 1/21/2010 11:23:00 PM
19 Comments:
The insurance and pharma lobbies will resist single-payer since it erases incumbent advantages from the current regulatory capture regime. Thus there is financing and support for advocacy against it. Also, pols of all ideological stripes are presumably beholden to these interests. So there's structural resistance to it in the political class.
Why oppose it, from a righty point of view? Well, it sounds un-American. It isn't necessarily socialized medicine per se, but as long as USG is the payer, there will be pressure to distort the market to achieve various goals.
It would certainly save money, at least in the short and medium term, and solve the universal coverage problem. However, once USG has inserted itself between buyer and seller, it will never go away.
The current regulatory regime is atrocious, but there is at least a chance that it could be reformed. Single-payer, once implemented, will never go away, and god only knows what baggy socialist monster it may morph into.
It seems like there should be a base of support for single-payer among small businesspeople with righty views for the reasons you've listed. However, that group probably punches beneath its weight because it is so atomized. And the idea is ideologically unpalatable to real free-marketeers.
I do not live in the US and have not paid attention to the details of the debate, so this is just a seat of the pants stab at an answer. Is there anything obviously wrong with it?
A Single-Payer system would be an enormous boon to the economy, for the huge savings we would enjoy from lower medical adminstrative costs alone. Hospitals now have to employ small armies of billing specialists who are familiar with the myriad major medical insurance providers and their different reimbursement policies. So much adminstrative overhead would just disappear overnight with "Medicare for all".
Besides, any single-payer plan would be a basic, fairly high deductible policy, which would still allow Americans to customize their coverage levels with the private, supplemental health insurance plans of their choice. That is how single-payer works in Japan, and it seems to suit them well.
(For the sake of disclosure, I am an independent insurance agent offering both major medical and supplemental health insurance.)
Ziel:
You are exactly right (always a first).
Single payer makes a lot of sense, if properly structured. Can this, or any US congress, work out a legitimate single payer plan? That seems doubtful.
I think conservatives, in general, reject it outright because they think it is a Democratic/Liberal idea.
Not sure how you educate the public on the benefits and that it is not a partisan idea but I'm sure that your dozens of readers can move it in the right direction.
Harlem
American businesses no longer have the health-care albatross around their necks when competing with foreign producers
Single-payer would not necessarily reduce the costs to business. The first idea of how it would reduce cost, by getting the government rather than business to pay for health insurance, ignores the issue of where the government gets the money. Even if the government took away the insurance premia these business had to pay, the businesses would still pay for health care through taxes to fund the single-payer system. The only way that single-payer would take that albatross off the necks of businesses would be if the total cost of the system were less.
For health care to cost less, we would need rationing. Given how much hated HMOs are, and how their cost-control measures got scuttled when people didn't get what they wanted, it seems unlikely that we will get the type of rationing we would need. Indeed, demand for health care would increase greatly, and if the government tried to cut it back to save money, there would be rioting. We would also need for doctors to agree to make a lot less than they do now. And we would probably need to reduce a lot of regulations in order to make it easier for people to become doctors in order to compensate for this. If we didn't free up regulations to go with the decreased salaries, we might well face a severe doctor shortage.
For the results of single-payer to work, we would need for Americans not to behave like Americans.
Glaivester - assuming the single-payer system won't be overall more expensive than the current system, you're right that the cost to business overall will be the same. But presumably it will be implemented like Medicare, with a very high income limit, and so should greatly reduce the cost of a manufacturing concern to cover the rank-and-file worker. It depends though on how it's implemented, so I'll grant you that point isn't so convincing.
The insurance companies have too much muscle, and therefore, the politicians are afraid to go down this path(to mix metaphors). For health care reform to pass, the insurance companies have to keep their cut, or at least, a substantial portion of it, even if this isn't the most cost-effective solution.
Money talks, bullshit walks . . . .
Obviously single-payer in the USA would give us the Canadian scheme, or (even worse) Britain's NHS.
But we know how horrible those are, if only from the sad stories of the medical refugees who wash up on our shores.
Single-payer is certainly the goal of the leftists in Congress but they don't want to come right out and say so because the justified opposition would then be insurmountable.
Instead the left plans to give us the crazy Obamacare scheme. Then when its ill effects become famous enough, offer single-payer as a relief.
The relief, I would say, of leaving the frying pan for the fire.
Don't talk to me about single payer. I've met too many of those refugees, like my niece's father-in-law, told to go home and promptly die by Finland's single-payer system, he got very effective, not exotic treatment here in the USA thanks to his son's foresightedly marrying an American.
I realize mere anecdotes do not a policy justify, but the fact is that single-payer means a virtual end to medical innovation, which is the only real hope for extending our pleasant lives.
Single payer necessarily means political budgeting, which means rationing and cost-shaving, which means staff will unionize to push cost-savings onto infrastructure and research rather than salaries, producing an exaggerated case of Baumol's cost disease for the system, such as we see with unionized labor in all goverment agencies and government-monopsonist markets. The same forces which give us innumerate yet tenured schoolteachers making $40/hour to preach homilies to Gaea in dirty schoolhouses with libraries that haven't been updated since the Carter Administration, while asking for parent volunteers to prepare assignments, score homework, and coach the kids would rapidly give us well-paid but unfireable and careless hospital workers in dirty decrepit hospitals where patients would only get fed or bathed if their relatives sat beside them to do the work while the paid staff watched TV in the lounge.
(Assuming you could even get into a hospital. Many people would just die while waiting for appointments, since delay is always the biggest gun in the cost-containing bureaucrat's arsenal.)
As for new drugs, devices, or techniques; forget it. R&D spending wouldn't survive the first national recession. To a government workforce, tenure, salaries, and benefits are always more urgent than R&D.
Full disclosure: I wish we had a "catastrauhpic" insurance plan in place for those who literally have no other option, or whose conditions are not covered by their insurance. Nobody should have something dramatic happen to them, and not be able to get it surgically repaired. No one losing a finger in an accident for instance, should have to make a choice about whether he can afford to get it sewn back on (like in Michael Moore's movie). We aren't that poor--yet.
If I could think of a way to make a single-payer plan go, it would be this:
Everyone would get physicals every two years, and their risk would be assessed at that time. You'd be checked to see if you smoked, and you'd be given a drug test. You'd be weighed in water to determine your amount of body fat. Your liver and kidneys would be looked at to check for signs of alcoholism. You'd be checked to see how much inflammation there was in your tissues. You'd be given a pamphlet about excercise and nutrition that would tell you all you needed to know about eating healthy and moderate excercise (20 minutes on a treadmill at 2mph pace at least every other day).
The worse that you scored on this assessment, the higher rates you'd see deducted from your taxes. If people thought they could save themselves $30 a month out of whatever tax increase they'd pay to be in this program, we might just see people doing things like slimming down-and getting some excercise, not drinking to excess, quitting smoking, not using drugs.
As it stands now, with so many modern jobs being sedentary affairs, many people just dont get enough excercise and car commuting means they dont have to walk even a quarter-of-a-mile a day. If everybody merely had a cheapie treadmill in their home, they could probably get the 20 minute walk a day they needed to get their blood flowing, and burn enough calories to at least not be super-obese. Our underclass, I fear, would cost us a real fortune if we had a single-payer-universal coverage system because those welfare mammas would be sitting in those offices for everything under the sun continually. Most "free" things end up getting abused.
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The 'best' thing IMO, would have been for one state to have tried something like this (not California either, some regular state), and see how it worked and how much it cost them over a decade period. Then we could have had an "experimental example" to reference to see if we could "make it go" everywhere else. As it is, its a big leap into the void from where we are at.
I apologize for galling you; I didn't intend to do that and I regret it.
I was just trying to answer the question you posed, which was why nobody was pushing single-payer. I thought that the left was merely dissembling and the right simply recognized it was a bad idea.
I suppose I got too excited, though I was sincere.
(In case it may be of interest, I'm a fan of semi-compulsory individual private insurance with tax-funded subsidies for poor or bad-risk citizens. The weak compulsion would consist of limiting eligibility for subsidies to people who had previously voluntarily purchased private insurance. That is, under my scheme the government would simply, but absolutely, not subsidize anyone who had "gone bare" before s/he got sick or injured.)
No, no, your comment was what I was looking for - I was only trying to make a bad pun on "Vercingetorix".
Oh shucks, now I'm ashamed I didn't see your pun.
Perhaps I should divide my proposal into three parts.
Or perhaps I should suggest replacing the HCFA with a council of druids.
Anonymous said...
"Everyone would get physicals every two years, and their risk would be assessed at that time. You'd be checked to see if you smoked, and you'd be given a drug test. You'd be weighed in water to determine your amount of body fat. Your liver and kidneys would be looked at to check for signs of alcoholism. You'd be checked to see how much inflammation there was in your tissues.
The worse that you scored on this assessment, the higher rates you'd see deducted from your taxes."
While were singling out the smokers (who save us money on social security by the way), the drinkers, and the over-eaters, may I ask what extra premium will be charged of those people who engage in behaviors that contribute to making health-care expensive, but which are not socially disfavored?
What about the sexually promiscuous, who are prone to venereal diseases. Will they be made to pay more? What about bicylists and motorcyclists, who are much more likely to get seriously injured in accidents, and to sustain the kind of injuries which - if it doesn't kill them - which can render them a paraplegic, quadruplegic, or even a vegetable for the rest of their lives, and I might add, a great expense to the rest of us. Same goes for skydivers, mountain-climbers, kayakers, and other extreme-sport enthusiasts. How much more will they pay for the priveledge of engaging in their seflish hobbies - behaviors which could cost the rest of us a lot of money down the road.
Martin B gets to the real problem. There are plenty of utilitarian objections to single payer, but the biggest objection from a conservative POV is that nationalizing your health care means nationalizing your body. Everything you do can be regulated, as just about everything can be conceivably tied to your health. This would be a horrid direction to take for anyone concerned about personal liberty.
Martin B wrote:
"What about the sexually promiscuous, who are prone to venereal diseases. Will they be made to pay more? What about bicylists and motorcyclists, who are much more likely to get seriously injured in accidents, and to sustain the kind of injuries which - if it doesn't kill them - which can render them a paraplegic, quadruplegic, or even a vegetable for the rest of their lives, and I might add, a great expense to the rest of us. Same goes for skydivers, mountain-climbers, kayakers, and other extreme-sport enthusiasts. How much more will they pay for the priveledge of engaging in their seflish hobbies - behaviors which could cost the rest of us a lot of money down the road."
Martin B,
You make some great points there. We would have no way to screen for those. Im not -for-national health care btw, it was just a hypothetical scenario of a way that things could be initially approached. I do know, Martin, this though............heavy-ish people seem to populate the waiting rooms in doctors offices more oft than not. We are an extremely overweight country now. Thats one aspect of our help that we can help ourselves. If the government was going to take up the plow and farm this field, they'd have to do *something* to try and reign in costs. Trying to create incentives for people to eat less, excercise more, and enjoy alcohol in moderation would seemingly be a way to cut some costs. The government could ask people if they were into extreme sports activities, but of course respondents could simply lie to them. There are quandries all around the national health care debate. Ive been blessed (knock on wood) with good health through excercise and a reasonable diet myself, and only know what has been effective for me personally. That being said, if I were in a car accident and rendered a vegetable, I'd end up costing my insurance company a fortune for the rest of my life.
I am for a some type of 'disaster' insurance for people with no coverage for necessary surgeries. I state that in the interest of full disclosure.
I suspect that single-payer (or any other government-run plan) would mean the end of alternative healthcare except on a cash basis.The medico-government establishment would quickly snuff out their competitors.
The bicyclist comment was very interesting: does anybody have a clue whether the health benefits of biking to work outweigh in terms of medical care the risks of catastrophic injury?
I don't.
Firstly let's be clear that in the UK and France and any other single payer system you can easily buy top up insurance from the likes of Bupa if you like. This ensures you have no waiting list and are treated in a private hospital, of which there are many. Most top up premiums in Europe are around 10 times cheaper than the main rates for the USA. In fact if those who could afford to do that would do it then the waiting lists would plummet. Nobody in Finland or anywhere else is ever denied the right to pay extra to ensure prompt treatment!
Secondly, no system will ever be perfect and the US system has many more flaws than the UK or French systems. If you want anecdotes then I have two relatives who have both been refused insurance after having had the cheek to use their insurance; one had hepatitis and nearly died, and the other had most of her intestines removed and could have died. The reason the latter got so bad is because she wasn't sure that any of her 3 jobs gave her insurance. Now if they get ill they'll have three options a) if they find a hospital that accepts them they'll likely go bankrupt paying the bills, b) go to Mexico, c) die.
The reason your waiting lists are so short is because so many people just aren't allowed in the queue. Meantime, in France lo and behold the waiting lists are short too, yet I pay far less than I would in the USA. That difference is the profit of the US insurance industry.
Meanwhile do you think it's right that you have to call up your insurer to find out if you are actually covered for any accident rather than just call a doctor? My cousin from LA got suddenly ill when visiting, we called 15 and he saw a doctor within 5 minutes - literally, and on a Sunday. the cost (extra on Sunday) was 50 dollars. He was amazed.
Having answered V's conservative objections I'll answer the main question of why nobody is pushing it. It just might have something to do with the vast amounts of money spent on the electoral campaigns of the politicians on both sides of the aisle who are making these decisions. It might also have something to do with the reds-under-the-bed, fear-mongering of the asinine and ignorant US press, all of whom assume that the US system must be best because - hey it must be...
The US healthcare system is over-regulated because of aggressive healthcare lobbyists, lawyers, and activist groups operating on the state level. Health insurance providers are simply not allowed to sell people a well-tailored policy at a price they can afford in many states. The use of life expectancies as a proxy for "quality of health care" is a red herring, because there are many pathologies in American society that are much less prevalent in Europe. And Japan, the country with the longest life expectancy of all, is the best example of this. The Japanese do not live so long because of their fantastic health care, they live long because of their way of life!
The "healthcare reform" agenda that Congress is working on seems like a Cloward-Pivenesque attempt to use federal regulation to deal a deathblow to our healthcare system, so that we will be forced to eventually enact a communist-style national health system. A free-market reform would be to invoke the 10th amendment appropriately to allow insurance companies to offer plans on a national level. That way, someone from California can buy a healthcare plan from a provider in Missouri, where they're not required to pay for sex-change operations.
That said, I'd be in favor of a very basic government-subsidized plan to help out the lower class. But it would only cover the most cost-effective treatments. If you get some exotic cancer, too bad. Here's some hemlock. The miracle of your birth does not entitle you to all the latest and greatest 21st-century technology to prevent your death or illness.
Our healthcare system, by way of its higher payments, also subsidizes most of the medical and pharmaceutical R&D in the world. I'm in favor of policy that would prevent these innovators from milking our system.
By the way, a big part of our healthcare cost problem is the government underpaying for Medicare and Medicaid, and institutions offloading the cost to private payers. Thus, "Medicare-for-All" should be dismissed as a joke. A parasite cannot survive without its host.
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