The first time I wrote about single-payer, in a column at The State, my headline was “Can anyone (any viable candidate, that is) say ‘single-payer?’”
That was 2007. As I said at the time:
CAN ANYONE among those with a chance of becoming president say “single-payer?” If not, forget about serious reform of the way we pay for health care.
It doesn’t even necessarily have to be “single-payer.” Any other words will do, as long as the plan they describe is equally bold, practical, understandable, and goes as far in uprooting our current impractical, wasteful and insanely complex “system.”
And the operative word is “bold.” Why? Because unless we start the conversation there, all we might hope for is that a few more of the one out of seven Americans who don’t have insurance will be in the “system” with the rest of us — if that, after the inevitable watering-down by Congress. And that’s not “reform.” Actual reform would rescue all of us from a “system” that neither American workers nor American employers can afford to keep propping up.
But the operative word to describe the health care plans put forward by the major, viable candidates is “timid.”…
Which is what led us to “Obamacare,” an overly complex, timid approach that still leaves millions of Americans uncovered.
But when I wrote that, I knew we weren’t likely to do any better than that, because the only “name” Democrat willing to say “single-payer” was Dennis “The Menace” Kucinich.
And today, the charge is led by… Bernie Sanders. And even he wants to call it something other than single-payer — namely, “Medicare for All.”
The somewhat better news is that he has 15 senators with him this time (all Democrats, of course) — only 45 votes short of what it would take to get the proposal through the Senate before it went down in flames in the House, as it surely would.
Never mind that EVERY alternative advanced looks insanely over-complex and inefficient next to a system that simply covers everybody. No more worrying about making too much money, or too little money, or getting laid off and losing your medical coverage. Or sticking to a lousy job for the benefits, rather than going out and doing something bold and courageous that might help build our economy. No more of doctors having to employ people who spend all their time trying to navigate the bewildering array of different kinds of coverage their patients have.
And I’ve never heard a reason not to do this that didn’t sound idiotic. The most devastating argument opponents come up with is that you might have to wait for certain kinds of procedures. Which certainly beats waiting until you die if you don’t have coverage under the current non-system.
Other countries, including those most like our own — Britain and Canada — adopted this approach long, long ago. But in this country, we have this completely irrational resistance that makes it impossible even to have a calm conversation about what makes sense.
It’s time we got over that. And we may be making progress in that direction. But we have such a long, long way to go…
Related Posts
See the picture I ran with this? It reminds me that it would help if, when making commonsense proposals, Sanders could manage to look less like a kook.
And before you say I deliberately picked an unflattering picture — I grabbed that still image from Sanders’ own Twitter feed…
See the picture I ran with this? It reminds me that it would help if, when making commonsense proposals, Sanders could manage to look less like a kook.
-Brad
This raises an interesting question. What exactly does a “kook” look like? It’s a matter of opinion of course but I personally don’t think there is anything that even remotely suggests “kook” when I see Bernie Sanders. I see “kook” plastered all over Lindsey Graham. Further his voice projects “kook” whenever he opens his mouth and utters some screeching, skin-crawling utterance about some new military adventure (or for that matter when he says something sensible). I see “kook” in the facial expressions and hair of Donald Trump. Clearly John Bolton belongs in the “kook” hall of fame with his dated, 70s porn-star mustache. Ditto Dick Cheney with his scowl. Closer to home we have the ultra obnoxious Joe ‘You Lie’ Wilson with very much the look of a “kook”. As does Mark Sanford.
But really does it matter one iota what one looks (or sounds) like? Suggesting someone looks like a “kook” calls into question whether the person doing the calling is himself a bit of a “kook” for placing such an inordinate amount of importance on looks and style. Just because someone doesn’t meet your own personal standards for what is a “normal” look does it add any value to the conversation? Does it advance the discussion or score any debating points? No, of course it doesn’t. It is merely a crude comment that only reflects on the person making it. Frankly I’d far rather have someone who looks like a “kook” than a normal looking person who constantly gets things wrong and pushes policies in the wrong direction. Give me kooky Bernie over someone “normal” looking who gets it wrong any day.
Your headline says “paying for healthcare” but I don’t see any explanation of how the “paying” will be implemented. It’s easy to say “single payer” and wait on the tax fairy to solve the hard part of the equation. The devil is truly in the details because you are talking about changing the entire system of who pays, who gets paid, how much it costs, who determines what gets paid for and what doesn’t, who decides on which treatments are allowed or not.
Will you accept single payer with abortions (including partial birth )and birth control included? Will everyone pay into the system or is this just going to be like Social Security where those who make more pay more? Will people on Medicare and Medicaid now pay any more than they are paying now? If not, why not? Will you force every hospital and doctor to be a part of the system?
I’m fine with single payer if it includes shutting down Medicare, Medicaid, and the VA and there is a flat tax that pays for it along with co-pays to prevent some abuse of the system. But I hold out no real hope that things will be much better. There’s no evidence that our government can run a decent health care system that isn’t a cesspool of fraud, waste, and poor performance. But if we want mediocre health care for all, let’s do it. Too bad we’re spending money in Afghanistan that might help people here. You won’t accept any military cuts to pay for what you want.
The money people pay now would go into this system. It’s not that hard.
Genius! Why didn’t anyone else think of that!
Except you’re going to need MORE money to cover everyone to the same level, right? Where is that coming from? Or are we going to start with the same amount of money but just divide it over 300 million people? That would be interesting.
We’ll end up with two systems, you know. One for the rich and one for everyone else. My friend who is an ortho surgeon isn’t going to take a pay cut .
Except you’re going to need MORE money to cover everyone to the same level, right? Where is that coming from?
-Doug
If you merely eliminate the age requirement for Medicare then everyone will be on that system. This adds cost of course but you are adding younger people who tend to be healthier. The trade-off is you don’t need private, and very expensive, health insurance. Your taxes may go up but that will be more than offset by the savings and efficiency. Plus we have no need to pay extreme salaries for some moocher insurance CEO or extreme profit. Seems pretty obvious to me.
Except the market pays what the market allows. You want the best employees, you better pay more than minimum wage. I realize this goes against Socialist values where every job is give a set wage regardless you are at the top of your class or come in last.
Hey I got something besides cars and road signs, tonight I’ve gotten apartment complexes and chopsticks.
Uh, bud, Medicare depends on more workers paying in than those who receive it. Are you suggesting Medicare for all will work without raising the tax?? Nonsense.
Currently the total cost includes taxes, premiums, copays, and out of pocket costs. Start with all the deductibles and copays. Where does that money come from in single payer? You well have to raise taxes to cover it. Then add in everyone who will seek “free” healthcare when it is available. If those people are paying zero into the system now, where will the money come from for their costs?
People who are for single payer can’t be bothered to think about how it actually would work. Because they live in a fantasy world where someone else pays more for what they want.
Of course taxes will go up. At least initially. No one is claiming otherwise.
But you won’t be paying health insurance premiums. Since EVERYONE will be covered EVERYONE will have affordable access to preventive treatment. This is not some brand new, never-tested proposal. Everywhere else in the world has some version of this and everywhere else in the world pays far less in healthcare. Most countries even pay less in healthcare related taxes. And they generally have better outcomes.
The taxes will have to increase to cover the total amount paid for insurance premiums, copays, and out of pocket expenses PLUS all the coverage for everyone who doesn’t use the system to its fullest extent now. Plus illegal immigrants, too, right? Or can we at least limit it to American citizens?
Medicare tax is currently 2.9% for everyone making under $200K ($250K couple). Those above $200K pay an additional 0.9% (3.8% total — thanks rich people!!!).
Want to bet any single payer system will have some complex formula to try and stick the rich with most of the bill? Taxing millionaires is always a winning idea with people who can’t be responsible for their own situation (What? Give up my $999 iPhone for health care? Are you crazy???)
Has anyone floated an actual idea of what the tax rate would be in a Medicare for All program? 10%? 15%? No cap whatsover on contributions?
I want to hear Hillary Clinton say she’s okay with giving back 10% or more of her millions every year.
Do you really believe that a single-payer system will be as expensive as the wasteful, overly complex one that we currently have, with profit built into it at multiple layers for multiple players?
I don’t.
But I can’t prove that to you, so I’ll never convert you…
I thought you weren’t a money or numbers guy. Yet you’ve figured out this highly technical and complex financial problem. Or did you just take what Lindsey Graham said and repeat it?
I am on Medicare and think it is great. I’d love to see everyone on Medicare. However, I don’t think Bernie Sanders is going to lead anyone to the promised land. First, he hasn’t done the hard work of a real plan to pay for it. Certainly there would be much less need (not no need, as Medicare demonstrates) for private insurance and that would help balance the books. However, the ACA experience has shown that many people don’t think they need insurance, aren’t paying now, wouldn’t save anything by paying into a single payer system, and would be furious about the genuine coercion (as opposed to ACA’s relatively low fines) needed to make the system work. Second, Bernie’s folks are so strident and sanctimonious that it makes me grit my teeth and want to move onto some other topic, any other topic. Cat memes anyone?
I should add that I find myself agreeing with Doug. (This also happened a few weeks ago, surely the Apocalypse is near.) Contraception and abortion access would be flash points and would lead to even worse issues than under ACA. Personally, I believe people should have access to both when they need them and have no interest in paying for insurance that has been edited to accommodate some else’s religious beliefs.
There are two issues in play here. (1) What would be the best option for an American healthcare system and (2) What is the best option politically feasible for an American healthcare system. Clearly Medicare for all is not going to happen in the near future. However, as a long-term goal that is the likely end game for this debate. 30 years ago it seemed unthinkable that smoking would be banned in most public places. I remember many on this blog objecting to smoking bans in restaurants. That seems pretty ridiculous now. But in our clumsy American manner we got there. Same with gay marriage and legalized marijuana. I predict that some younger politician will pick up the torch and move in the direction of Bernie’s proposal and eventually he will be hailed as a hero. For the time being let’s at least try to correct the flaws in the ACA and provide most Americans healthcare.
I am on Medicare and think it is great.
-Lynn
And so does every single person I know who is on Medicare. My mom has been on Medicare for 23 years now. She also has a rather pricey supplemental policy. But she pays very, very little out of pocket for medical stuff. I find that to be a very good thing.
BECAUSE THEY AREN’T PAYING FULL COST! Their healthcare is subsidized by those of us paying more using private insurance. And they didn’t contribute anything close to what the typical Medicare recipient receives in benefits. One trip to the ICU likely costs more than anyone contributed.
Let’s do the math. A person who earned 50K for 40 years and paid 3% paid in $60K. How long would it take to burn through $60K in a hospital stay? My son’s one day appendix removal was $30K. Medicare typically pays at much lower rates (which is why some doctors won’t take Medicare patients).
From the CDC:
Per capita national health expenditures: $9,990 (2015)
Total national health expenditures: $3.2 trillion (2015)
Total national health expenditures as a percent of Gross Domestic Product: 17.8% (2015)
So we need to come up with 3.2 trillion dollars per year to get what we have now. Surely nobody believes the cost savings that MIGHT come from single payer will offset the costs of adding everyone into the system. So let’s stick with 3.2 trillion dollars. The country’s total income last year was 13 trillion dollars. Can you do the math? That’s 25% of total income. Now nobody is going to accept a 25% tax, right (well, except those lazy people who will say tax millionaires at 90%).
Now, total net insurance premiums in the U.S. were 1.2 trillion dollars. So if we can magically eliminate all those (and put every insurance company out of business including hundreds of thousands of employees and billions of revenues lost to the companies that support the insurance industry), then we’re still left with 2 trillion to come up with.. or 15.4% of total U.S. income. Now, for me, I’d cut military spending by 25% because I think healthcare is more important. That would get about $150 billion… but that ain’t happening in Brad’s world. He believes everything is possible if you just put your mind to it and don’t worry about the money.
Single payer won’t happen in our lifetime because it’s too hard to maneuver through the cesspool of Congress. Better to give everyone a $15K check to go buy their own insurance and let the market sort it out.
Doug your math is fuzzy. Mainly because with everyone covered many expensive treatments are prevented. Plus Medicare can negotiate with big pharma, big hospital and big everyone else to keep costs down. Everyone wins with Medicare for all. Here’s the Wiki article on per-capita spending by nation.
https://en.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_per_capita
“Their healthcare is subsidized by those of us paying more using private insurance.”
And what’s wrong with that, by the way. You do understand that INSURANCE works by a lot more people paying in than will need expensive health care. The point of single payer is to get all those people in the same pool, making that process work better.
“One trip to the ICU likely costs more than anyone contributed.” See? Now you’re catching on to the concept of insurance…
You’re not purchasing a product with health insurance. You don’t pay in X amount and get X value of healthcare in return. If you’re lucky, you’ll pay in far more than you ever get out of it, personally. If you’re unlucky, you’ll get more in medical care than you paid in.
And if you don’t like that (and I know how libertarians think they, as individuals, should personally benefit from any payment they personally make), then you have a problem with the concept of insurance…
Except do you understand that most of the people not paying into the system now won’t be paying much if any into the single payer? If you don’t have a job, how much will you contribute? If you earn $8 an hour, even a 25% tax will only result in paying in $3750… enough for one trip to the ER for a sprained ankle. And nobody making $8 an hour is going to pay even 1% of their pay for “free” insurance when they can get it for zero now.
How do you think people who got insurance through Obamacare are getting covered? By subsidies paid for by everyone else. Did that make health care more affordable for everyone? No – it made it affordable for some and cost more for others.
Will you support taxing everyone for single payer? Right off the top like Medicare?
Insurance is pooled risk that should be paid for equally. Not based on income. Why should my income determine how much my insurance costs if the risks are pooled? I don’t pay more for car insurance for the same model and year as my neighbor even if I make twice as much money.
And we can’t even discuss taxing those with poor health habits at a higher rate (like we do for bad drivers).. That would be “selfish” and “libertarian”.
For example, at my company we all pay the same amount for insurance whether it is the CEO or the secretary. We have choices of plans for family coverage or single and that’s it. $125 a month for single with $5000 out of pocket max and the company covers most of that $5000 for everyone when required.
That’s how insurance should work. Shared risk, shared cost, coverage for major costs.
Talk to a doctor about Medicare, the ones I know say they’ve been cutting reimbursements for years. A process that cost $400 10 years ago, was reimbursed $400, today he’s lucky to get reimbursed half that. There are several procedures he does where he doesn’t even recoup the cost of the supplies used for the process. It’s like SC State Dental Insurance, how many dentists will put a crown on for $285 or fill a tooth for $35?
Yeah, that’s how you contain the rise of costs. With everyone on Medicare, that mechanism would be more effective.
Of course, it’s impractical to reimburse less than the ACTUAL cost of providing a service, but how much of the rise in health care costs do you think match the actual cost of providing the service?
Would you go to a dentist who advertised $35 fillings?
“Yeah, that’s how you contain the rise of costs. With everyone on Medicare, that mechanism would be more effective.”
I’m sure the doctors can’t wait to see their incomes cut significantly while their own expenses remain the same. Surely that won’t result in any negative impact when doctors either refuse to treat single payer patients or set up cash based practices or just decide to retire.
There will be negative unintended consequences of any major change to the system. Increased wait times definitely. Rationed care likely. Plus a bunch of other things not even considered.
Dang. Now you’re going to have me sitting up nights worrying about doctors being able to put food on the table…
Sorry, but I couldn’t resist that opening.
Make no mistake — I think doctors should be well compensated for their contribution to society. Of course, I think the same of schoolteachers…
The next time you need surgery, go down to the elementary school and see if there’s a teacher willing to do it for you at a discount over the surgeon who spent years in medical school and residency.
People should be compensated for their expertise, not based on what you think is a reasonable income — why is it that you claim to not care about money but DO care how much money a doctor makes?
The best way to cut doctor salaries is to increase the supply of doctors and decrease the demand for services. Healthier people plus more doctors practicing would drive down costs faster than any artificially mandated price / wage control.
Give people incentives to get healthy and invest in more medical schools. And how about allowing other hospitals in the area to open up cardiac units to increase the availability?
Don’t worry, they’ll easily be able to afford food in India, because you’ll be seeing the doctor via telemedicine.
This post from another thread seems to fit here, too:
Sander’s idea is half right (the universal coverage part), but his plan will “break the bank.” California just looked into a similar program for their state, but an appropriations committee estimated it would cost $400 billion, over twice the state’s annual budget.
Universal catastrophic coverage has elements from both progressive and conservative playbooks; it combines the federal guarantee of insurance for all with the cost-controlling benefits of insurers competing for that business. For more details, search “universal catastrophic coverage.”
Yes, that’s better. But what about my “free” scooter and diabetes supplies I see on the ads on television? Who’s going to pay for my free stuff?
What kind of TV are you watching? “Gunsmoke” reruns?…
Here’s the list of nations by life expectancy:
https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy
So spending BY FAR the most on healthcare gets us ranked below places like South Korea, Chile and Costa Rica? Seems like this whole free market approach is not working very well.
Because our demographics, diet, stress levels, and many other factors are different. I bet our nation per capita uses more prescription drugs than all those others. Got a problem, take a pill. Side effects from the pill? Take another pill? Feeling bad about your side effects? Take another pill.
We also probably do more screening, more “just to be safe” MRI’s due to malpractice fears, more money spent on end of life situations and ICU, more money on premature infants… You think they’re spending millions of dollars on 26 week old premies in Chile or Costa Rica?
You’re comparing apples to oranges at a highly aggregated level. It’s junk statistics.
Shouldn’t “just to be safe” MRIs, even IF unnecessary, contribute to better outcomes? Sure it may cost more money but you can’t say it reduces life expectancy. Same with spending millions on preemies. Look we have and will continue to go round and round in circles on this, but the indisputable bottom line is simple. We pay way more than anyone else and have a shorter life expectancy than 30 other nations. Making excuses or blaming demographics as a scapegoat just doesn’t cut it. It’s just indefensible to continue doing things the same way indefinitely and expect the Free Market Fairy to come along and make everything all right.
Yeah, why deal with the details when you can stick to an aggregated number that eliminates all the variables as long as it supports your argument?
Break out life expectancy of Japanese Americans… or white females.. I bet the life expectancies are much closer to other countries. If that’s true, then there are other factors involved. Hispanic females in the U.S. have a life expectancy of 83.7 years. White females are above 80. Both of those are higher than the average in Chile and Costa Rica. Black males are at 71.7 in the U.S.
What you forget, Doug, is that we are already paying for indigent health care both through various federal plans (medicare, medicaid, etc) and greatly increased hospital prices to cover emergency services for the uninsured. In addition, we end up paying higher premiums to support big Pharma (what?? Allow the government to negotiate for lower prices? Heaven forbid!), and to support the insurance companies, which are for profit entities. And it need not pay for everything. Basic good health care and catastrophic health care should be covered, and medically necessary equipment (basic w/c yes: scooter maybe not). Perhaps extra health/medical care could be a (tax) add-on for those who can afford it and choose to do so.
Imagine the bureaucracy of trying to decide what is basic and what is not. The same government that created the tax code?
Be careful what you wish for.
Maybe we can let Equifax decide. Since they’re a private company I’m sure they’d get it right.
How many mistakes (because that’s what liberals like to call them) made since they’ve been in business?
Continually looking for simple solutions to difficult problems is one reason our society is such lousy problem-solvers and that we spend so much time and effort shouting at (or past) each other. Both the delivery issues (overuse without co-pays, “shyster” medical suppliers, shortages of providers with expanded use) and the pay-for issues will need considerable study, collaboration, and hopefully some deference to folks with expertise. Many things will have to be examined in finding adequate ways to pay for the system, and I expect a slower phase-in than the Bernie bill calls for will be in order.