Why Not Bigger

Matt Stoller thinks he disagrees with me about health care but really we're more-or-less on the same page. I think these mandate-and-subsidize plans are badly flawed compromises. Democrats tend to embrace them because they think they're more practical than even more ambitious schemes. But there's really nothing especially practical about them. Their best elements -- and you see this especially in John Edwards' plan -- tend to be efforts to trick congress into putting the country on a slippery-slope to a single-payer health care system. But the idea that you could pull a fast one on AHIP like that is silly. With all due respect to the cleverness of left-of-center wonks, nobody's that clever.

Under the circumstances, the plans will either fail or else, as Matt says, "the best parts of the plan get removed in a compromise" and you wind up with something that's not really worth passing. I would much rather see people trying to build support, directly, over the long run for single-payer health care and the marginalization of private sector insurance.

Incremental interim measures should be genuine increments -- steps in the right direction -- not efforts to square the interests sound health care policy with the financial interests of major insurance companies. John Kerry's 2004 plan, which involved having the government step in to cope with super-catastrophic medical expenses, was good in this regard -- a quite small measure that might have passed, but which created the sort of thing that could have been scaled up (or, in this case, down in terms of the threshold) over and over again, just as SCHIP expansion is a well Democrats can keep returning to until all children are covered, and then there can be efforts at expansion to parents, to college students, etc., etc., etc.

Comments

i too thought that kerry's 2004 plan was an excellent step in the right direction; however, the lesson of 2004 in that regard was that it was completely and totally ignored/drowned out.

the advantage of saying i've got a comprehensive health plan is that it's much harder to get ignored/drowned out.

which doesn't in any way obviate matthew's comments, just noting the political reality that small, well thought-out incremental steps don't really lend themselves to a soundbite culture.

Posted by howard | September 21, 2007 5:02 PM

National level regulation of insurance companies to do e.g. guaranteed issue is an important incremental step.

Posted by mq | September 21, 2007 5:07 PM

It seems to me that Hillary's campaign is run on two things: Fear (of being attacked as left-wing), and sucking up to big-moneyed interests.

Not that she would be anywhere as bad as BushCo, but she would continue the US down the path where policy debate is dictated by Fox News, and the rule of gold continues to expand.

Posted by Gore/Edwards 08 | September 21, 2007 5:07 PM

Do you actually think single-payer is a better system than, say, France's? What is the best single-payer system in the world?

Posted by Anonymous | September 21, 2007 5:48 PM

Anonymous, maybe the VA?

Posted by Eric K | September 21, 2007 6:13 PM

That's a good example - I would like to know how it compares to the French or Italian systems.

Posted by Anonymous | September 21, 2007 6:26 PM

Hum...it is not clear how mandatory-private insurance is incrementally a step toward national single payer health care. Seems like an 'intermediate' solution, yes. Does not imply future 'progress' toward single payer.

Having got the inner-english-teacher behind me, I think there are two disadvantages to the mandatory-private plans. They do not reduce the complexity health-care-providers face in getting reimbursed. Some plans would pay more, some less for the same services. Some providers would still have incentives for not accepting certain plans. The result is that some specialists would not take your insurance.

And the incentives of the insurers are still to 'cherry-pick' the least sick clients and short-change the providers.

Still is a huge improvement over the present accidental system.

Posted by JohnMcC | September 21, 2007 6:34 PM

Since the Dem candidates are proposing the same plan, within the margin of tweaking allowed a new President, the problem is how to get it passed and not artichoked to death (fn). Here's my suggestion: work out single-payer in detail as a serious plan B. Say that if Plan A is watered down, the alternative isn't the status quo or insignificant reforms, it's plan B. If you don't want Germany, you can have France or Canada.
(Footnote- explanation of artichoke as a verb: Count Geoffrey of Anjou absorbed Normandy in the 12th century town by town "like a man eating an artichoke" according to a contemporary chronicler. It's an older and bettet image than salami tactics, which doesn't lend itself so nicely to verbing.)

Posted by James Wimberley | September 21, 2007 6:38 PM

Let's remember that the administrative costs needed to deny care are just as expensive as simply giving the care in the first place.

Which makes the insurance companies, who are practicing medicine without a license, and killing people as a result, murderers -- just like the tobacco companies.

So, the corporate death penalty for the insurance companies, say I.

(Of course, we need to get the corporations under some sort of human control in any case, as both the tobacco and the "health" insurance companies show. A good place to start would be the abolition of the legal doctrine that corporations are persons, have free speech "rights," et cetera, an idea that the Bush Court headed by Roberts is now busy taking to the absurd extreme.)

Posted by lambert strether | September 21, 2007 6:44 PM

Matt, for something to be more practical doesn't mean that it has to "fool" everybody, as you put it. You're right that AHIP won't be swayed by sloganeering.

The masses, however, ARE swayed by sloganeering. The accusation of socialized medicing becomes much easier to rebut if you can simply say: "No one's forcing you to do this, you have a choice."

I sometimes think you think much too logically about things, and then project that onto other people. It's the same as arguing that the Iraq war couldn't have happened, because there's no way that Moveon's eventual founders would have been taken in by the arguments. It's a sorry state of affairs, but politics, and the decisions that stem from it, depend much more on the catch phrases people create, and not on the actual policy.

That being said, has anyone considered that maybe Hillary proposed this plan because ... she thinks this is the right thing to do? Every single article I've read seems to take it for granted that she's deliberately limited the plan and is instead hoping for the slippery slope to do the rest.

Posted by gheby | September 21, 2007 6:52 PM

Re: I would much rather see people trying to build support, directly, over the long run for single-payer health care

Good grief, how much more long run do we need? Every other civilized country has had universal health care for generations! Granted these Democratic plans are not ideal, but they're still vast improvements over what we have. And there are people suffering right now today-- they need help now, not in the long run, when, as Keynes reminded us, we are all dead. Moreover the stars are now aligned for a major health care overall Lety's do it, not whine and moan because we can only achieve the good, not the best!

Posted by Jonf | September 21, 2007 8:20 PM

jonf,

Do you even read the material you quote? He said "single-payer health care," not "universal health care."

The risk for advocates of single-payer is that once we have multi-payer universal coverage, the chances of your being able to convert the health care system to single-payer are probably even lower than they are now. Realistically, your only shot at getting single-payer is as part of a broader reform that radically alters both funding and coverage. Other countries that already have single-payer or quasi-single-payer health care systems (Britain, Canada) are moving towards multi-payer arrangements in which private insurance plays an increasing role in total health care funding. I think your chances of getting single-payer are fading away with every passing year. Now is your best shot, and it's a very long shot at that.

Posted by Mixner | September 21, 2007 8:53 PM

Medical reform will not occur until and unless people demand it. And no, we don't need any more "incremental steps."

Posted by Happlen | September 21, 2007 10:01 PM

Their best elements -- and you see this especially in John Edwards' plan -- tend to be efforts to trick congress into putting the country on a slippery-slope to a single-payer health care system. But the idea that you could pull a fast one on AHIP like that is silly. With all due respect to the cleverness of left-of-center wonks, nobody's that clever.

Under the circumstances, the plans will either fail or else, as Matt says, "the best parts of the plan get removed in a compromise" and you wind up with something that's not really worth passing.

Emphasis mine. To me this is the key question. Can Edwards/Hillarycare pass relatively intact or not? I don't believe anybody knows the answer to that.

If such a plan were to pass, however, would it not get us on the road, or on the slippery slope, to robust national healthcare?

If the health insurance lobby isn't going to be fooled about Clinton's plan (and I agree they won't be fooled at all), they're not going to be all that crazy about single payer either, one supposes.

I think the advantage to the more centrist approach is that, although you're not going to get the support of the health insurance industry, you are going to get at least some support of other major players who aren't yet on board with single payer, like suburban middle class folks, or moderate Republicans (I know there aren't many left, but there are a few), or conservative Democrats, or the AMA, or maybe even the Chamber of Commerce.

Sure, eventually either way we'll get to single payer/national health care, but it could be a long, long time, and I'd just as soon get everybody covered now. I know that means increased revenues for private sector health insurers, but if they're more heavily regulated, they're going to start to pretty closely resemble public utilities anyway. And the revenue increase is unlikely to be matched by a corresponding profit increase (all those previously untouchable pre-existing condition unfortunates). Which leads me to one last point: for, say, a 49 year-old self-employed diabetic, what we have now is a veritable crisis. Something needs to be done.

Okay, one more last point: I think progressives genuinely underestimate the degree of antipathy in the country to what talk radio will call "a government takeover" of healthcare. Maybe I'm wrong, and there's some polling out there that gives one cause for optimism. But I haven't seen much. Meanwhile the clock is ticking for that diabetic...

Posted by Jasper | September 21, 2007 10:16 PM

Re: He said "single-payer health care," not "universal health care."

On previous occasions he has expressed identical skepticism about universal healthcare.

Re: The risk for advocates of single-payer is that once we have multi-payer universal coverage, the chances of your being able to convert the health care system to single-payer are probably even lower than they are now.

Does that matter though? I would think the goal should be healthcare for everyone. As long as that isacheived why should it matter how? Many European countries have multi-payor systems and these are nonetheless held up as praise-worthy models. This is where I part company with some on the Left, when their goal is not helping people, but sticking it too their foes (i.e., some part of the corporate world). You see the same phenomenon on the Right and it's frankly disgusting.

Posted by JonF | September 21, 2007 11:03 PM

I wish that some newspaper or magazine would report about universal health care systems around the world. If they did, people would see that multi-payer plans virtually identical to the ones proposed by Senators Clinton, Edwards, and Obama are widely used. They're used in Singapore, the Netherlands, Germany, Switzerland, and many other countries. The per capita medical expenditures in these countries are less than ours, the health statistics are better, and the plans are popular. Stating that they can't work is foolish.

Posted by Stan | September 22, 2007 7:18 AM

Well I don't know that it is fair to call the Singapore plan 'multi-payer'. While it is depicted as Health Savings Accounts, the picture transforms a great deal when you examine the details.
NCPA: Medical Savings Accounts: The Singapore Experience
On examination the plan looks like Medicare Plus. It is funded by mandatory payroll deductions, with some supplementation by the government for poorer workers. Medical costs are strictly controlled by the government as is medical training and outside insurance is discouraged.

Certainly there is a fairly large private component on the service end but Singapore's system is much more single than multi-payer. Actually it is not a bad model, but it requires a rate of taxation and a level of government control that would make Cato folk blanche with horror.

Posted by Bruce Webb | September 22, 2007 12:14 PM

The per capita medical expenditures in these countries are less than ours, the health statistics are better, and the plans are popular.

Differences in health statistics between nations have virtually nothing to do with differences between their health care systems. Any effects from the health care system are swamped by social, cultural and environmental factors, like diet, exercise, smoking, stress, etc, and basic public health measures. That's why Costa Ricans have a life expectancy about the same as Americans, despite spending only about 5% as much per capita on health care. They have a better diet, a much lower rate of smoking, and get much more exercise.

Posted by Mixner | September 22, 2007 2:50 PM

I would much rather see people trying to build support, directly, over the long run for single-payer health care

Easy for you to say when you have health insurance and no major health problems so that you have to deal with flaws with your health insurance. Many others don't have insurance or are having trouble with the insurance they have and cannot wait that long. Something is better than nothing.

I am slowly coming to the realization that the incremental installation of single payer is wise. In ten years, it would be better to have people complaining from within the frame of most people having coverage, rather than from nothing having changed. There will be more strong support for single payer then because more will fully understand what it can do to improve the situation even more.

Plus, to introduce all at once might not possibly yield the savings expected as the boomer generation ages and demands expensive life saving techniques for all. All the European systems are facing this raise in expenditures due to technology advances. You risk the chance of backlash from "rationing," anger at the single payer system when it's not its fault. Better for all to learn first that there's going to be "rationing" no matter how you pay for it, that there was "rationing" with health insurance cos. still involved.

Posted by artappraiser | September 22, 2007 4:04 PM

The other issue the anti-incrementalists conveniently overlook is that the founding fathers carefully constructed our system of democracy to be incrementalist. In fact, the system of government (structure of the House versus the Senate) was itself a bold-faced compromise between the larger urban states and the smaller agrarian states. I'm sure that zealot partisans on both sides labeled the compromise a "sell-out to the special interests".

It's a lousy system of government for lovers of grand sweeping change. But, there is method to the madness. Generally speaking, the incrementalism of our system of government serves to protect those who might disagree with the kinds of "bold sweeping change" that, for example, a dictator might be able to impose.

Posted by hwc | September 22, 2007 4:48 PM