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The Stuff About Single Payer That We Don't Like To Discuss

nycweboy's picture

(Hi - I usually post at my own blog, but I've been growing into a regular Coreente visitor and commenter. I could give a long explanation of how I got here, but basically, I've been writing a blog for 3 years or so, I'm very liberal, and I feel very strongly about healthcare issues, which I've been exposed to for a really long time.

I've been following a couple of threads the past few days, as well as writing a both sides view of where we are on "healthcare reform" in Congress, and this post - which was a comment to DCBlogger's post - crystalizes, for me, some things I've been meaning to write about single payer and our current troubles. Whether you agree or not, I'd love to hear the takes of others on these ideas.)

Let me start by saying that I firmly believe that, ultimately, some sort of single payer system is probably the only solution for healthcare access and cost in the US.

However, I think the proposals for "single payer" in the context of healthcare reform suffer from a conceptual challenge, where no one, really, has described the steps that get us from where we are to where we want to be.

That, I think, is one reason for the seductive appeal of the "Public Option" - for many well meaning lefties, it became a symbol of the potential for future single payer progress in the context of the current, badly flawed bill: create a government run insurance plan, subsidize its premiums, artificially lower its reimbursements to Medicare-like levels... and eventually, many employers would exit insurance in its favor, and individuals would go there by natural selection and economic interest. The failure to create a "public option", robust or otherwise, was built in: it's basically unsustainable to create an entity (a 3rd or 4th entity, really, within government run healthcare) that takes in less than it needs to operate, and then tries to lowball its suppliers.

This, I think, is why "cost control" has been so fundamental to why the current reforms are a mess, unless costs are addressed. To get to some sort of "single payer" Americans have to understand that profit motive will need, in some fashion, to be drained away from healthcare. That's a massive change, in itself... one that is nowhere near occurring, yet. And maybe not ever.

As much as I think progressives were distracted by the "siren song" of Public Option, the reality, too, is that single payer has yet to coalesce into a coherent, workable solution. It's at this point, when one suggests just this idea... that someone will then insist that "Medicare For All" is just such a plan. I believe, firmly, that Medicare For All has been a similar "Public Option" siren song for single payer advocates, an unrealistic attempt to shoehorn a solution into a problem that isn't at all realistic or workable. It misunderstands how Medicare works, how Medicare is at base the cause of many of our cost and coverage problems, and how expansion would make a number of problems we have demonstrably worse.

The real progressive solution, I think, is actually Medicaid For All, which is a nonstarter for many progressives, and a telling admission of how far we have to go to really find a workable single payer option. Medicaid, which is designed to serve the most desperate at the bottom of the net, is the system which already covers everyone - from children to single adults (in some cases)... to poor seniors, to people with disabilities. It's structures already deal with areas - like pediatrics and obstetrics - that Medicare doesn't. But the enormous structural problems of Medicaid as it currently stands, and the failure of many activists to make Medicaid reform a more central element of the overall reform package (which is why Nelson, actually, was right in insisting on full Federal funding for Medicaid for all)... goes to the class and economic issues that are very much the real hurdles to any single payer plan that might actually work. Medicare is a popular, middle class entitlement. Medicaid is for poor people. There are reasons, and not especially nice ones, for Medicare Fir All that no one, really, likes to bring up.

Until single payer advocates have an actual paln - one that addresses myriad of elements from the VA, to employer based insurance that most people have - and like, still - to Medicaid and public hospitals and so much more... we don't have a plan. We have a slogan and a nice utopian ideal... but not a practical, actionable plan. Without that... we're just not where we need to be. And as I started... I wish we did. I want to help make it real. But we've got to start from a place that says... we've got a lot of work to do. And that we're ready to actually do it.

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mass's picture
Submitted by mass on

could just be extended out demographically over the years. 65-55, 55-45, etc.. Indeed, Bill Clinton proposed a Medicare buy-in to 55-65 year olds for the last six years of his Presidency. This isn't something I am uncomfortable talking about at all, and I don't believe this is the reason progressives hung their collective hat on the P.O..

If the Democrats wanted health care to be a winning issue they would have run on expanding Medicare(as it was designed to be extended) since it first passed. They would have hammered Republicans with it election cycle after election cycle. The only reason Democrats haven't truly wanted health care as a winning issue is because it doesn't have a donor constiuency. The thing is neither does the PO. As I have always said, Medicare for All is easier to pass politically because access to Medicare is long supported by the public, and it's far easier to implement. And, passing the PO was always going to be at least as hard as passing any Medicare extension because it suffers the same political problem, it has no donor constiuency.

nycweboy's picture
Submitted by nycweboy on

... has all sorts of structural issues, which is one reason, among a number of them, that I think Medicare expansion was discussed and abandoned at a number of points along the way to the current, dreadful bill. Medicare, from a budgeting standpoint, can't really cover its current enrollees, it will be gaining new enrollees at a huge rate in the coming years, and the idea of exponentially adding ten more years worth of the Baby Boom in a fell swoop would be a budgetary disaster, especially absent other, necessary reforms in reimbursements and administration of benefits. I agree that Medicare is popular with the public and that makes, in some ways, an easy sell. In theory. But Medicare is not universally loved, has enormous structural problems that Congress won't tough (for fear of angering seniors), and as I said, serves as the underpinning for a good bit of what's broken in our current state of things. I'd have more faith that "Medicare for All" or "Medicare For More" proposals had some realism to them if advocates were more forthright about those structural problems and had anywhere near the kind of proposals to address them. Instead, i think, it serves as a way translate to the larger audience... "don't be afraid of single payer, it's just like that popular government program you kind of know about and generally think of as a good thing." The devil is in the details, and few people, really, seem to want to deal with the details in depth. And again, that's my impression of single payer advocacy overall - a great "Big Idea" that still struggles when it gets down to the details.

mass's picture
Submitted by mass on

for a government program. With Medicare there IS a structure. The PO is a fantasy. There is no program, there is no reasonable method for financing, there's nothing there. Clearly, taxes needs to be raised to fund Medicare over the long term, but this is by far cheaper than creating another public health care program.

This argument sounds like an excuse for having supported the "PO". At the end of the day, I'd bet my house the PO "movement" will die but the movement to expand Medicare to every American will live on.

nycweboy's picture
Submitted by nycweboy on

I've written numerous times, in numerous places that I do not support the "public option", that I think it was a mistake to make it so central to the reform effort, and that it's a distraction from reforming the things that really need reforming. And one of the things that desperately needs structural reform is Medicare. Until that happens - to the program as it currently exists - talk of expanding it is simply unrealistic. That's the bottom line, at least for me.

mass's picture
Submitted by mass on

There is nothing about 65 that is more workable than 55. Medicare has structural problems. It's one of our only two major domestic programs, so this is not a real surprise. Medicare needs to be more stream lined, more comprehensive, and it requires more tax revenue, etc., BUT Medicare will never end, it will be improved, and it will always outperform private health insurance, because Medicare is loved by the people, is one of only two major domestic programs the US administers, and despite it's structural problems is still more cost effective than private insurance. There is just no reason to reinvent the wheel when you have a behemoth like Medicare to work with.

Submitted by lambert on

... we don't really need to give a lot of attention to that ourselves.

Our job is to change what is seen as possible. I'm surprised our career "progressives" don't understand that. Or not.

Submitted by lambert on

... and bailing out the insurance companies instead shows that the entire "cost" discussion is full of sound and fury, signifying nothing.

Ditto the "structural problems." I'm totally from Missouri on that one. Until health insurance for profit is seen as the fundamental "structural problem" the entire discussion is based on ideology, even fantasy. Just sounds the usual suspects are setting up another opportunity to loot the system, to me.

Yes, I agree that the budgetary aspects of single payer are an issue. It's only the country as a whole that saves the $350 billion. Some smart guy like Weiner could explain all that down the line. Remind me what's wrong with having the whole country benefit?

Submitted by jawbone on

from the very beginning of his launch, post-inauguration, into discussions of what his health INSURANCE plan would look like.

He also brought Baucus's former chief of staff, the guy with health insurance emphasis, on as one of his ass't chief's of staff. Hhhmmm. Could that mean he wanted a Baucus solution, not a Kennedy one?

PNHP describes its Medicare for All plan as an Improved or Enhanced Medicare which would cover all, comprehensively, from dollar one, with vision and dental. Most working people who have anything withheld are already on Medicare's books for their deductions. Would the amount increase? Probably. I don't have an answer for what the right amount would be, but bet it's been addressed somewhere.

What has been addressed is that having everyone in the pool for Medicare would actually help with current Medicare recipients' funding.

I wonder what mighta, coulda, shoulda happened if Obama had meant it when he said all ideas were on the table and would be priced out, scored by CBO (Yes, I understand most of the savings from single payer cannot be scored the same way the BHIP-PPP* can be scored, but many studies show the real savings are there. HR676 does budget for the job losses from the insurance parasites having to slim down.)

Which brings me to LBJ -- How did he manage to get people on Medicare less than a year from the passage of the Medicare legislation? And why can't that be done for moving decades of age groups into Medicare now?

*BHIP-PPP -- Big Health Insurance Parasites Profit Protection Plan

Submitted by lambert on

Nice to see a crosspost, nycweboy. That said [lambert reaches for a big hatchet--]:

Here. (Check the bill, too; it's got lots of good stuff in it, like a transactions (Tobin) tax, and it's very short.)

That said, most of our energy -- for reasons that I imagine are obvious -- has gone into simply getting heard in the face of the news blackout imposed by the press, the Dems, and career "progressives"* -- as well as the polluted discourse caused by [a|the] [strong|robust|triggered]? public [health insurance]? [option|plan]? Implementation took a back seat -- particularly since other countries have already implemented it with great success. I mean, is it really a problem? The stats wouldn't be as they if it was! It's not a matter of "liking," it's a matter of first things first. Perhaps I should regard the request for implementation detail as a sign that our efforts have succeeded, and the ground for argumentation has shifted from "should we" to "can we"?

As for the cost issue: The cost issue is the profit issue:


Pragmatically: Medicaid access is income and access-based. That means (a) that it's not a right, unlike Medicare, and (b) therefore welfare, meaning it's political poison. And as you point out, it's at the state level. So, advocating for "Medicaid for All" amounts to the idea that "Medicaid Not Be Medicaid." Advocating for Medicare for All, on the other hand, means advocating for a program that's well understood and proven to work. (And there's even an easy implementation path: Lowering the age of eligibility progressively, as in the Kennedy bill, before he drank the KoolAid.)

NOTE * I am really, really tired of the "well meaning" (career) progressives trope. Nobody ever seems to explain how censorship and exclusion are compatible withe being "well meaning." And I don't know many "well meaning" people who run bait and switch operations.

nycweboy's picture
Submitted by nycweboy on

No, I want Medicaid to be what it was meant to be: a federal program, operated by the Feds, that guaranteed care for the poor in every state. The block grant program - A Reagan era invention meant to deliberately underfund the program - does not work and needs significant reform. One could point out - and I have, repeatedly, in a number of places - that we're about to create an enormous Medicaid disaster, because the bill cynically achieves its budgetary promises by throwing millions more into Medicaid while continuing to underfund it. Progressives can either get started, now, on agitating for improving and fixing Medicaid... or believe me, it's going to happen anyway.

I've read HR 676; I have a number of problems with it, and I think it won't serve, ultimately, as the "right" way to go about implementing single payer, should that ever occur. I think the real worth of HR 676 lies in at least beginning to draw out, in theory, what a conversion to a single payer plan might look like... and why, in some respects there's more work to do to flesh the idea out.

I'll say again: it's the very fact that Medicaid is unpopular, unloved by virtually all who look at it - never mind those who are in it - that tells me we're miles away from a serious attempt at single payer; until we begin by figuring out how to get adequate coverage and decent care for the people society cares about least... we cannot argue that we have a society that's ready to figure out how to help everyone do better. Structurally and fiscally, Medicaid is a better, government run fit for the [problems we have, expanding coverage to more of the population, and subsidizing that coverage in a way that could, in theory, go a long way to reducing costs. If you can't get Democarts - the theoretic party of the working classes - to fix the program that supposed to help the poor... well, you know the rest as well as I. I think the fact that many progressives, including single payer advocates - caring active people - run screaming from dealing with Medicaid is indicative of the deeper problems we have, and the challenge of drawing single payer from dream to reality. And I know it;'s not a popular thing to say. But I do think it has to be said, and discussed.

Submitted by lambert on

... to get medical care, you have to admit the program requiring that is going to be a hard sell. Though, granted, the Dems think they can sell making the IRS a collection agent for WellPoint, so perhaps all things are possible.

* * *

As far as the challenge: Why don't you make a proposal?

Submitted by weldon on

and I don't know anyone who has it who isn't grateful to have it. So I'm not sure what you mean by "never mind those who are in it." My various medications run about $600/month absent Medicaid or some other insurance, or about 75% of my monthly income; with MediCal, California's Medicaid program, they're free, and I can invest in luxuries such as food and utility bills. The primary gripe I hear is that eligibility requirements are too strict, and leave many low-income individuals uncovered; it's tough to qualify if one has no dependents and isn't officially disabled, at least here.

I think Democrats can fix Medicaid. Certainly the majority were fine with the expansion of it in that abomination of a Senate bill. As the doctor in the Moyers interview Lambert linked to said, that was an item that should have been addressed separately, and as a budgetary item it could be addressed through reconciliation.

I'm not sure what you mean by "subsidizing that coverage." Medicaid is already completely subsidized. And I don't know who is running screaming from it, either. But that aside, what are the problems you see with implementing single-payer beyond the reflexive resistance from the health insurance industry and their shills in elected office?

ADDING: If one expands Medicaid to cover everyone, then it's no longer Medicaid--it's simply universal health care. So if calling it Medicaid For All is a problem, don't call it that.

nycweboy's picture
Submitted by nycweboy on

weldon, Thanks for your insights - I don't think we get enough views, actually, about Medicaid from people who actually use it. What I meant - and what my experience has been - is that other times when I've written about Mediciad, I've gotten thoughtful, but frustrated posts from people who use Medicaid who would like to see it strengthened and improved. I was probably less than precise or fair in my wording of it, but my point, really, is that we could build on the pressure from within, and without, to reform Medicaid and strengthen it, if we put our energies towards that. As you say, there is the will within the Democratic Party to get it done (and I think, even some ability to shame soem Republicans into joining in).

I see problems implementing single payer because it will be a leap, for many people, from the way go about accessing, receiving and paying for their care. The common response is "all of that will be easier" and it could be... but mostly, it will be different. This is a country full of people who don't like different, who like what they know and resist change (which is, of course, also very human). I don't think Single Payer has been well explained, and I think it's easy to say that for a person who is already insured it will mean a lot of good things... but it's still really very vague, I find, trying to get explanations of how transitions and things would work. Does single payer mean ending the VA? What about VA hospitals? What about hospitals run by cities and states? One problem I've had for more than a year with our debate is that we're very focused on a discussion of health insurance as a proxy for the whole discussion of healthcare. Insurance reform is one of a number of problems - others having to do with cost and access and practice methods and quality of care and all have considerable complexity. Moving to single payer really touches all of them - or, if it doesn't... then single payer isn't a solution. It's kind of more of a band-aid, perhaps a better, stronger band-aid... but not a cure for what ails us.

Myself, I've come around to a general feel for the French model - a base insurance, set and subsidized by the government that covers a standard set of benefits for all, with options for employers to add coverage as a benefit to their workers. That model looks more like our current system, is explicable, merges Medicare and Medicaid (and the VA, in theory at least) and creates the kind of "single payer" many people, I think, have in their heads. That solves a huge amount of the "risk pool" issues in current insurance. At the same time, it doesn't ignore the free market, or choice, or competition. And it says if you can afford to pay more for improved care or access... then by all means, go ahead. I think some single payer advocates do need to face that a single payer system can't serve a the vehicle to eliminate class distinctions in this country - it may set a base for everyone, but some people will, still, want to pay extra for more. And we have to, I think, allow that to be okay.

On your final point, especially, I agree: expand Medicaid for all... and call it what you like. That does seem like the right answer.

Submitted by lambert on

... but I'm missing or not hearing the advantage here. We've got a choice between:

1. Expanding eligibility for an already beloved Federal program that we already know works, and already treats health care as a right; and

2. Revamping a hated and vulnerable welfare program and moving it from the state to the Federal level.

I'm very unclear on the advantages unique to Medicaid of door #2.

The advantages of door #1, Medicare For All, is that it solves every single one of the problems you raise:

a) "Not explained well." No need to "explain" in the first place, with Medicare. People already understand it, because their parents or someone they know have it.

b) "people who don't like different." I'm at a loss to understand that people care about their insurance companies. I'm betting they care about their doctors. Under single payer, they can keep their doctors. It's single payer: Handles the billing.

c) VA, schm-VA. I'd say keep it no matter what. Why not?

d) On hospitals, see the HR676 FAQ and text. It's phased.

Frankly, fixing Medicaid incrementally seems like another roach motel for progressive energy to me.

Submitted by gmanedit on

You're confusing nationalized health care and single payer.

(This is just funny: "Does single payer mean ending the VA? What about VA hospitals?")

Fixing health care is complex; fixing health insurance isn't.

Go to and start reading.

Submitted by weldon on

In some states Medicaid providers are scarce and overburdened, waiting times for appointments can be annoyingly long and continuity of care can be an issue. There are variations from state to state—I've lived in Hawaii and California, and I was happier with Hawaii's version (plus it was, you know, Hawaii)— so that may account for variations in the level of satisfaction, but the bottom line is that with Medicaid, impoverished and disabled people get medications and routine health care that would otherwise be out of reach, and they get emergency care without racking up impossible hospital bills.

Medicare is a very popular program. Fix the prescription drug benefit donut hole, mandate system-wide price negotiations with drug makers (or promote reimportation) and means test it (to replace Medicaid), and you have single-payer. Closely regulated private insurers could offer supplementary insurance, as in the French model you cite (which is also means tested with respect to co-pays), but their role would be dramatically constrained. That too is a familiar scenario; you can't get away from those ads for supplemental policies.

City and county hospitals wouldn't be impacted too much. I worked for a county hospital in the late 1980s. and almost all of the patients were covered by Medicare or Medicaid, or fairly often not at all. The big change there would be that the cities and counties wouldn't have to absorb the cost of treating uninsured people or trying to collect money from them. The same is true of many university hospitals and clinic systems.

Conceivably the savings could be used to bring facilities into line with private hospitals and clinics. The latter segment is whence all the wailing and rending of garments would arise.

The VA system is genuinely socialized medicine, with providers working directly for the government and facilities that are government owned and operated. Absorbing it would require privatizing the facilities and providers, which wouldn't seem to make much sense, or expanding it to include everyone, which would mean outright nationalization of health care, which would never fly regardless the merits of it. So I think it would have to be maintained as a separate program serving a narrow population, and I can't see that as being a deal breaker for anyone. Taking away a basic veterans benefit would be a tough sell.

Single-payer actually does have a built in feature addressing class distinctions, or at least capital-labor conflicts, and it's an important one. Erasing the fear of losing health care when changing jobs offers employees more leverage against employers. That's among the unspoken reasons that large corporations are opposed to single-payer despite the evident competitive advantage of substantially reducing the cost of benefits. There might also be some advantage for workers with respect to moving jobs from the US to countries with universal coverage.

I don't think it's all that complicated, and I think it could be sold in very user-friendly terms if there was a consensus to push for it (enormous if, obviously). In any event, one thing I think we can all agree upon is that the road to a sane health care system here doesn't include a detour providing private insurers with an additional $50 billion a year from which they can divert yet more money to lobbying against actual reform.

Submitted by lambert on

This whole discussion reminds me of old saying that "If we had some ham, we could have some ham and eggs, if we had some eggs."

"If we made Medicaid Federal, we could have Federal health care for all, if Medicaid wasn't only for some."

I'm unclear on the advantages, either from a technical or a political standpoint, of turning Medicaid into a Federal Program that treats health care as a right, when we already have a Federal program that treats health care as a right.

Yes, of course people on Medicaid are grateful to have it; it delivers needed care. And?

DCblogger's picture
Submitted by DCblogger on

we have a bill, HR 676, it is easy to explain and gets the job done. It builds on an existing structure, so would be easy to implement. We have dozens of co-sponsors (even though they failed to stick to their guns) and we have a nationwide network of grassroots organizations working to pass it. What is not to like?

Or you can go the state route, which is probably how it is going to happen, unless Congress passes something that would prohibit state systems.

But I don't get the philisophical/ conceptual discussions when we are half way through a political fight.

We have a workable proposal in place with a strong coalition behind it, why no go with it? don't forget, Corrente is just a tiny part of this. All we are doing is giving some online visibility to those who are doing the heavy lifting.

Submitted by weldon on

Previously I was in Hawaii, both of which have better coverage than many if not most other states. To clarify, though, I'm not advocating Medicaid for all; as I say, if everyone is covered than it isn't Medicaid.

Submitted by gmanedit on

"until we begin by figuring out how to get adequate coverage and decent care for the people society cares about least... we cannot argue that we have a society that's ready to figure out how to help everyone do better": That's not how America, or anywhere outside of utopia, works. Selflessness is a hard sell. (If you want to see how we treat "the people society cares about least," look to the prisons.)

After World War II, this country was prosperous enough that the working classes could think themselves middle-class. Despite its downside—the elimination of class as an analytical framework—at least we had social stability. Medicare is popular because it sidesteps class issues.

The beleaguered middle class is not going to want to reach into its pockets to pay for an expanded welfare program, which is what Medicaid is. They want something that benefits them.

Just look at that chart—a third of that spending goes to insurance companies, which do nothing to provide health care. Reread lambert's comment at 9:41am:

Leaving $350 billion a year from single payer on the table and bailing out the insurance companies instead shows that the entire "cost" discussion is full of sound and fury, signifying nothing.

Come on: Other countries have done it; we don't have to reinvent the wheel. This is the only country in which accident or ill health leads to bankruptcy. Socialization of risk is wildly popular; people hate everything else in the proposed bills.

madamab's picture
Submitted by madamab on

But it seems that Medicare was the federal program that was eventually meant to cover all people, not Medicaid. So, how is wanting to use Medicare for its original purpose all class-warfare-ish and anti-poor?

At least there is a bill in the House that could be used to start the process of universalizing health care. If Congress is somehow forced to, as DCBlogger says, base its decisions on evidence, that bill could be combined with other single-payer proposals and or modified to resolve whatever practical implementation flaws you see. Which, by the way, I think it would be good to outline.

The "public option" margle fargle is appealing to "progressives" why? Because they DON'T care about poor people. The type of "progressives" whom I have seen pushing the margle fargle are exactly the same people who told Hillary's working-class supporters to go jump off a cliff. Moreover, the margle fargle is the perfect storm for Obama "progressives"; a marketing slogan that makes them feel good about themselves, but ultimately does more harm than good.

I find it hard to believe that you are claiming SP supporters don't have a plan and that's why the margle fargle was appealing. Yes, that's what Obama "progressives" like: bullet points and a solid plan. That's why they supported him instead of the person who actually, you know, HAD bullet points and a plan.

Submitted by jawbone on

I see problems implementing single payer because it will be a leap, for many people, from the way go about accessing, receiving and paying for their care. The common response is "all of that will be easier" and it could be... but mostly, it will be different.

How is this a solution stopper?

Going to HMO's, initially with very limited access to choice of docs, was very different. Really, really different. The need to change docs whenever an employer or individual changes health insurers is also different. And hated.

Now, granted, back when Medicare was implemented, most people just assumed they could select their doctor, based on recommendations, know the physician, lots of things. But were not used to having their selection tightly controlled.

My elderly, now deceased neighbor, threw a celebration party when she could go on Medicare. She had several chronic conditions, and for years was forced to change specialists to fit the company's insurance plan's list of docs. She hated, hated, hated that.

And those damn referrals -- for chronic conditions, especially! I will not miss those when I get on Medicare in only 330 days -- and, yes, I'm counting. Not only to see if my savings will stretch, but also see how many months I can go w/out insurance.

What with each month costing over $1100/month. Plus the copays and deductibles....

Now, I'll be OK next February. Millions won't be OK. It's set to take years to get Obama's plan on line.

Submitted by hipparchia on

voters, citizens, advocacy groups are not required to come up with legislative strategies or detailed plans of 'how to get there'. that's what legislators get paid the big bucks for. we the voters tell our representatives what we outcome we want [national health insurance, everybody in one pool] and it's up to them to hammer out the details.

delegitimizing advocates' efforts because they don't have detailed plans for getting from a to z: this has been one of the more successful strategies to divert the energies of would-be single payer advocates away from advocating for what they truly wanted [single payer, medicare for all, hr676. wev].

you don't like hr676? you want complexity? you don't need complexity ackshully. canada's single payer bill is like 10 or 11 pages long, and hr676, if you cut out the double spacing and wide margins is about that same length. all we're discussing here [with single payer] is the financing of medical care, not the delivery of it [though there's some of that in hr676 and s703]. it's not necessary to spell out in the legislation exactly how much each hangnail has to cost and under what conditions you can or cannot see a doctor about it.

the va, ihs, military: these are all mini-nhs's, where the govt owns the hospital and clinic bldgs, employs the drs and nurses, and pays for the care. there's no compelling reason to dismantle these silos right away in the process of giving medicare to the rest of us. hr676 leaves the va and ihs to be re-looked-at in iirc 5 or 10 years after the passage of medicare for all.

paying for it? taxes, baby! do we need to cast in concrete exactly where these taxes are to come from before we're allowed to agitate for medicare for all? hell no. bernie sanders' s703 has a tax scheme [a mixture of payroll and income taxes iirc] spelled out in the bill. hr676 does not, but john conyers' site details his proposed tax scheme [mixture of payroll, income, and financial transaction taxes]. anthony weiner's amendment to substitute hr676 for the house bill last summer had yet another tax scheme [i don't think it's available online anymore]. and there are yet other proposed tax schemes that allocate the revenue slightly differently among various types of taxes. all this can be [and would be] hashed out in the legislative process anyway, no need for us to advocate for both single payer and only one particular tax scheme to pay for it.

obstetrics and pediatrics. this one always makes me laugh. what? the people who administer the fund that pays for old folks are too stupid to know how to pay for pregnancies and births?! seriously, cms - the centers for medicaid and medicare - is one federal agency, using multiple trust funds to pay for various kinds of services and/or for various populations. the original medicaid program was particularly meant to care for [poor] pregnant women and their children, so the federal govt already knows how to do this, it's only a matter of which trust fund to pay it out of [and there's not really anything stopping us from combining all the various trust funds into one, which in fact, is what hr676 does].

plans? paths? the best-laid plans of mice and men gang aft agley, the poet tells us. lbj wanted medicare to be medicare for all, but we all know how that turned out. best laid plans: a bit of history on how medicare for all turned into medicare for the old and medicaid for the poor [who was robert ball and why should we listen to him anyway?] ... for a very brief description [scroll way down] of how single payer came to be in other countries ... the rocky path to single payer in canada ....

but if you truly want to dig into the policy details on some of your points of concern, your worries that nobody is addressing your points are unfounded; it's mostly only blog readers whose eyes glaze over on the details. pnhp is the single payer policy think tank to consult. they've been writing policy papers since 1989 or so, they've testified in senate and congressional hearings, and you can dig through their [admittedly not user-friendly] archives or contact them and ask for help. they seem to be very responsive to anyone who's genuinely interested in single payer.

Submitted by jawbone on

what roach motels refers to. Concern troll traps for activists not toeing the party line...among other possibiities.

What about the VA system? Time for the smelling salts!

Actually, I recall several comments about how those in the VA system would benefit greatly from having universal care. The VA has specialized knowledge of how to treat terrible injuries, but it also is stretched greatly to handle every vet wanting services from the VA system. If they could go to regular medical providers for simple things, there surely could be more specialists for the things which might be way outside the experience of many civilian doctors. And the VA could assist with the treatment of injuries and ailments which aren't seen all that often in the civilian system.

Anyway, hipp, great post/comment.

Submitted by hipparchia on

so it's not as good as it used to be pre-bush2 but it's still very much better than it was when clinton inherited it and put a very competent person in charge of turning it around.

one thing to keep in mind about the va system is that a lot of the patients don't rely on it exclusively even now. many also have some [or even a lot] of their health care paid for by medicare, medicaid, and/or private insurance and go to the same drs and hospitals that you and i do [i used to have a couple of links with detailed breakdowns on this but have lost them]. there does not necessarily have to be a huge rush nownownow to figure out all the minute details of how to integrate it into medicare for all. for practical purposes you just say to these people that the care that they get from the va won't change and the care that they get that's paid for through other sources will paid for by the new and improved medicare.

the indian health service is similar. the govt owns a few hospitals and clinics and employs a few drs and nurses, but a lot [most? i forget, i've lost those links too] native americans don't live near these hospitals and clinics, so the ihs pays for them to go see ordinary drs in private practice and go to the same hospitals that you and i and medicare and medicaid patients go to. under medicare for all, the ihs could easily continue to operate the hospitals and clinics it has now and the new improved medicare could either pay directly for those native americans who need to go elsewhere, or it could pay some amount into a separate fund to be managed by the ihs [there may be some tribal rights or treaty issues involved, but again, it's not my job to know this, it's the legislators' job to deal with it].

the ihs has been woefully, woefully underfunded for ages [probably for its entire existence]. the house bill devoted about 200 pages to the ihs and the senate bill devotes about 5 pages to it. i have no idea if the proposed fixes in either bill are good or bad, but i find that factlet interesting.

concern troll traps. i like vastleft's roach motel meme, so i thought i'd do a little bit to propagate it here.

beowulf's picture
Submitted by beowulf on

On my very first comment here last summer, I suggested that the "far-left" option should have been VA Healthcare for All

Barbara Lee has a VA-style United States Health Service bill (that Ron Dellums first proposed back in the 70's). Lee should update her bill by reframing it as an expansion of the VA and not a new government agency. And then VA Healthcare for All should always be mentioned as one possibility, give publicity to advocates, repeat (even if to dismiss) their arguments, ask for CBO scores, etc.

At this point, every doctor and hospital exec in the country would be stroking out (though, curiously there's not much more Republican pols could say about it that they're not already saying about Obama's bill). So a compromise proposal to simply expand the existing Medicare system won't sound like such a bad idea. The moral of the story is, if you want the moon, you start by asking for the Sun.

From where the Democrats are right now... Even if there was no wealthcare lobby, they won't endorse HR 676 anytime soon, the poison pill in the bill is the doubling of payroll taxes required to fund it, yes it just replaces current premiums but in a bad economy people go nuts over tax hikes. So now you're fighting a two front war, against AHIP on one hand and tax protesters on the other.

I think the smarter play is Pete Stark's Americare bill. It allows any individual (or employer) to shift their premium payments from their private insurer over to the Medicare trust fund (the premiums are income-scaled and at no cost to anyone under 200% FPL). The beauty of Stark's bill is that moves people (and hundreds of billions in revenue) into Medicare but it doesn't raise taxes on the middle class to do so. I can't exaggerate how big a selling point that would be for Democrats from swing districts (and thanks to this president, they're ALL in swing districts). A member of PNHP, DrSteveB, wrote up an excellent summary of the Americare bill last summer (check out the two graphs he includes).

three wickets's picture
Submitted by three wickets on

Would this be like the Medicare buy-in, and could it pay for itself.

beowulf's picture
Submitted by beowulf on

Pete Stark has been Ways & Means health subcommittee for decades, so he knows his stuff. His 60 page bill is far superior to the 2000 pages of dogfood (to mix metaphors) that we're looking at now. For one thing, the Medicare buy-in limits Premiums, deductibles and annual caps at a lower level (max of 5% - 7.5% of income for all combined, IIRC), and and there'd be no cost for any of that for all current Medicaid, SCHIP recipients plus all minors and every adult under 200% FPL.

Every other Medicare buy-in bill I've seen is unsubsidized and thus unaffordable for many. I should add that if passed, Stark's bill would provide (per Commonwealth Fund study) 100% coverage and reduce National Expenditures beginning its first year (none of this weak tea "bending the cost curve" business). It would start Jan. 1, 2011, three years to the day before Obamacare would start. That's what... 120,000 to 150,000 uninsured people who'd die in the interim?

three wickets's picture
Submitted by three wickets on

We really have to begin disassembliing the private insurers. Obamacare gets in the way.

Submitted by hipparchia on

there are no taxes written into hr676 as it stands right now.

the 'doubling' of which you speak is actually more of a tripling [from 2.9% to 9.5% of payroll] and then there's an added income tax on the top 5%. this is just one proposed tax scheme. bernie sanders has a different tax scheme in his s703, and i think anthony weiner had yet another for his planned substitute amendment.

also i've seen a couple of other proposed schemes scattered around the web that would work well, and might more palatable to working folks in these parlous economic times. for one thing, there's no reason that payroll taxes have to be split evenly between employer and employee, even though that's the way we do it now.

Submitted by hipparchia on

this was my original compromise position after arguing for vha for all in other forums. since i was one of maybe 3 people on the whole wide web at the time [or so it seemed] arguing for full socialized medicine, i finally gave up and threw in my lot with pnhp and healthcare-now.

and now i'm positively thrilled that alan grayson is proposing a medicare buy-in. sigh....

beowulf's picture
Submitted by beowulf on

While Veterans (depending on disability and income status) are eligible for VHA care, the family and widows of disabled veterans are provided care by a tiny single payer system (a few hundred thousand beneficiaries nationwide) run out Colorado called CHAMPVA. Its similar to the Pentagon's Tricare except that it charges no premiums (deductible is $50 to $100 a year) and is run by VA employees and not contractor (Tricare has run by three Medicaid-style management contractors). Although it has a tiny customer base spread throughout the country, since its Uncle Sam... Medicare providers must accept CHAMPVA patients at Medicare prices. As an added bonus, CHAMPVA gets to use and the rock-bottom VA prices for drugs and medical devices (if their local VA hospital has space available, they can also go there for care).

So if I was in Congress (for my, umm, one and only term) I'd throw everyone for a loop and propose CHAMPVA for All. The implicit threat to doctors and hospitals is that if they didn't keep costs in line, we'd transition over time to a straight VA system... In college football terms, the option play option. :)

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries. The program is administered by Health Administration Center and our offices are located in Denver, Colorado.

Submitted by hipparchia on

promise me just one thing: if any of my posts ever turns out to be 'magisterial', just cancel my fucking account. please.

awesome otoh ... i think i could live with that. :)