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