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Saturday, May 12, 2018

Single Payer Health Care Coming in 2020

Single payer health care is the crown jewel of the egalitarian welfare state. It is a prize that the left has pursued vigorously for decades, in Europe as well as here in the United States. Some countries established it already before World War II - Britain comes to mind - while others did not get around to it until the 1950s (Sweden) or even the 1960s (Canada).

The American left has been trying to create a socialized health care system here for decades, and they have made gradual progress through an incrementalist strategy. Now, gearing up for 2020, they are making an all-out push to get over their long-desired finishing line. As a single-payer pundit recently put it, "single payer or bust". 

A single-payer system would be bad for the American people. Its basic tenet, that everyone has the right to health care, is all it provides above our current system. It does not provide health care anywhere near what that right suggests. Its foremost consequence is widespread rationing, with people suffering for months, in some instances more than a year, to get health care that, under today's system, they can get within days or weeks. 

From the conservative side, the response to the left has been weak at best. Based on how the Republican party has handled this issue since the 1960s, it is reasonable to expect that the left will win. The only line of defense against the dark arts of socialized medicine is an effort by fiscal conservatives to learn this issue, inside out, and fight back to defend and restore market-based health care. 

To win, conservatives are going to have to show the same tenacity that the left does, and just to understand how persistent the socialize-health advocates are, consider how well their incrementalist strategy has worked. 

It started in the 1960s. Despite proposals for it, President Johnson did not include single-payer health care in his Great Society project; instead, we got Medicaid which was sold as a last-resort program for the poor, and Medicare for the elderly. The single-payer torch was passed on through the decades, with President Clinton making a stern effort with Hillarycare. Like Lyndon Johnson, he had to settle for a consolation prize - the "Medicaid for kids" SCHIP program - but his efforts nudged America a bit closer to the final goal. Clinton's hard work on the issue made it easier for Obama to take their next step.

With Obamacare, we are now within striking distance of a completely socialized health care system. It has premium controls, coverage mandates and enrollment regulations that, if tightened just a notch, would be the death knell for the private health insurance market. This is, of course, by design: since the left has not been able to get single-payer health care passed in one legislative piece, they have settled for a legislative war of attrition on the private, market-based system. The goal is to wear down the American people's resistance to socialized medicine and, at the "right" moment, propose a totally government-funded health care system where taxpayers, and only taxpayers, pay for all health care that Americans need - and want.

That last part about "want" is important. Let us get back to it later. What is important here and now is to recognize that the left considers 2020 to be that "right" moment. 

There is no doubt that the left has been successful with its incrementalist approach. As mentioned, they have been able to establish three tax-paid public health insurance programs as partial victory trophies. With Obamacare they were also able to ensnare opponents to government-run medicine in a regulatory web that is almost impossible to penetrate.

At least for the politically weak-minded. In November last year, in an article for the American Institute for Economic Research, I explained the reason why a Republican-led Congress could not deliver on Obamacare repeal:
The feature of President Obama’s medical reform that brought Republicans to their knees is a combination of: a) the individual mandate, forcing every American to get covered, and b) the tax-paid subsidies to make coverage “affordable” for everyone. Together, the mandate and the subsidies constitute “universal coverage” of health insurance. In the eyes of congressional Republicans, they also constitute an insurmountable bulwark that makes Obamacare de facto irrepealable. Republicans admitted defeat to Obamacare because they could not guarantee the same level of medical-insurance coverage as the individual mandate and the tax subsidies could do.
It is, of course, possible to guarantee the same coverage. All you have to do is:

a) open the entire country as one single market for health insurance plans and allow plans of all organizational forms to participate (for-profit, non-profit, traditional businesses, confessional associations, cooperatives...);
b) give out the tax subsidies as vouchers;
c) force all participating plans to list their coverage in a transparent fashion; and
d) remove coverage mandates and let people shop for the plans they want.

Four things will happen:

1. Premiums will fall drastically because of the large market, with widespread competition and big risk pools;
2. Because of the fall in premiums, any given dollar amount in a voucher will buy substantially more health care coverage than under the current Obamacare system;
3. Those who want an absolute gold-plated health care plan (something nobody will ever be allowed to access under single-payer; trust me, I have lived in two single-payer countries) will be allowed to add money on top of the voucher; and
4. Niche providers will specialize in covering people with needs outside of the market mainstream.

The immediate objections from single-payer advocates include:

I) Not everyone gets everything health care;
II) People with chronic diseases will not get coverage; and
III) It is unfair that some people can buy better health insurance than others.

There are an abundance of responses to these objections. Briefly,

I) That is not the case in single-payer health care either. All you get is a right to health care. As experience from single-payer countries shows - see, for example, my chapter on fiscal eugenics in The Rise of Big Government - over time that right becomes increasingly detached from what health care government can actually provide people with. For example, single-payer advocates might ask themselves how long the lines for health care are in Canada, and how long they would be if Canadian demand for health care could not spill over into our free-market based system. 

II) First of all, this is not true. Chronic diseases are covered by employer-based insurance plans, they were covered before Obamacare and they remain covered today. But more importantly, people with chronic diseases are by no means guaranteed coverage in a socialized system either. There, it is government who decides what medical conditions are covered, and the decisions are normally made on terms of fiscal eugenics disguised under a method called QALY. Again, I refer to the chapter on said subject in my latest book.

III) An employer-based insurance system does not discriminate between high-income and low-income employees. Furthermore, since a free market system allows insurance companies, associations, cooperatives and other entities to provide tailored products for everyone, the system offers low-income families considerably better, and more reliable, access to health care than a system run by government. 

As for the "fairness" argument, it is worth noting that it rests on an egalitarian ideology that also suggests that there should be no differences in what food people eat, what clothes they wear or their housing. Rather than refuting this ideology here and now, may I suggest a brief review of socialism.

What matters here and now is, again, that the conservative movement (if I may include libertarians under that term) learns to fight back against the leftist socialized-health onslaught. Just to give an example of what this movement looks like, in the latest issue of Dissent, a surprisingly readable leftist publication free of the vile rhetoric that is otherwise endemic among the left, sociologist Josh Mound outlines the case for "How to Win Medicare for All". He credits Senator Bernie Sanders with having placed this issue at the forefront of the leftist political agenda:
Sanders, in short, helped make Democrats more of a single-payer party than it has been for a generation. Despite what skeptics say, this shift is nothing short of remarkable. The center of gravity in the Democratic Party on healthcare policy has shifted decisively to the left, returning the Democrats to the full-throated endorsement of government-provided universal care that they retreated from in the decades following George McGovern's 1972 loss.
As mentioned earlier, there was no real retreat, just a pause in an incrementalist approach. That said, Mound's point is hugely significant, and he is right. Support in the Democrat party for socialized health care is widespread, to a point where it is becoming difficult to run as a Democrat in 2020 without endorsing this idea. 

Mound then goes on to outline a strategy with which Democrats will win popular support among voters in general for a single-payer system based on Medicare. The one issue he carefully avoids - as do all advocates of this fiscally reckless idea - is how he intends to combine health care for all with a financing system that has even a remote chance of paying for all that health care. 

This is a valid question, for two reasons. First, there is not one single-payer country in the world that has been able to provide all the health care that people want (as opposed to need) without putting a thick wedge of rationing between "right to health care" and "access to health care". Secondly, in order to have a chance to provide the health care that people need (as opposed to want), a government-run system must rely on an increasingly stingy definition of "need". Again in my book The Rise of Big Government, as one easily accessible example, I discuss the consequences of that stinginess with reference to the patient death rows in the British National Health Service. 

Mound's only reference to a funding system includes raising taxes on the "rich" or "very rich", to make it more progressive. He ignores the fact that the Trump tax reform actually increased the progressivity of our personal income tax system. He also ignores the fact that approximately five percent of the U.S. population pay more than half of the taxes that fund the federal government. If that is not progressive enough, then would Mr. Mound please explain what small segment of all Americans should fund the federal government in order to meet his progressivity criteria.

Mound, a postdoctoral fellow at the University of Virginia with a doctorate in history and sociology, is seconded in his ignorance of the fiscal side of single payer health care. His foremost companion on the spring 2018 issue of Dissent is Adam Gaffney, a physician and health care researcher. Gaffney's contribution is a historic review of the Canadian path to single payer, and contains some interesting albeit cursory references to Europe. His article deserves a response of its own, which will have to wait until next week. For now, let all conservatives out there be put on notice: if you like your health care, you can't keep your health care unless you are willing to fight

a) against single-payer, and
b) for a solid free-market alternative. 

The left has made their 2020 ambitions clear. Will the right step up or stand down? 

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