I'm not sure I agree with this:

It's a sincere disagreement, and there's a compelling strategy to the approach: Single payer can't become the consensus choice for the country if it doesn't first become the consensus on the left.

My advice to the single-payer crowd is get a couple big businesses or associations on board then come back to your liberal friends. We'll have a much tougher time saying no.

I think Single-Payer is the best possible solution to our health-care crisis, but I'll be supporting Obama's efforts when the time comes. So long as it includes a public plan. If that goes, I will be deeply disappointed and probably won't expend any energy in support of whatever is put forward.

My only concern about the public plan competing with the privates is how do we keep it from becoming a dumping ground for all the people they don't want? Is outlawing private insurers from discriminating on the basis of pre-existing conditions sufficient to prevent that?

Or is there a set of policies that single-payer advocates want to see inserted into hybrid legislation and could stomach supporting even if the final legislation stops short of full single-payer?

You betcha (again)!

An option in the final plan that allows the citizen the right to enroll in a government-only plan. Single-payer for a pool instead of everybody. There are risks to this, but better than the alternative.

Incrementalism in defeat of private-sector evil is always good. And it accepts the reality that many are happy as is, and others want to see some proof of concept before jumping in.

Anonymous above is little ole me

I'd feel better/stronger about this if the coalition's seams weren't quite so obvious - the stitched together coalition of unions, and progressive nurse and doctor orgs says to me that the coalition isn't quite broad enough... and it features a number of players with vested interests in how the plan turns out. Single payer has some attractive elements... but I've yet to hear convincing, clear explanations of how we move from our current systems to single payer (i.e. single system - saying we're keeping Medicare and the VA and Medicaid... and moving everyone else to a government run program is not Single Payer... it's just messy government amalgamation), and I've yet to hear something beyond rosy notions of how amazingly low administrative costs of such a plan would be, without much evidence to back it up.

There are enormous hurdles here, and one of the biggest is one the coalition ignores: that is, it's composed of groups who are better informed on the current systems and the crises within them... that's still not true of much of the public, and it leads to two fallacies - people who generally agree with each other convinced that everyone agrees with them, and an assumption that, without filling in the details, people understand the what and why of a single payer proposal. Neither is true, and it's dangerous to blithely assume they are. I'd love to see what they come up with... but I'm not convinced it's either a road to an ultimate solution... or that it can really defeat the incrementalist notions that we have to adapt what we have... with an eye, maybe, towards single payer... but down a long, long road.

There's a lot to say about this but for now (as I get 2 kids to bed) I just want to make sure readers get a glimpse into the "bigger picture" about what went down in CA last year; what follows are the comments in the post Ezra links to re, as he puts it "what the Nurses did in California"

"The League of Women Voters also oppose [CA bill] AB8 for the same reasons the nurses oppose it. It is just a scheme to pay the insurance companies premiums with public dollars. This is VERY BAD MEDICINE!!!!
Posted by: Sylvia Hampton at September 10, 2007 04:05 PM

This bill is a major setback for true healthcare reform. It leaves out millions of Californians, offers no controls on rising healthcare costs, and delivers massive subsidies to insurance companies that offer nothing but waste, denials, tax evasion and fraud. The ONLY true healthcare reform--favored by Californians 2 to 1, is SB 840 (Kuehl), single-payer health insurance for all, for life, for less.
Posted by: Don Schroeder at September 10, 2007 05:33 PM

We in the One Care Now Campaign are not stopping the fight for Single Payer. The public has already voted that they want Single Payer. It would cover all, for less, and forever. All the other industrialized countries have it and their citizens never want to trade Single Payer for our corrupt system where folks are literally dying because they don't have regular access to care and insurance CEO's are making $1 billion!! It's American genocide.
Posted by: Lynn Huidekoper at September 10, 2007 11:02 PM

Also important to note is that the California office of the national organization COnsumer Watchdog strongly opposed the CA health insurance bill, as stated in their Sept 2007 LA Times OpEd:

Mandatory health insurance? No sale

Jamie Court, Op-Ed Commentary September 25, 2007
Los Angeles Times

"Forcing citizens to buy an expensive, unregulated private product is nothing less than taxation without representation. If California were to follow the Massachusetts model for mandatory private insurance purchase (the only one in the United States), Californians would have to prove on their tax returns that they were insured or face tax penalties. ..."

Read the Op Ed at this link http://www.consumerwatchdog.org/patients/articles/?storyId=15602

If California were to follow the Massachusetts model for mandatory private insurance purchase (the only one in the United States), Californians would have to prove on their tax returns that they were insured or face tax penalties...

To my mind (and I live in Massachusetts) the most undesirable aspect of the Massachusetts plan is it's lack of affordability to non-trivial swathes of the population (which is another way of saying its insufficient subsidies). I could get behind a national version of a "Massachusetts + more robust subsidies" plan. It's true such a plan wouldn't include particularly robust cost controls, but those could start to be implemented in the next round of reforms.

Jasper and others,
I, too, live in Massachusetts and understand in excrutiating detail the insurance law that Romney signed in April 2006. At the time many reform advocates were extremely aware of the MA Plan being doomed to failure (no cost controls--especially for those already insured, inadequate subsidies for the newly covered, crappy policies in the "Bronze Plan" categories. Before the law (that was largely written by MA Blue Cross and Blue Shield and the Heritage Foundation) was even launched it was clear that it was faux reform.

I was among the few advocates in MA who publicly tried to amend/stop passage of this deeply flawed and wasteful MA law but instead were forced to witness the unending misrepresentations/ lies about "The MA Plan" that were spread by it's architects and implementers. These folks continue to bask in the warm and fuzzy spotlight of "MA has acheived 97% coverage", and they continue to conveniently omit the fact that the MA mandatory insurance law is sucking up about $1Bil in NEW state spending. This $1Bil is to fund what is largely a boondoggle for the private insurance industry, and a few well-connected marketing firms. Many state residents are still getting crushed/bankrupted by sky-high health costs and/or not able to access needed care.

We'll see if the MA Plan implodes or if fears about the faux reform limping along (and raping our state budget--just one example: my kids' public school budget--all public schools--are being cut about 10%, drastic public health cuts are occuring, etc etc) will be realized. One very real fear is that much of the federal "stimulus" money coming to MA will be used to keep the MA mandatory health insurance law going, and going...

For more specifics on the MA law see http://masscare.org/ma-health-reform-law

The key thing, as I see it, is that a final plan will not be successful in the long run unless it has a single payer component. Note the qualifying word, "component." It merely has to share the risk and streamline the core of the system, but does not have to be single-payer in its entirety, and indeed probably shouldn't if we want the best possible system. There is after all a great deal of difference in how applicable a market is to something that people simply won't do without (e.g. accident and emergency) compared to something that is relatively more discretionary (non-urgent care administered in relatively small and affordable increments, such as chiropractic treatment). It's worth noting that the top-rated health care systems in the world, according to the World Health Organization, tend to embody this concept of mating single payer for catastrophic coverage with supplemental insurance taking care of more discretionary parts of health care. France is the outstanding example.

Our current system has become so inefficient, so costly, so cannibalistic of our economy that we cannot afford to get it wrong this time. But getting to the French ideal requires compromise from everyone. And so far, I don't see the Obama Administration or the Senate Finance Committee accepting a significant single-payer component outside of Medicare, and I don't see the left accepting a significant private component. As long as there is that divergence, we're likely looking at a short-term fix whose inevitable failure to control costs and assure coverage in the medium term will seriously discredit government.

Before I sign off, it's worth considering how the French pulled it off. They guaranteed that the system wouldn't interfere with the doctor-patient relationship, and right from the start they outsourced administration of even Sécurité Sociale, the single-payer component of the system, to their insurance industry, while allowing insurers to continue selling supplemental insurance.

There's also yet a broader component to the system; a payoff for doctors' inevitably lower salaries. By making medical school tuition free and sharply limiting torts, the risk component for doctors is small.

It has the air of an all-round grand compromise, and indeed it was. My question is whether we can pull off something similar in this country. Perhaps we ought to take those WHO rankings from 2000 (pity they don't do them any more) as an incentive.

A good starting point is Paul Dutton's excellent August 2007 article on the French system in the Boston Globe.

I have some thoughts about the potential benefits of noisy agitation from single-payer proponents for supports of the legislation we're likely to see from President Obama and Bacaus/Waxman/Kennedy on my blog here:

http://dlpfc.wordpress.com/2009/02/03/bring-on-the-single-payer-agitators/

In short, I argue that, although many believe our health care system should be reformed, the plan is going to be vulnerable to shouts of "socialism." If the public debate includes a loud voice pushing back from the left, the plan should be insulated from the only real danger it faces from Rush Limbaugh/Fox News, because people will find it much harder to take seriously the idea that the proposed legislation is dangerously radical if they repeatedly hear that it is not nearly liberal enough.

Dearest 'weboy',

First read. Then post.

"I've yet to hear something beyond rosy notions of how amazingly low administrative costs of such a plan would be, without much evidence to back it up."

LCGHC Home Page:
"Cost Savings. A guaranteed health care system can produce the cost savings needed to cover everyone, largely by using existing resources without the waste. Taiwan, shifting from a U.S. private health care model, adopted a similar system in 1995, boosting health coverage from 57% to 97% with little increase in overall health care spending."

Truly, you are an ignorant dufus.

Do you think that countries who love capitalism just as much as we do are ALL on nationalized medicine because their hearts are in the right place?

Insurance == Economic Friction

"Truly, you are an ignorant dufus."

what a great opener to begin a discourse to try and influence someone with your point of view.
that is sure to work.

Ann here, wanting to say that I really appreciate Daniel Bliss' thoughtful comment above. Especially the paragraphs about "how the French pulled it off" (I must have missed that 07 Globe article and will look for it).

After 20+ years of advocating for meaningful health system reform which has included learning about--and being excited about--the benefits of "single payer" reform and the improvements it would bring to all ordinary Americans, especially the working class patients I care for in the inner city, I'm ready to accept the need for a "grand compromise", as Daniel puts it.

Certain principles and components must not be negotiated away in the grand compromise, these include having a meaningful public insurance plan option that provides comprehensive coverage and is fairly and equitably financed without punitive fines or other punishment for the low income working class as exists under the Massachusetts mandatory insurance law.

Moving from the policy to the political, it seems clear that the Leadership Conference for Guaranteed Health Care has much more in common than it has major differences with the Health Care For America Now coalition.

Might there be a way to build a bridge between the two?

snowball, feel free to comfort yourself with the notion that Taiwan is totally like how it would be if the US went to single payer... but don' call that a serious rebuttal to my point. Moreover, you have no idea where I come down on any of this - which, as it happens, is closer to Daniel Bliss - I think we can achieve something along the lines of the French... but that's a public system with a private component, and basically subsidized insurance. I also hear what Ann Malone is saying, and I think she's right that ultimately we need to find a compromise, one that focuses on care. It's the "let's tear everything up and start over" notions I object to, not the idea that we need serious reform.

An option in the final plan that allows the citizen the right to enroll in a government-only plan.

That's next to useless, because it will just be gutted by politicians held captive to insurance company money.

What I WOULD support in terms of incrementalism is to simply expand Medicare and SCHIP one step at a time. Indeed, I would support cutting all governmental subsidies (including through tax credits) to private health insurance and pouring the money into public care programs. If we can't have universal single payer now, fine. The correct incrementalism is to get the taxpayers' money out of insurance companies and build up our public programs over time.

While I'm not a "single payer" advocate (I see as many problems with it as with our current very dysfunctional system), I'm convinced it's probably where we'll wind up unless something fundamental changes. 79 million Baby Boomers retiring with almost no money in the bank and a sufficient chronic illness burden to render them uninsurable in the private sector will trigger tremendous pressure for a government "fix." Unless the private sector gets it's act together very quickly, "Medicare for Everyone" will be the default option because it will be the only lever available. For those of you on the left, I'd suggest that you just need to sit tight and let events come to you. For everyone else, better get off your collective backsides and prove that a pluralistic, private sector system can actually provide equitable, efficient, effective, timely, safe, and patient-centered care. That's going to be a very heavy lift and the clock is ticking.

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