On the one hand, it seems clear to me that what we really ought to have is single-payer health insurance. You can find a good explanation of single-payer insurance (sometimes called Medicare for all) at Physicians for a National Health Program. In brief:
Under a single-payer system, all Americans would be covered for all medically necessary services, including: doctor, hospital, long-term care, mental health, dental, vision, prescription drug and medical supply costs. Patients would regain free choice of doctor and hospital, and doctors would regain autonomy over patient care.
Physicians would be paid fee-for-service according to a negotiated formulary or receive salary from a hospital or nonprofit HMO / group practice. Hospitals would receive a global budget for operating expenses. Health facilities and expensive equipment purchases would be managed by regional health planning boards.
Clearly, our present system is broken. An PNHP points out on their main page:
The U.S. spends twice as much as other industrialized nations on health care, $7,129 per capita. Yet our system performs poorly in comparison and still leaves 47 million without health coverage and millions more inadequately covered.
This is because private insurance bureaucracy and paperwork consume one-third (31 percent) of every health care dollar. Streamlining payment through a single nonprofit payer would save more than $350 billion per year, enough to provide comprehensive, high-quality coverage for all Americans.
On the other hand, creating single-payer health care might be next to impossible. Private health insurance companies are large, profitable corporations with quite a bit of political clout. You don't expect them to go out of business voluntarily, do you?
Conventional wisdom says that single-payer health care is either undesirable or just not possible. We're told that it's equivalent to "socialism," and once that label has been put on it, we're supposed to accept without question that it's bad.
Even if it's a good thing, we're told that it's not politically feasible. The only Democratic presidential candidate to support single-payer health care, Dennis Kucinich, was alternately ignored and portrayed as a lunatic by the the mainstream press. Third-party candidates who supported single payer, such as Cynthia McKinney of the Greens, were ignored. HR 676, the Expanded and Improved Medicare for All Act was introduced in a previous session of Congress, and never made it out of committee.
Like most of the other Democratic presidential hopefuls in the recent election, Barack Obama takes a middle of the road approach. There is one feature of his plan that offers some small amount of hope for real change, and that is the proposal to allow people who are currently uninsured to choose between private insurance and a public health care plan.
In recent posts (the first here, the second here), I've supported this kind of health care choice -- preferably for everyone, whether or not currently insured. But the good folks over at PNHP say it won't work. According to the guide PNHP has created for the Obama medical insurance house parties:
Adding the option to purchase a public plan like Medicare will merely replay the disastrous Medicare HMO experience. For the past 20 years Medicare patients have been allowed to opt for the traditional Medicare program or enrollment in a private plan paid for by Medicare. This option was supposed to stimulate competition and lead to improved efficiency. Instead, the private plans have used every trick in the book to undermine real competition and drive up costs – e.g. selectively recruiting healthy, profitable patients while leaving the sick and expensive ones to Medicare; and successfully lobbying Congress to add extra payments to prop up the private plans. The GAO estimates that private plans cost Medicare an extra $8.5 billion in 2008, raising premiums for all Medicare recipients (not just those enrolled in private plans) and depleting the Medicare Trust Fund.
PNHP offers much more information about the shortcomings of the Obama/Biden/Daschle health care proposals and the need for a single-payer plan. In brief, PNHP argues that Obama's proposals are similar to plans enacted in several states over the past 30 years that have failed to contain costs and also failed to establish universal coverage. PNHP argues -- quite persuasively, I think, that only by eliminating wasteful private insurance companies can we make the savings necessary to control health care costs.
On the other hand, Sarah van Gelder notes that insurance companies are doing everything in their power to squelch the option for people to choose between public and private plans. Van Gelder calls Jacob Hacker's plan to allow a choice a perfect compromise between the current system of private insurance and a single-payer plan that would eliminate private insurance:
The nonpartisan Lewin Group estimates that Hacker's plan would save the U.S. economy $1 trillion over 10 years, while covering 99.6 percent of Americans.
The Massachusetts system, enacted in 2006, is a stark example of what happens when there is no public option. Everyone in the state is supposed to be covered, but their choices are limited to private plans. Premiums have been rising 8 to 12 percent per year, which means the system will soon be out of reach of individual families, employers, and the state government.
A public option assures that there is a benchmark against which private companies must compete. Without such a benchmark, private companies have no incentive to contain costs or improve services.
It's hard to argue with giving people a choice.
But the health care industry is arguing. The New York Times says medical associations are encouraging their members to attend the health care discussion groups being organized by the Obama transition team around the U.S. Past efforts to reform the health care system stalled in the face of powerful health industry lobbyists with huge campaign war chests. Will the industry be as adept at dominating the health care policy discussion when it's happening in living rooms and coffee shops around the country?
Is the Hacker plan a workable compromise, as Sarah van Gelder argues, or a dead end, as PNHP says? Would the insurance industry be fighting so hard against it if it didn't have some potential for eventually leading to a single payer system? On the other hand, Obama's healthcare discussions seem to have been set up to avoid any discussion of the single-payer option. Is it better to try to stretch the bounds of the discussion to include single-payer, or is it better to fight for the right to choose between public and private plans?
I just don't know. Does anyone else have a point of view to share?
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