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single-payer system

This morning’s post by Matt Yglesias notes a fairly obvious but important issue that bears attention.

The comportment of conservative Supreme Court justices in oral argument leads many people to seriously consider what would happen if ACA is crippled or struck down. (Like Jonathan Cohn, Henry Aaron, David Cutler, Charles Fried, and Jonathan Chait, I was appalled by the oral argument. You can read my column at healthinsurance.org for more on that subject.)

Several commentators assert, or at least have mused, that overturning ACA might improve the prospects for a single-payer system. It’s easy to see why one might think so. Single-payer is less vulnerable to the commerce-clause challenge that bedevils the mandate. Outright failure of ACA would discredit bipartisan, market-based strategies within many core Democratic groups. The political and organizational simplicity of single-payer is appealing, too. Killing ACA heightens the contradictions of our fragmented and costly health care financing system, while taking off the political table some of the most workable strategies for incremental reform. Absent a serious and workable alternative, Medicare for all might look surprisingly attractive some years from now.

Still… I just don’t see it.

In the first place, I am confident that a smart and determined conservative judiciary would entertain new constitutional challenges to a single-payer system. Such a system would end or would damage much of the private insurance industry. It would reorder relations between the states and the federal government. It would upend self-insurance arrangements under ERISA, and more. If you believe ACA’s 2,700 pages was long and complicated, wait until you see the junk DNA that would accompany a politically and administratively viable single-payer bill. That’s fertile legal ground for opponents, even absent the current political polarization of the federal judiciary.

Continue reading “No, Overturning ACA Would not Smooth the Way to Single-Payer Care”

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As I read the spirited debate over whether Obamacare will drive health insurers out of business (here and here), I wonder if we need to bring the discussion back to fundamentals: The key problem with U.S health insurance is that there is too much of it – whether provided by private insurers or government.

Avik Roy and Rick Ungar disagree on the likely outcome of Obamacare: Private-insurance monopolies or government monopoly (a.k.a. “single payer”).  I think both are correct.  Private monopolies will arise (within each state or regions within larger states) to exploit the huge subsidies (tax credits) available through the so-called Health Benefits Exchanges.

But this will only persist for a few years.  Today, the politicians supporting an increasingly shaky Obamacare must ensure that the health-insurance industry remains divided – some hoping to profit from Obamacare’s forthcoming monopolies and others fearing exclusion.  This prevents them from coming together in a unified effort to repeal the law.  The Democrats’ success at keeping the health-insurance trade association on-side and on-message is pretty impressive, given the fact that even the U.S. Chamber of Commerce now publicly advocates repeal.

The likelihood of Obamacare surviving both the U.S. Supreme Court and next year’s voters is pretty slim, so its supporters cannot afford to let any more hostages escape.  (The pharmaceutical industry, for example, is also refusing to join the repeal movement.) So, while Democratic leaders cannot stop single-payer extremists like Mr. Ungar from telling the truth, they must continue to pretend that the end-game is simply a “fairer” private system, rather than a government take-over.

Continue reading “Shopping for Health Coverage Versus Shopping for Health Care”

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