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POLICY: Now let’s remember a few basic things about Medicare, single payer, vouchers et al, with brief UPDATE

Well either the doppelgangers are firing off or a few people have been reading this blog or the Jungian collective unconscious is working. In any event several of the issues about single payer versus vouchers that have been raised here have been echoed elsewhere.  First Fuch’s co-author Zeke Emmanuel in a guest spot over at Washington Monthly in response to Kevin Drum (the host there) spends some time explaining how insurance organizations (plan sponsors, an intermediary layer, call it what you will) could actually provide some innovation and be allowed to compete over that, rather than risk selection.

May be so, but there are two obvious points. First, there’s no reason why competition amongst that intermediary layer need not be controlled by a single payer system — something like that is starting out in the UK now.  My major point is that a quick Medicare-for-all legislative rush which puts us in one big risk pool is much more politically likely than an attempt to create a formula that gets us to perfect risk adjustment which Congress will pick to death while it’s legislated.  Second, Emmanuel reckons that we won’t get to single payer without a national crisis (and I agree) but then he thinks that the voucher system is palatable enough to somehow sneak past the special interests in the absence of said crisis. I don’t think so. Significant universal insurance reform will be so difficult to do that it’ll need a national crisis.  But then I’d call, say, 80m uninsured Americans a national crisis — or at least one that may show up politically if enough of the uninsured are male Republicans in the south –and we may well get there if current cost trends continue.

Zeke also reminds us that Medicare isn’t such a great program either, and I completely agree. Medicare is basically a welfare program for hospitals and providers, and soon to become one for drug companies too. It’s the fact that it doubles as a way to stop old people from being unable to afford hospital care and thus from dying in the streets that gives it such popularity.  But that income protection for seniors part of it can be preserved while making the overall program better. First off, the amount of money paid to those provider organizations can be reduced (and will be), but they need to improve their productivity and stop delivering "flat of the curve" medicine (i.e. more money with no comparable output). Some hints in this direction include implementing some of the lessons from the Dartmouth crowd’s work on overuse of resources in ICUs. The other part about Medicare is that it can be used as a force for good and to foster innovation. With all its warts that’s what P4P is all about, and I don’t see why Medicare is worse at doing that than private health insurers, which anyway tend to follow its lead.

Finally, I’d like to remind all parties that the gulf between the universal insurance crowd and the single payer crowd isn’t so big, as they both have everyone covered and everyone in a single big risk pool (called America). And with some variations, the Europeans show us that multi "intermediary" systems such as the ones in the Netherlands, Germany and Switzerland can be very effective.

UPDATE: Jonathan Cohn, who seems to be giving it away over at TMPCafe these days instead of selling it at TNR, has some pretty sensible points to make about the eventual similarity between universal insurance and single payer.  He doesn’t quite get to my logical conclusion — which is that we get to some type of government-funded quasi-competitive regulated market via an extension of Medicare’s single payer model — but I think he’ll be there eventually.  And I think he’s in some agreement with me about the politics of all this. i.e. Life has to be really bad and this has to be done once and quickly…..Gramsci called that Fortuna et Opportunta, or waiting for the time to be right and then giving the right legislation (or revolution in his case) a big shove.

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SonnytheorajonesAbbygadflyAbby Vigneron Recent comment authors
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Sonny
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Interesting topic. I wrote a long post about the Washington Monthly article and Kevin Drum’s analysis last week. Didn’t see a trackback link around here, oh well:
http://www.politicalbloviation.com/index.php/archives/8

Ron Greiner
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Ron Greiner

theorajones, My Mom lives in Ames. That’s where they pick the leader of the free world at Hilton. It’s not fair but somebody has to do it. Let me understand if I’m understanding you correctly. Are you suggesting that Governor Jeb Bush go to Ames and in the first debate for the next President in ’08 and say, “I know Iowa is the second state in America in percentage of citizens over the age of 85. I understand you have a very fragile population and incomes are a lot lower here than in New York City. I understand you have… Read more »

theorajones
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Sure, Ron. It is a rank injustice that New York gets more money to care for Medicare patients than does Des Moines. Gosh, is there a difference between New York and Des Moines?
http://swz.salary.com/costoflivingwizard/layoutscripts/coll_result.asp?presentsalary=35000&presenthomemetrocode=119&presentworkmetrocode=119&newhomemetrocode=52&newworkmetrocode=52&currentlocation=119&newlocation=52&x=33&y=7
And hey, if you’re arguing that states should get back from the feds what they give, I really don’t think you’ll get much argument from New York, which sees 16 cents of every dollar it sends to the feds distributed to other (mostly red) states. And as a Florida resident, you seriously need to stop harshing on California–their taxes are subsidizing your lifestyle!
http://www.nemw.org/fundsrank.htm

theorajones
Guest

You know, that whole discussion at Drums’ place really moved me over into the “we need to argue for Medicare for all” camp which, to be perfectly honest, is someplace I never expected to be. I agree with what you’ve posted above, and would like to add one additional point. From a policy perspective, it’s far easier in the US to privatize than to un-privatize. If we really start missing insurance companies, it’s not like it would be too terribly difficult to start up a Congressionally mandated demonstration and then expand it. I’m certain that there’d be a few lobbyists… Read more »

Ron Greiner
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Ron Greiner

Exactly Abby,
California, where they say they have it all
They got riots, fires and mud slides
They got sushi in the mall
Shake and bake with the quakes
And Democrats run amuk
Are you a vegan Matthew or a pretenditarian?

gadfly
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gadfly

I came out here for Berkeley, and I was sorely disappointed to find I missed the Free Speech Movement by over a decade and now the students all belonged to business organizations and carried cell phones. 🙁

Abby
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Abby

Matthew,
I’m sure you’re quite clever, but California is such a screwy state. I think people who choose to move there must be a bit mad, not that cleverness and madness must be mutually exclusive.

gadfly
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gadfly

Now that you’re quoting Gramsci, can we start talking about health industry Hegemony?

Matthew Holt
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The clever Brits moved to California

Abby Vigneron
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Abby Vigneron

Ron,
That made my day. You can’t move, because you have to take care of your neighbors’ plants. I love it!

Ron Greiner
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Ron Greiner

My “mum” has already been saved by the Mayo Clinic in Rochester, Minnesota. In Iowa they didn’t have a clue. I’m not saying care is better in Florida either. Todays Tampa Tribune is reporting that a dermatolgist here is finally barred from surgery. He was diagnosing everyone with cancer for Medicare reimbursements. He operated on one man 122 times. If you google Medicare Savings Accounts your friend Dan Parrin pops up first and says, “Insider: Medicare Savings Accounts can now be offered by law, by insurers to seniors. The problem is that while the law that allows it, it also… Read more »

Matthew Holt
Guest

Ron, this is a function of the way Medicare HMOs get their, money which is based on overall Medicare costs in that area, which are a function in turn of provder behavior. Florida has the most expensive end of life care because a combination of medical culture and Medicare incentives allow it. If Florida docs were forced to behave like docs in Minnesota and spend 2/3 less resources on end of life care (with actually better results!), Medicare would cost less there, and therefore the payments to private plans would be lower (and save the taxpayer money). I agree that… Read more »

Ron Greiner
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Ron Greiner

The problem with Medicare is that it discriminates against certain states. In Iowa my mother doesn’t have an HMO option in Medicare like we do here in Tampa. My mother pays $171 a month for a Medigap insurance plan and $78 a month for Medicare part B. Of course her coverage doesn’t pay for Rx either. In Tampa Medicare pays so much to Medicare HMOs that they are advertising that there is no cost to enroll and no monthly premiums and the HMO will pay the $78 a month for the part B premium and also covers Rx. My Mom… Read more »