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.