Matthew Holt

A vote for single payer, austerity-style

I spent summer 1984 in Boston and generally found it an oppressively hot place. I’ve spent a few winter days there and found it an oppressively cold place. I’ve always thought that, given the absence of passport controls, if you lived there and could move to California and didn’t, you were probably crazy. And yesterday the residents of that fair state proved me right.

As I said earlier this week, it now appears that health care reform is dead. I just can’t see a scenario in which there are 60 votes to pass anything. I also don’t see the Dems having the cojones to go to reconciliation or to cram the current Senate bill through the House quickly. Instead (as Bob Laszewski says below) the moderate Dems will run for their lives away from health insurance reform—although I just don’t understand what Bob thinks “reform” would have meant if it had really required 6–10 Republican Senators.

So my prediction is that we end up with nothing.

In which case 23 year old kids with cystic fibrosis, or basically anyone else unlucky enough to be marginally sick or marginally employed, are screwed. Or at least are uninsured and will be screwed if something goes wrong. Now of course that’s only a minority of people. But then there are those trying to get by under the dogmeat program known as Medicaid. And add to them the millions more with marginal and declining insurance. So for more people health “insurance” will continue to get more and more unobtainable.

On the other hand, what’s also left town has been any hope of systemic delivery system reform. And in the short run the delivery system will cheer.

Which means we get more of the same for a while longer. But eventually the increase in costs and the increasing numbers left out of the system will bring us back to the point of reform. Here’s what Vic Fuchs said in 2007

Short-term prospects for enduring comprehensive reform are virtually nil. Over five to ten years, prospects are fifty-fifty unless there were a major economic, political, social, or public health crisis. In the long run, major reform is inevitable.


No nation can continue to allow health care to drain away resources that would be more socially productive in education, the environment, security, and other policy areas. It will come sooner rather than later if policymakers recognize that the United States must find its own approach, one that is congruent with basic American values: equality of opportunity combined with exercise of personal freedom.

It’s pretty clear that policy makers have not found “its own approach”. So the next approach will come at a time of extreme need, and the response will be a lot less palatable than many inside the system would like.

CODA: Ever noticed that if it involves spending $100 billion a year and promoting the interests of corporate defense contractors, we invade foreign countries with no plan, less rationality and no debate? (Obama’s “surge” of 30,000 troops to Afghanistan will cost about $30bn a year). But if it’s spending about the same net dollars annually to give health insurance to the working poor, all hell breaks loose? Could it be that at some point the medical-industrial complex regards this as a threat?

13 replies »

  1. “Why can’t they be seperate?”
    Probably because that’s where the majority insured get their healthcare and don’t want to give it up – until of course it too gets unaffordable.

  2. “I guess we can throw the sick young poor out of access to healthcare (and with the savings) into good well funded schools in their own neighborhoods to balance the books. Hold that illness until you graduate and get a job with a company that can afford to offer health coverage”.
    or we can start health care “access” reform by divorcing the employer based health care system. Why can’t they be seperate? We can start with that.

  3. “Fact is, Medicaid is going to bankrupt states far and wide. It’s a black hole, which will destory a whole variety of state-funded budget items, not least education. As you know, the young poor will never escape the cycle of poverty in the context of collapsed educational systems.”
    I guess we can throw the sick young poor out of access to healthcare (and with the savings) into good well funded schools in their own neighborhoods to balance the books. Hold that illness until you graduate and get a job with a company that can afford to offer health coverage.

  4. Hahahaha!!!! Holt must have been hopping mad last night. It’s alright, though, Matt – keep taking potshots at Republicans, talking about Iraq and Afghanistan, whining about the “last 8 years” (regardless of the fact that the last year, and even the last three, were dominated by Democrats), and of course, blaming President Bush. No, really – keep going. Maybe Dodd’s and Burris’s seats will turn red in November too.

  5. Where to start Maggie? How do you know why Mass voters abandoned the Dems? I certainly don’t, although Brown made HC a signature issue (his vigorous response to the Dec 25 attempted terrorist attack may have been the clincher).
    It is clear now that we will never, ever have single-payer system Never, ever, ever, ever. That liberal wet dream has proved to be a chimera. I don’t know exactly what will emerge, but it must contain free market elements. That much is obvious.
    As to Medicaid, you seem to be arguing that it’s underfunded (due to racism or some such nonsense). Fact is, Medicaid is going to bankrupt states far and wide. It’s a black hole, which will destory a whole variety of state-funded budget items, not least education. As you know, the young poor will never escape the cycle of poverty in the context of collapsed educational systems.

  6. Medicaid is “dogmeat,” not becuase it is a government program, but because it pays providers 70% of what they would be paid if they were providing the same service to a Medicare patient rather than to a poor patient.
    It is not easier to treat the poor—it is often harder.
    So why the differential?
    The legacy of racism. When Medicare and Medicaid were passed, southern Congressmen told LBJ that if proividers who cared for poor patients under Medicaid (many of whom would be black) were paid as much as those caring for seniors (mainly white because many blacks didn’t live that long)the South would refuse to vote for the bill.
    Knowing that they were dead-serious, LBJ had to give in.
    Let me add that the vote in Mass. was NOT a referendum on health care reform. Most people in Mass. are glad that they did health care reform (even though they’re having a very hard time figuring hout how to pay for it because they haven’t really gotten seroius about controlling waste.)
    It is in Massachusett’s interest that the rest of the country have health care reform. Otherwise, sick people will begin moving to Mass., much as poor people moved to New York State in the 1960s when NY had a good welfare/Aid to Dependent Children program and most of the country did not.
    Yeterday, Mass. voted against the Democrat because they are upset about the economy (JOBS –much more impt. than health care to most people) and because they are unhappy with Obama either because they think he’s too liberal or not liberal enough.
    The notion of “working with Republicans to find workable solutions” is simply code for “working with Republicans to make sure that we don’t spend $$ on the working poor.
    Matthew is right: the working poor are being screwed–and will continue to be screwed–until more of the upper-middle-class find themselves sliding down the greasy pole of class and wealth in America, and find that they in imminent danger of becoming lower-middle-class. Only then will the become interested in “equality of opportunity.”
    By then, reform is going to be very, very expensive.
    But I am becoming convinced that Fuchs and others may be right: that is what it will take.
    Perhaps, at that point, we’ll move directly to single-payer becuase relatively few people will have employer-based insurance. Though I suspect that the upper-class,who will still have employer-based insurance, (not to mention concierge medicine) will fight, tooth and nail, to keep their privilege.
    And they won’t want to help pay for single-payer for the rest of us.

  7. From your post: “it now appears that health care reform is dead” Not exactly The Democratic version of HCR has been wounded, but a bipartisan HCR plan can still exist. This would require that the Democrats compromise on issues that have caused angst to the GOP and to the public. Massachusettes is a microcosm of public opinion on pending health care legislation. The Democrats and the administration were way out front of the public on this issue, and Coakley was the first victim of the pushback.

  8. Once again, my friend Matthew Holt mystifies me. He can’t be recommending a single-payer, government-monopoly program, because he calls Medicaid “dogmeat.” But I recall seeing him write elsewhere that a program only for poor people will be a poor program. It’s kind of like claiming that the way to make housing projects better would be to make everyone live in housing projects.
    So, I guess he’s advocating a program of mandatory, regulated, private insurance a la Suisse. But I suspect if “reform” will drift away for another 15 years, it will never come back as a Big Government proposal, because the failure of Medicaid and Medicare will be obvious to the man in the street.
    By which time, I hope that people will demand reform that makes health insurance the property of the individual, not the employer or the state.

  9. I don’t know about “government control” but Liberals have a definite problem when it comes to understanding that universal coverage doesn’t have to mean government spending. The German government accounts for less than 15% of total health spending (vs. 46% in the US) and yet they have a single system that covers everyone. Everyone is in the same boat.
    Too much of the discussion of this effort has focused on public spending and not enough on achieving universal care at less total cost.

  10. This was never about health care. If it were, the Dems would have considered a variety of approaches. This was always about government control, about creating dependent classes, about enhancing political control.
    The public overwhelmingly supports universal coverage, but the public became wise to the real motivations at play.
    Obama & Co. now have an opportunity to go back and do what they had promised, namely to work with Republicans to find workable solutions to the problem.

  11. While I’ll forgive your slight about MA residents, our state is anything but crazy. On the single issue of health care our new senator may prove to be the obstructionist, but a bill as truly partisan as the one moving through congress had no real chance at passage. Bob Laszewski had it right, health care reform will require some balance. The voters of MA seem also to be in search of some balance in their desire to seat a senator who is more than a rubber stamp for the latest democratic party cause.

  12. Where you ok with the Party of no when it had a D next to their name or was obstruction patriotic then? Can’t have it both ways Mark, and seeing how your quickly on your way to minority party status better watch what you say now or regret when it is used against you tomorrow.

  13. Our government is truly messed up if a clear majority in both houses cannot pass a bill. We are hostage to the “party of no”. It seems that the Democrats are afraid to offend all of those nice Republicans by passing something that the majority wants and needs. We are truly screwed!