By WILLIAM ROSENBERG
A ‘single-payer’ plan is a target on the back of its supporters. But what about a ‘Medicare Public-Private Partnership’?
MOUNT VERNON — In February 2017, President Trump famously said: “Nobody knew health care could be so complicated.” Nobody other than about 99.9 percent of the almost 300 million people in the U.S. with insurance, that is. Yesterday, I received a copy of “Get to know your benefits,” the 236-page “booklet” for my new health plan. Like most people, I’ll never read the book, but its weight alone says “complicated.”
And it’s safe to guess that Trump also will never read his Federal Employee Health Plan information, even though one Aetna choice available to him has a “brochure” of only 184 pages. Thinking about the amount of information available to health insurance plan consumers, I began to wonder what Health and Human Services Secretary Alex Azar meant, also last February, when he said, “Americans need more choices in health insurance so they can find coverage that meets their needs.”
Presumably, were we to have more choices, we could study the hundreds of pages of information about each available plan and make better choices. According to the federal Office of Personnel Management, federal employees who live at 1600 Pennsylvania Ave., Washington, D.C. 20500, have a choice of 35 monthly plans. Too bad the president doesn’t live in Maine, where he’d have only 20 plans to study!
On Vox, the vivacious new topical news site, staffed in part by former writers at the Washington Post Wonk Blog, Sarah Kliff writes how Donald Berwick, MD, the recent former Administrator of the Centers for Medicare and Medicaid Services and the Founder of the prestigious Institute for Healthcare Improvement, has concluded that a single payer health system would answer many of the US’ health care woes.
Dr. Berwick is running for Governor of Massachusetts and this is an important plank of his platform. Of course, it is easy to show that single payer systems in other developed nations provide comparable or better quality care at about half the cost that we do in the US.
All else being equal, I might be inclined to agree with Dr. Berwick’s assessment. But the US is special in two ways that make a single payer system unlikely to produce anything but even higher health care costs than we already have.
First, it is very clear that the health care industry dominates our regulatory environment, so that nearlyevery law and rule is spun to the special rather than the common interest. In 2009, the year the ACA was formulated, health care organizations deployed 8 lobbyists for every member of Congress, and contributed an unprecedented $1.2 billion in campaign contributions in exchange for influence over the shape of the law.
This is largely why, while it sets out the path to some important goals, the ACA is so flawed.
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.
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.