Tuesday, August 4, 2009

From Public Option To Single Payer: In Which I Reveal Our Secrets To Republicans

I see that my Republican friends Tigerhawk and Pejman Yousefzadeh have both linked or posted a video in which Barack Obama talks about his plans for gradually moving us towards single payer health insurance. It's been kind of a hit in the GOP blogosophere -- Michelle Malkin had it up a couple days ago.

Because I'm not Michelle Obama, I don't know how much the president sees the legislation currently forming in Congress as a way of getting us to single-payer health care. But the message of the video is certainly right in that a lot of Democrats hope that it'll move us in that direction. And I'd like to fill in my Republican friends on exactly how we get from the public option to single payer, because I think they'll like it.

One big problem facing Democratic health reformers is that for all the problems with the current system is that it's really easy to scare people about what could happen to them under any other system. Even though people in other countries with government-run plans are very happy with them -- lots of countries have voted themselves from a private system to a government-run system, while no democracy has ever gone the other way -- Americans don't have firsthand experience with the wonders of, say, French health care. Medicare, which is basically single-payer insurance for old people, only kicks in at age 65, so most people don't have firsthand experience with how good it is.

This is why in the post-1994 era, Democrats have opted for proposals that allow them to say "If you like your insurance as it is, you can keep it." The plans currently making their way through Congress allow them to say this. The "public option" of a government health care plan that looks a lot like Medicare is just an option. If you don't like it, turn it down and stick with your current plan.

So how do we get from the public option to single-payer? Here's the nifty part: we do it using consumer choices in a free market. We Democrats are confident in the ability of the government to provide a health insurance product that will beat the private market on price and quality. Old people love their Medicare, and it's held down costs better than private insurers. So we're pretty sure that if we give American consumers the choice between private insurance and a public option that's basically Medicare, they'll choose Medicare of their own free will. On price and quality, it's a better deal.

If enough people do that over a fifteen-year period or so, we could end up with a situation where the vast majority of Americans have individually decided that government health insurance is what they want. And then when we propose offering everybody free coverage funded out of tax revenue, kind of like how everybody in a city has free fire department coverage funded out of tax revenue, it'll get majority support. It eliminates a lot of bureaucracy and hassle if people don't have to individually contract for fire protection. Similarly, the administrative efficiencies that come out of giving every American a single basic health care plan funded out of tax revenue will make expanding it to everyone a good fiscal move. We'll have gotten over the big political barrier to setting up French-style health care today -- the fact that people don't know how good it is. They'll know how good it is, because they chose it in a free market and are enjoying its benefits.

Here's what I hope Republicans will like about this: The crucial step in the grand liberal plan to set up single-payer insurance happens in a free market. We give consumers a choice between a government-run plan and a private plan. If the private plan offers a better deal, people will choose it, we won't get a critical mass of Americans on a government plan, and we'll never get to single-payer. But if the public Medicare-like plan offers a better deal, people will choose it and the move towards single-payer will begin. We're confident that the economics of health care works out so that the government can offer individuals a better deal than corporations can. You may think otherwise. We propose that the matter be decided according to your market-based ideology: by letting individual consumers decide.

(One thing that's kind of annoying us right now is that the public plan has to compete with a hand tied behind its back. According to the House bill, it won't even be available to large employers via the health insurance exchanges for at least two years, maybe more. We're hoping for a plan that allows for a level playing field, and whether we get it will be the outcome of Congressional negotiations.)

As far as the eventual health care utopia goes, we don't want to ban private insurance -- in my years as a lefty blogger, I haven't come across a single American explicitly advocating for something like the old Canadian system where you aren't allowed to contract with someone else for private insurance. If you want some additional insurance on top of your government-guaranteed Medicare, feel free to call up the AFLAC people or whoever and they'll sell it to you. But since the government has out-competed them across most of the market, private insurance companies will be a lot smaller than they are today. (A lot of people who use the words "single payer" really mean "Medicare for All" even though it's likely that you'd get some additional private add-on insurance vendors on top of the government plan.)

Minor personal note: As a former John Edwards volunteer, I really like telling people about this, because this whole idea came out of his campaign. The idea that the public option could slide us into single-payer through individual consumer choices actuallyshowed up on his campaign document laying out the proposal. I spent a lot of the last primary campaign winning Democrats to the Edwards side by telling them about this strategy. Of course, the whole Edwards thing didn't go very well in the end, but the health care plan was so good that it survived into the present. Now I get to tell Republicans about it! Still fun.

PS -- Here's one simple chart showing the superiority of government-run health care systems over the current US system. Everybody else spends a lower percentage of GDP on health care than we do by running a government insurance program. Most of them get universal coverage, while we don't even manage to cover our entire population for that exorbitant cost. Figures like this are part of why Democrats are confident that a government-run insurance option will outperform private insurers and eventually move us to single payer.
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