Progressives: Don't Get Hung Up on Single Payer

As a health policy wonk, whenever my vocation comes up among people of a progressive stripe, the conversation inevitably leads to (and usually ends with) the refrain, "if only we had single payer." Having dealt with the American health care system both as a consumer and as someone who reads hundreds of pages of its rules and regulations on a weekly basis, I understand the allure. Health care in America is an unholy pain in the ass. I would love to be given a card that lets me go to any doctor I want any time I want for free. But that's not happening, even in the rosiest scenarios,

Yes, we can and must do better, but "single payer" isn't some holy grail. If we just handed out Medicare cards to everyone in the country tomorrow, we'd still have to choose between traditional Medicare and Medicare Advantage. We'd still have to choose a Medicare Part D plan if we want prescription drugs. We'd still face 20 percent coinsurance and a litany of copays, meaning that we'd probably also shop for supplemental coverage.

Even if we somehow swept the Canadian system of paying for care down from the North, we'd still have to deal with the endemic perverse incentives of hospitals who are paid by the procedure, medical malpractice, fraud and abuse, the profit motive, and a good number of other aspects of American health care that are untouched by who pays for it. If the politics of enacting single payer above insurance companies' objections is tough, it's nothing compared to all the pharmaceutical companies, device manufacturers, hospital and medical associations, all demanding that the tax payer float the costs of every new, expensive thing without prejudice.

Imagine all the ads on TVs for scooters and diabetic testing kits if everyone had insurance that was guaranteed to pay for anything and everything with only a doctor's note. That's America.

I don't like our health insurance system, but consider this: every year these captains of industry don't take a growing percentage of our health care dollar. It's steady. It may be 10 percent, it may be 25 percent, but it doesn't change. At the same time, hospitals and doctors are paid more and more and more annually. Put those two facts on a curve and the math it pretty clear that health care costs are going up, and it's the cost of health care (not health insurance) that drives it. We could save money with single payer, but the pressures to spend more and more on the newest gadget, or the guy with the fanciest medical degree will remain. Medicare deals with this in the same way that private insurance does, and faces real political and regulatory constraints. It's health care that's expensive, not health insurance.

That said, even people with really good coverage must sort through a morass of deductibles, copays, preferred providers, pharmaceutical tiers, and who knows what else before a claim is either paid out based on some hidden algorithm, or it's rejected by some mysterious technicality. Forget it if you're poor, have crappy coverage, or can't be bothered to learn the rules of a game whose rules are both arbitrary and capricious. In my work, I'm constantly exposed to a regulatory structure that's designed to both encourage a functioning, competitive market and reduce abuses of the consumer that are often a result of that competition. I have to be familiar with dozens of federal, state, and private rules, and am supposed to have some wisdom about how they all interact. I'm reminded again and again that one person's policy pet peeve is another's cash cow, and that even with the best intentions, the everyday consumer is powerless against this deluge of legal jargon. The market can help here, but not without some strong, sometimes complex, sometimes controversial protections for regular people. We can and must do better.

Single payer would be simpler to deal with. It'd probably be somewhat cheaper too. Had we gone for it in the 60s, when Canada and other nations did, before medicine got so expensive and profit-driven, it'd probably have been a much better decision than any alternative proposed since. But here we are today. Health care is far more complex and costly than it was in 1965. With the power and economic influence that health care has amassed, I doubt that even Canada would be able to pass today what it did back then.

It's possible that a few states will move ahead with legislation, despite the recent setback in Vermont. It's even possible that Single Payer will spread like wildfire until some day decades hence, the Alabama legislature approves CrackerCare to become the 56th state in the union with a fully public system. But progressives can't just sit around and hope.

Right now, all the energy in health reform is on the conservative side. All the model legislation bandied around statehouses calls for greater "consumer participation," where larger deductibles and copays, an ever growing stack of confusing insurance products each with its own shell game, and fewer regulations is somehow supposed to lead to a utopia of Joe Consumer shopping for his chemotherapy from a number of willing, transparent bidders, each vying for the shrinking balance in his Health Savings Account. That's reality, and it's happening now. The progressive answer to complex, though thoroughly bad legislation with a good chance of passing cannot be "yeah, but Single Payer." It has to be complex, good legislation.

So what are some progressive ideas that might work within the confines of today's health care system? A few general principles are a good place to start.

1. The consumer should be freed from having to think about whether they're better off going for the cheaper or the more expensive chemothreapy. That's a job for doctors and insurance companies. As a consumer, I can shop for those with the right tools. I can't be expected to decide how best to treat my cancer.  
2. If it's cheaper health care you're after, deductibles and copays are a waste of time. A $5,000 deductible keeps consumers away from doctors who might prevent a problem early on, and then, once it's a $100,000 life-threatening problem, doesn't really affect the consumer's decisionmaking. It's the quintuple bypass surgeries that make health care expensive, not the visits to the cardiologist.
3. The government should set rules for negotiation between doctors and insurers. It should ensure that a neutral third party is available to appeal an insurance decision within  24 hours.
4. The consumer should be able to deep-six any insurance plan that gives them the run-around any time they want (within reason). That's consumer-driven health care.
5. The government should provide and publicize good evidence on what's good and what's a waste of money, regardless of who stands to make money off of it. Insurance companies can do with this what they will (within reason).
6. If we're going to have private insurance companies, they need the same bargaining power that the state would have. Much of Europe has private insurance. The difference is that everyone has it, and the companies bargain collectively. Let the insurance association sit down with the medical association and come up with a fair price for things.  
7. Insurers should pull from the same risk pool. Right now, plans are carefully crafted to keep sick people out. They might not offer a particular drug, or have a higher copay for a given condition. If insurers' risks were adjusted across the whole population, they'd compete on who offers the best service, not who has the cheapest patients.

There must be a clear progressive alternative to the status quo in the post-ACA era. Progressives need to get better at talking a big game while playing small ball.  Single Payer is a nice, simple idea, but it's not the only way to achieve better health care for more people for cheaper. We can't wait around for a perfect alignment of political forces to usher in some new, magical era of free health care for all. We can't expect its opponents to take it lying down. We need to work on the system as it is, today, before someone else does. We need to do this now.