Home / General / The CA Single Payer Non-Plan is Not a Valid Litmus Test

The CA Single Payer Non-Plan is Not a Valid Litmus Test

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People like RoseAnn “Trump will bring us single payer” De Moro and, natch, David Sirota are trying to run a con conflating a refusal to support a particular single-payer “plan” being floated in California with opposition to universal health care in principle. The rather obvious flaw in the scam is that the California proposal is a joke. Drum explains why, but these are the two most obvious reasons:

Prop 98. Like it or not, California has a school funding law put in place years ago by Proposition 98. It’s insanely complicated, but basically requires that 40 percent of the state budget go to K-12 schools. Using round numbers, if the state budget is $100 billion, school spending has to be at least $40 billion. If state spending goes up to $300 billion, school spending has to be at least $120 billion. Aside from being ridiculous, it also leaves only $120 billion for the health care bill. Oops.

As far as I know, there is no tricky way to get around this. It would have to be dealt with by a ballot initiative. That’s obviously not going to happen in this legislative session.

Waivers. This is the issue nobody pays attention to, but is probably the most important of all. To implement single-payer, California would need $200 billion in new funding plus $200 billion in federal money that currently goes to Medicare, Medicaid, veterans health care, and so forth. Without federal waivers to give California access to that money, the plan can’t go anywhere. As Duke University researcher David Anderson puts it, “If there aren’t waivers, this plan is vaporware.” What do you think are the odds that the Trump administration will grant all those waivers? Zero is a pretty good guess.

Along the same lines, Michael Hiltzik points out that self-funded health care plans are governed exclusively by federal law. That means California would need an exemption from the law. What do you think are the odds that a Republican Congress will grant that exemption? Zero again?

Really, the waiver point is in itself the ballgame. There’s no way of making single payer work without getting federal health care money and the requisite legal waivers, and anyone who thinks that Trump, Ryan and McConnell would work with California to implement single payer would put their life savings into a degree from Trump University. And the waiver problem not only makes this plan vaporware as until 2021 at the earliest, it also makes it unworkable as a model period, unless you think Republicans will never win another presidential election again. As Drum says, universal health care — whether single-payer or another variant — is going to have to be implemented federally, not on states that have to have annually balanced budgets and depend on federal spending.

As with people who insist on “single payer” per se as opposed to “one of the many European models of universal health care, most of which are more plausibly attained in the American system” being the ultimate goal but even more so, trying to make supporting the farcical California proposal is a litmus test for Real Leftism has nothing to do with universal healthcare. The point is finding another reason to say “the Democrat Party sucks.” That’s it. As Dayen says, the people pushing this as a viable single-payer plan are quite simply lying to their supporters.

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  • reattmore

    Asking whether a plan will work is so totally neoliberal!

    • FlipYrWhig

      It seems like the whole raison d’etre of “the left” is to come up with newer and newer litmus tests to declare their foes to have already failed. I don’t know why this electrifies them so easily.

      • postmodulator

        Beats working.

      • outrage is the goal.

        • nadirehsa

          “Outrage” is the goal of the Left? That’s really what you think?

          I guess the Democratic Socialists of America out there at pro-ACA rallies doesn’t count as the Left? Or the community potluck I’m organizing for this weekend, where I’ll be recruiting for a vote canvassing drive I’m conducting in July, also does not count as the Left?

          Or all the people I’ve organized to attend Die-ins outside MoCs offices? Or the overnight healthcare vigil I went to? Or the citizens’ town hall I organized to pressure our house rep to vote no on the AHCA (which worked, by the way)?

          Either you’ve excommunicated a whole lot of leftists, or the brush you’re using to tar us is big enough to blot out the sun.

          • “Outrage” is the goal of the Left?

            not ‘the Left’, “the left”.

            • nadirehsa

              So excommunication, then?

              • sure. why not.

                any other words you’d like to put in my mouth?

                • nadirehsa

                  I don’t think I’m putting words in your mouth, but I would genuinely like to hear you explain who counts as “the left” (presumably this means fake leftists?) and who are true leftists.

          • Scott Lemieux

            “the left” != the left, if you know what I mean, although I prefer “leftier-than-thou” to reduce confusion.

            • nadirehsa

              Ok. That is more helpful, thank you.

              ETA: I do think that there’s significant slippage between uses of “the left” as “leftier-than-thou” and “everyone to my left.”

              I can see the “Citations Omitted” response coming, so let me just say that I don’t have a compelling case assembled to back up my perception of slippery nomenclature. So I can accept it if people on this board say I’m reading too much into things here.

              • CP

                Considering your much longer response below, I’m confused about why you’re so confused up here about what people mean by “the left.” The people you were describing/critiquing below are a pretty perfect description of what most people here (quite a few of whom were at one time Sanders supporters) are attacking as “the left.”

              • djw

                ETA: I do think that there’s significant slippage between uses of “the left” as “leftier-than-thou” and “everyone to my left.”

                Of course, a good deal of people who complain about “the left” are, in fact, very much on the left themselves. It’s something of a hallmark of “the left” to conflate preference for a particular tactical or strategic approaches to political ideology more broadly.

            • Rob in CT

              “Our Leftist Betters”

          • efgoldman

            I guess the Democratic Socialists of America out there at pro-ACA rallies doesn’t count as the Left?

            All six of you?

            • nadirehsa

              Have you been to a march and counted? Just because you didn’t hear about it doesn’t mean it didn’t happen.

              Also, I’m not part of the DSA, nor do I organizer for them.

          • Justin Runia

            It’s great that socialists want credit for supporting the ACA *now*, after contributing to the “more than half the country hates the ACA” narrative that gave credibility to repeal and replace in the first place.

            • nadirehsa

              Republicans aren’t trying to repeal the ACA because some socialists said something mean about it.

              • Justin Runia

                No, but they were aided pretty much from day one by grumbling from Teh Left that boosted the disapproval rating of the bill over 50%. It wasn’t until Trump was inaugurated that approval broke 50%, which would have been handy in a couple elections prior…

            • Paula

              It’s “great” that our leftist betters spent the last 7 years lambasting health care reform and then turning around, lambasting Democrats for “not caring” about the ACA by talking about Russia.

              I realize it’s petty shit, and they’re not responsible for the technocratic nature of the process that unfolded, but I really really hate that they are technically on my “side” because they’ve done little to help themselves or me w/r/t to health care dialogue.

      • djw

        It seems like the whole raison d’etre of “the left” is to come up with newer and newer litmus tests to declare their foes to have already failed.

        This dynamic is central, I think, to understanding what’s going on with the “single payer is the only acceptable form of universal coverage” crowd.

        • nadirehsa

          I think the “single payer only” crowd is animated by two forces, one positive ( to me), one negative. The positive: they are against capitalism in general, and capitalism in healthcare specifically. It’s not intended ironically when leftists say we think for-profit healthcare is immoral.

          The negative: I don’t think people really understand the nuances of single payer vs. Medicare for All vs. the AmeriCare plan floated years ago, or the hybrid European systems, etc. I’m trying to help with this when I organize around health care actions. Scott’s post discussing the nuances of healthcare systems a few weeks ago was excellent in this regard as well.

          • Rob in CT

            I’d agree with this, though I’m not particularly anti-capitalism (I don’t love it, but I see nothing obviously better than managed capitalism to switch to). Markets have their uses. Universal Healthcare* as a right, as opposed to as a commodity, is the right concept.

            The details matter, and by details I don’t just mean the mechanics of whatever plan gets cooked up but also the political system(s) we have to work through. So there’s the “do we build off of Medicare? Medicaid? Tear it all down and start over?” question, and there’s also the “how do we pass this” question. Both matter.

            * – some level of care – there will always be arguments over how generous a public plan should be. Should it be completely free at point of service? Does it cover X (abortion is the obvious high-voltage wire here)? Are there any other limitations?

          • nemdam

            It should be mentioned that being against capitalism is not a view shared entirely by the left and I would bet only a small minority of the Democratic party. I’m not making a judgment, but I’m just demonstrating how impossible it would be to gather support for single payer if one of its goals is also to degrade capitalism.

            • nadirehsa

              This is a very age-dependent assertion. Older liberals? Correct. They are capitalists. If you look at the polling of younger people re: capitalism and socialism, however, things are changing, IMO.

              • CP

                Speaking as a Younger, I don’t think you should put too much hope in that. “Socialism” is popular because we’ve grown up in a world where “socialism” had literally no meaning other than “what teabaggers and one percenters call anything they don’t like.” And when you define it that way, it’s not so bad! I strongly suspect, though, that as you get down into the nitty gritty of things that involve raising taxes and increasing regulations and whatnot, a lot of that support bleeds off.

                • nadirehsa

                  Also a Younger, and I don’t think that’s true. I think the younger cohorts are genuinely further left (probably due to racial/ethnic diversity and formative experiences in the ’08 crash).

                  But maybe you’re right. Only one way to find out!

                • CP

                  “Further left” is correct, I think. But the U.S. is so far to the right on economics, and the national discourse even more so (in the sense that our self-image and much of what we tell ourselves about the country, or at least have since the eighties at least, is well to the right of how the country actually works) that you could keep going left for quite some time and remain reliably capitalist. It doesn’t necessarily mean people are going to be down with, say, Scandinavian level tax rates.

                • nadirehsa

                  It doesn’t, no. Let’s go as far as we can, then, and then go from there. Either way, we’ll end up with a better society.

                • djw

                  My observations as someone who teaches a few hundred youngers political science every year are in line with what I think is the best read of the relevant public opinion data:

                  It does appear to the be the case that youngers are legitimately and meaningfully further left on matters economic (this appears to be true even among those who identify as Republicans, relatively to older Republicans). They are also less allergic to the word “socialism.”

                  To take from those two facts that they are actually “anti-capitalism” would, I think, be a substantial interpretive error. They are more likely to support a vision of a capitalist society with greater intervention and a more limited role for markets, and a broader view of public goods, than the one we’ve got now. But what they want is, obviously, a different, better kind of capitalist society, not a non-capitalist one. The water is muddied by the popularity of anti-capitalist rhetoric, from people who are very obviously adherents to a “capitalist social democracy” vision, if you drill down even a little into their worldview.

                • nixnutz

                  Further left than older people or than young people from 20 or 40 years ago? I really don’t know, I went to a very Marxist college and half of my close friends were in revolutionary Communist parties when I was in my 20s, so my perspective might not be typical. I think it might be the case that today’s left is larger but it seems to be far less radical, which may be a good thing.

          • efgoldman

            The positive: they are against capitalism in general, and capitalism in healthcare specifically.

            Translation: You live in Political Fantasyland, where actually getting people elected is an afterthought at best.

            • nadirehsa

              It was a fantasy when I was out canvassing for Democratic candidates to push the area I live in in a more leftward direction? I thought for sure that really happened. But I guess you know better, given your extensive work on this issue.

          • ForkyMcSpoon

            Single payer doesn’t do away with for-profit healthcare, because hospitals would still be run by for-profit corporations. And honestly, we’d probably still end up with supplemental insurance and providers who don’t take public insurance, etc. There aren’t really any systems that totally do away with it.

            BUT if you want to claim you’re for minimizing capitalism in healthcare, the British NHS should be your model, not Canadian single-payer. But I guess even the leftier-than-thous realize that they really don’t want to deal with the political fallout of attacking doctors’ salaries and independence.

            • nadirehsa

              This sounds a lot like, “You can’t completely get rid of profit in healthcare, so you should never try anywhere.”

              I’ll take what I can get. I would like something like the NHS. I will accept the ACA if that’s the best we can get right now; in fact, I’m very engaged in organizing to save it.

              The politics of provider salaries are extremely difficult; they may be insurmountable. That’s not a reason not to try.

          • Brien Jackson

            I don’t think this is *totally* right. It’s pretty rare to encounter a single payer advocate who is also adamantly opposed to privately owned hospitals, doctors in private practice, etc. So while there’s a sort of rump who are morally opposed to for profit health *insurance*, there’s very few people opposed to for profit healthcare outright.

        • NewishLawyer

          I’ve mentioned this before but a net acquaintance (who is probably to my left) opposed this legislation because of California’s other funding needs (he has school-aged children and is involved with schools in his town as an elected member of the board of education).

          But he got a lot of pushback from single-payer now types on his friend feed. Single-payer has become the must and I wonder if this is because many people on the left just don’t have kids and are starting to make more conscious decisions not to have them.

          • nadirehsa

            It’s your hypothesis that leftists don’t have children?

            • stepped pyramids

              It wouldn’t be NewishLawyer without the occasional bizarre hypothetical sociological explanation.

            • spencer_e9876

              “many people on the left” != “all people on the left”

              That said, I’d like to see some data to support that hypothesis.

          • Stella Barbone

            In my experience single-payer is popular because it is conflated with universal health care. I want UHC and believe that single payer would be slightly less expensive, but don’t rally care at all how UHC gets implemented.

          • Brien Jackson

            No, I think it’s because a substantial portion of them are reading hacks like Sirota who casually imply that single payer is the only form of universal coverage.

    • DN Nation

      You know, I supported to a point Bernie not getting bogged down in the details during the ’16 campaign. Aim for the stars, create a workable reality later. I think it makes for good turnout and moves the window.

      The only problem with my idea is that…when faced with the ability to make their plan a workable reality, these knuckleheads steadfastly refuse. At which point the only alternative they offer is “screw it.” Thanks, guys.

      • Micheál Keane

        Remember how Bernie’s health care plan saved so much money on prescription drugs that we were spending negative dollars on it? And when someone pointed it out, his campaign called him an insurance company shill.

        • Rob in CT

          That incident, plus the interview in NY (forget the publication) really shook me, and nearly changed my vote in the primary (and, if things had been closer, I very well might’ve voted Hillary over those things).

          • DN Nation

            New York Daily News: I get that point. I’m just looking at the method because, actions have reactions, right? There are pluses and minuses. So, if you push here, you may get an unintended consequence that you don’t understand. So, what I’m asking is, how can we understand? If you look at JPMorgan just as an example, or you can do Citibank, or Bank of America. What would it be? What would that institution be? Would there be a consumer bank? Where would the investing go?

            Sanders: I’m not running JPMorgan Chase or Citibank.

            Daily News: No. But you’d be breaking it up.

            Sanders: That’s right. And that is their decision as to what they want to do and how they want to reconfigure themselves. That’s not my decision. All I am saying is that I do not want to see this country be in a position where it was in 2008, where we have to bail them out. And, in addition, I oppose that kind of concentration of ownership entirely.

            • DocAmazing

              Yes, how outrageous that a presidential candidate did not have a detailed plan for a process that would need to respond to changing conditions and would require the input of financial industry specialists. A real candidate would have had an eight-hundred-page plan sitting in his lap.

              • Brien Jackson

                Lol, he didn’t even have talking points about an actual plan, and he had to beg off a question about the MetLife case because he didn’t know anything about it.

                You know who DID know about it, strongly criticized it, and could also explain the rough details of their financial regulation plans? Hillary Clinton.

                • DocAmazing

                  Because when I want to restore the provisions of Glass-Stegall, “Clinton” is exactly the name that comes to mind.

                • Brien Jackson

                  I know I’d trust the guy who promised to save >100% of prescription drug costs, that’s for sure!

      • Brien Jackson

        Does anyone else remember Joe for Lowell explicitly arguing that lying about what single payer was and promising everyone a pony to win, then springing the real bill on them later, was both the obviously correct and perfectly normal way to go about selling your policy preferences?

        • personwhoreadssometimes

          whoah seriously?

          • bj2745

            Yeah, it might have even been the thread where he finally flounced for good. He was literally claiming that no one ever analyzed candidates’ white papers before Bernie’s healthcare plan.

  • postmodulator

    This is almost certainly not what the California legislators have in mind, but I wonder if there’s any political value in forcing the feds to deny the waiver. Probably not, the six people who actually care about federalism already know that that GOP is full of shit.

    • ploeg

      If the plan is to temper-tantrum your way to political power like the Republicans supposedly did, then you might want to consider whether your coalition will fall apart once you have to put together a proposal that can actually become law. There might be some virtue to having your coalition fall apart now rather than later, but I doubt it.

    • stepped pyramids

      Well, the problem as far as I know is that there actually aren’t waivers in statute for some of these funding sources. Medicaid and (I believe) the ACA credits have waiver programs, but Medicare does not.

      • Brett

        For Medicare, you’d need an Act of Congress and reforms to the overall program to allow California to divert the FICA payments into its fund while opting the recipients out of the federal program.

        • stepped pyramids

          Exactly. And I believe there was even discussion of using VA funding, which… ain’t gonna happen.

          The national political environment in which California would be able to pull this off is one in which a national bill would be easy to pass.

        • j_doc

          This has already happened in certain specific contexts. Programs for All-inclusive Care of the Elderly (PACE) combine a person’s Medicare and Medicaid resources into a single pot that becomes sort of like a miniature single-payer system overseen by the PACE. The difference from, say, an HMO is that the PACE is a health care provider that is completely responsible for the care needs of its enrolled patients. It started under a demonstration project waiver some 40 years ago, and the concept was later written into law.

          I would see a state-level program working more like this, funneling money back from the federal government with some set “savings” level lopped off the top, rather than directly diverting payroll taxes.

          But yes, all such things would require a modicum of cooperation, or at least not antipathy, from CMS and HHS.

  • NewishLawyer

    I have seen a fair bit of anger on the left at the shelving of this legislation. Largely of the variety that the Assembly Leader is in the pockets of the insurance industry.

    The Senate plan is exactly the kind of unicorns and rainbows and pony legislation that gives the left a bad name from time to time. It was a fantasy piece of legislation offering full funding for any conceivable medical need including stuff not on most government insurance plans like mental health, drugs, and dental. It was estimated to triple the state budget, and the Senate didn’t even bother figuring out a funding mechanism. It seemed like something the Democrats could pass to imperil their supermajority status while also allowing the Leftier than Thou types (Hi Phil!) the opportunity to gloat.

    • SatanicPanic

      “The Senate plan is exactly the kind of unicorns and rainbows and pony legislation that gives the left a bad name from time to time. ”

      This is incorrect. The bill was intended as a starting point. I don’t think it’s fair to blame the legislators who put it forward because a bunch of left clowns latched onto it.

      • dmsilev

        The bill was originally pushed by the nurse’s union here, and they at least seem from the outside to be considering it a serious bill rather than just a starting point. And they’ve gone all “neoliberal sellout” on anyone critiquing it (Kevin Drum posted a chunk of an amusing email that he got from one of the union’s reps complaining about Drum’s assessment of the bill).

        My main takeaway is that I’m going to be a lot less willing to believe the nurse’s union on policy questions.

        • SatanicPanic

          They’re being stupid. I posted what Toni Atkins, one of the original sponsors had to say, and it’s very pragmatic. I love pooping on Sanders supporters as much as the rest of them, but the way people are framing this is not accurate.

        • DocAmazing

          Ah, solidarity. It was the nurse’s union that got us decent staff-to-patient ratios, that forced hospitals and insurers to knock off their “drive-by delivery” policies, and that kept a number of urban hospitals open that hospital chains wanted to close. But let’s by all means blow them off on matters of policy. WHat do they know about health care, anyway?

          • Brien Jackson

            Well their President knows that Donald Trump is going to get us single payer, that’s for sure!

          • Hogan

            Right in one thing, right in all things!

          • Hob

            1. As a former nurse who worked in California, I have huge respect for the accomplishments of CNA, many of which happened under DeMoro. (I wish I’d been a member, but I was in a SEIU local instead.)
            2. Most of those happened almost 20 years ago. The current organization shouldn’t get infinite credit forever for those accomplishments, any more than the Democratic Party should get infinite credit forever for Medicare. It’s fair to judge them on what they’re doing now— and dmsilev was clear in saying that they had built up a lot of good will which they are now damaging (“I’m going to be a lot less willing to believe…”).
            3. Your last line is ridiculous. Nurses are extremely credible on health-care matters that are directly connected to the actual work they do; the less direct the connection, the less I’m going to automatically consider them experts just because they’re nurses. The accomplishments you cited were in the former category.
            You, a doctor, presumably know a fair amount about the hassles of dealing with insurers, but that doesn’t mean you necessarily know anything at all about how to design a better system, or whether it’s possible to get it funded at the state level. I know a lot about computer programming and I still have trouble with my cable TV box. Argument from authority is always suspect, but much more so when “authority” is defined by “being more or less in the same field.”

            • bj2745

              This seems like a good time for a reminder that Doc opposes single payer reducing provider pay whatsoever, and thinks that all of the savings from single payer will come from getting rid of administrative overhead and insurance company profits.

    • nominal

      There’s been a version of this bill for years. It’s not a unicorn and pony thing, it’s more like a statement of goals.

      • Hogan

        A bill to say what kind of bill we’re going to pass later?

      • personwhoreadssometimes

        Why would a piece of legislation be a ‘statement of goals’? I admit I’m not an expert on the california legislation process, but couldn’t the Senate at least have specified what sort of taxes would be used to fund it?

    • AlexSaltzberg

      It was a fantasy piece of legislation offering full funding for any conceivable medical need including stuff not on most government insurance plans like mental health, drugs, and dental.

      One of the stranger side-parts to single payer advocacy (in the United States) is that they are proposing a new, better, and more generous health care plan. Probably because it needs to be better than the standard model as a selling point.

      It would be helpful to those advocates if they asked themselves why that needed to be in their proposal — that single-payer is not enough of a selling point by itself, but that better health care coverage is the thing they are selling to the majority of the public.

    • TheBrett

      A lot of it is basically Litmus Testing, like what the anti-choice movement does with Republicans at the state level. There’s nothing necessarily wrong with that*, and possibly some value in passing the bill and forcing the courts and Republican-dominated Congress/Presidency to reject it.

      * That said, it is incredibly annoying that this is starting to take on “Relitigating the 2016 Primary” tones again. Those were heavy in the angry email that Kevin Drum got about his post.

    • Paula

      The anger is also due to the fact that the CA Dem party is now the target of a lot of Bernie-or-Busters who want to deligitimize the newly-elected Dem party chair. It was a close election that led to the loss of the Bernie-endorsed candidate:

      http://www.latimes.com/politics/essential/la-pol-ca-essential-politics-updates-kimberly-ellis-blames-democratic-party-1498064936-htmlstory.html

      So here’s the thing: you can’t inspire people to believe in any kind of government, never mind socialism, if this is the tack you take when you lose an election. That’s a cynical conservative/Republican argument: the “right” people”didn’t vote, so therefore the result is illegitimate.

  • AlexSaltzberg

    On the plus side for single-payer advocates, I did not hear very much about how this legislation will take away my employer-provided health care. Most of the criticism was associated with the funding mechanisms and the overall cost.

    • SatanicPanic

      I thought that was an indication of how far we’ve come. People can tut-tut about how the funding was there, but that’s the easy part. The hard part is convincing people it’s not government overreach or taking away freedom

      • addicted44

        Wait…finding the sources to triple the current budget is the EASY part?

        • SatanicPanic

          Yes. That was a rough draft and we don’t know that will be the final cost. I suspect it’ll be revised down and the overall plan will be reworked. Getting people to be OK with giving up their employer healthcare plans is much harder than that.

        • nemdam

          I think it’s safe to say that if funding a tripling the size of the state budget is the easy part, this isn’t a real aspiration.

          Look, I have the perfect plan to create the ultimate social media platform which will make both Facebook and Twitter irrelevant. However, I need $100 billion dollars to make it work. But don’t despair. That’s the easy part.

          • nominal

            I feel like you’ve never done legislative work. The point is to put out a goal, and then figure out where to find funding. You routinely see stuff like “Let’s build a transit corridor in the Central Coast that does x, y, and z,” and then the engineers come back with costs. And they you either raise some taxes, scale back the project, or some combination.

            That’s all this was. “We want to do single payer” was the goal. They budgeted out the goal and it came back at $200 Billion. This was all about putting out a goal, so they pulled it.

            If we had a Democratic president, instead of pulling it we’d have something like “OK, let’s expand medicaid to income level x, and increase taxes on y to pay for it.” Or something similar. But we never got there.

            • SatanicPanic

              Yeah, I’m honestly surprised at the way people are framing this. I agree with Scott that it shouldn’t be a litmus test. But everyone is framing it in a really right-wing sort of way, like California is populated by kooks, and our legislature is fully of mini-Bernie Sanders. This was intended as a starting point- I know this because that’s what the people who introduced the law said it was. And maybe they do things differently in other states, but I feel like I’ve seen this play out multiple times here- we float some idea, everyone in other states says “that’ll never work”, we toss it around for years, eventually we get there.

              What are we supposed to do about it when some dummies latch onto an idea for their own ends? Not do anything? Somehow figure it all out in secret and only then try it? Neither is realistic.

      • djw

        “People can tut-tut about how the funding was there, but that’s the easy part. The hard part is convincing people it’s not government overreach or taking away freedom”

        This is really, really, backwards. Similar ideological critiques of, say, Medicare and Social Security, have no potency at all. People are stubbornly partisan but ideologically flexible, but much moreso risk and change averse. Medicare for all is already quite popular, at least when we don’t talk about how to pay for it.

        • SatanicPanic

          “risk and change averse”

          That’s my point. That’s the hard part. People were fine voting for High Speed Rail, despite that having all the signs of being a high-priced boondoggle*. But if it had been “High Speed Rail + after that, no flights between LA and SF” it never would have passed, because then you’re taking something away from people, which this will do. Of course, HSR did, in fact, become an expensive boondoggle, and has dropped in popularity, so ideally we’d do universal healthcare better than that.

        • nominal

          But they did! That’s the point. I mean, I wasn’t born yet, but I’ve READ about medicare and social security being called communism. But now we’re just talking about how much they cost.

          And that’s what has to happen to health care.

          • personwhoreadssometimes

            people still call both communism. go visit the Breitbart comment section.

    • Scott Lemieux

      Not really, because one way it avoided this problem was to offer public insurance so generous that almost nobody would be worse off. But of course if they thought that anything like the level of taxation that would be necessary to sustain that level of coverage was political viable, they would have included a funding mechanism.

  • diogenes

    1. Conservatives are not bound by logic and math, which we reality-based liberals perceive to be an impediment. In actuality, it has not even slowed them down during my lifetime. And while I am fond of saying “Eventually, reality imposes itself”, Lord Keynes spoke to eventualities.

    2. Flowing from 1, why should we restrict ourselves to reality? If conservatives can propose devolution to medieval times, let’s propose a workers’ paradise.

    I offer this only half in jest…

    • Rob in CT

      I have these moments too…

  • NeonTrotsky

    Quite honestly, then the people opposing this should talk about this instead of insisting that single payer will never be viable in the US, which is mostly what I hear/see on FB.

    • Steve LaBonne

      It won’t. Deal. There are far more plausible routes to universal coverage that are also far more often found abroad. People who want to talk about this stuff need to bone up on comparisons of health care systems in other countries.

      • Linnaeus

        Here’s a start: more money.

    • ForkyMcSpoon

      It seems they’re saying it won’t be viable at the state level, which will occasionally rely on cooperation from a Republican president.

      If a law were passed at the federal level removing the need to ask for waivers, that would make it much more viable. But at that point you could probably just pass single payer at the federal level. That still will rely on a Republican to administer it sometimes, but it’s not as easy to sabotage as revoking a waiver.

  • SatanicPanic

    I’ve said this before- it was a nice starting point. Not a starting point as in “we’ll do this now”, it was a statement of “here’s what we plan to do”. This is how we build momentum for it. Next it’ll probably be on the ballot, then it’ll pass, then lawmakers will throw up their hands and go “we can’t do this!” but they’ll have to, and right around that time Kamala Harris will be president and can hook us up with a waiver. This is how we do things here. Everyone pooping on it as a waste of time is missing the point. I bet your state doesn’t have cap and trade.

    EDIT- to add to this, here’s Toni Atkins, one of the sponsors of the original bill:

    Q: Do you envision a single-payer plan for California to be along the lines of the Medicare-for-all idea?

    A: Well, I think that’s one approach. Part of what we are doing and the bill that we put forward really is intent language for us to start the process to evaluate what program we could put into place. But, the key issue is universal health care. And there’s going to be a lot of work. This is the start. When you put a piece of legislation forward, as you know, we will be working on that throughout the year as it goes from committee to committee.

    http://www.kpbs.org/news/2017/feb/22/q-sen-atkins-single-payer-health-care-california/

    • ColBatGuano

      really is intent language for us to start the process to evaluate what program we could put into place.

      This sounds far more ambiguous than what people were saying after the bill was killed.

  • nick056

    Virtually no European country has a Canadian-style system. Germany, France, and, Switzerland, for example. all have attained universal coverage without traditionally defined “single payer.” In fact, the Swiss experience is most relevant for the US. They enacted pretty similar reforms to the ACA, in terms of control over private insurance, except much stronger: I believe the Swiss simply garnish your wages and set you up on a healthcare plan if you fail to purchase insurance. Of course, Randy Barnett is ready with a dump truck full of brocolli for the doorstop of the USSC in the event the US ever implements that model.

    But anyway this post is correct and very good. David Sirota is wanking it when he says the real problem is Dems, not the Republicans.

    • FlipYrWhig

      That’s Sirota’s “brand.” He’s mostly annoyed he hasn’t gotten enough notoriety for it yet.

    • Brett

      France is the closest, and I think most folks would call it very close to single-payer even if it isn’t as comprehensive as the Canadian system. One of the three funds covers over 80% of the population, and the government covers 77% of the costs on average (plus 100% on a lot of stuff), with supplementary insurance covering the rest.

    • Chaz

      This is not true. Britain has straight-up single payer, single provider. Spain has single payer run by the provinces. In Spain private insurance also exists but only 15% of people buy it. Taiwan also switched wholesale from the glorious free market to pure single payer in 1995 and apparently it’s gone very well.

      The British system is the cheapest healthcare system in Western Europe,
      whereas the Swiss system is the most expensive. The actual health
      results are about the same. Folks have looked at a lot of countries and generally the more a healthcare system leans toward state-run on the state-run–private sector continuum, the cheaper it is. (I don’t recall the original source on this but Matt Yglesias and some other bloggers posted it a lot.)

      • econoclast

        The Swiss system would be the most expensive just because Swiss everything is the most expensive.

        I’ve lived in a single-payer country, and in another country with UHC but not single payer, and I feel confident in saying that if the US passed single-payer, the middle class would hate it, and there would be a voter revolt. Single-payer systems are cheaper because they openly ration care by making people wait, and because they don’t pay for stuff that makes only a marginal contribution to health. It works, but it doesn’t fit the customer service mentality that people in the US have.

      • nick056

        Well GPs in Britain are private, but my point was to distinguish single payer insurance from other models of universal care, including an NHS model, where, like the VA, they just run hospitals and employ doctors outright.

        • Chaz

          Oh gotcha. But the terminology is that “single payer” just means the government directly pays the healthcare provider, not that they actually administer the healthcare providers.

          Systems where the government actually manages the hospitals and the doctors are government employees are called “single provider” (and are also normally single payer).

          So Medicare and Medicaid are single payer because the government pays for the services even though they’re privately provided. The VA is both single payer and single provider. The British system is single payer and it’s mostly single provider.

          And as you say the Dutch or Swiss systems, or Obamacare or Romneycare, are neither; they’re just tightly regulated, subsidized, mandatory private insurance. (Except Obamacare included a big Medicaid expansion so its actually a hybrid of private insurance and single payer).

  • Just_Dropping_By

    “Like it or not, California has a school funding law put in place years ago by Proposition 98. It’s insanely complicated, but basically requires that 40 percent of the state budget go to K-12 schools.”

    Which is why government spending priorities should never be constitutionalized. It’s way too inflexible and basically locks the structure of the budget into whatever it looked like when the amendment passed.

    • SatanicPanic

      “Which is why government spending priorities should never be constitutionalized.”

      This, so much this. Even worse is putting them up for votes as ballot measures, which we also do.

      • stepped pyramids

        There are programs passed by initiative I like (marijuana probably wouldn’t be on the path to legalization nationwide if not for ballot measures) but overall they’re a really bad idea. Especially when they amend the state constitution. Especially when you need another initiative to overturn it.

        • SatanicPanic

          I’m OK with some statements of principle, some things like the MJ initiative- that one is probably good for getting out voters. But anything involving spending I’m not big on. then again, we’ve managed to get some tax hikes through, which I’d never thought would happen.

          • stepped pyramids

            I would be OK with an initiative system that boiled down to “we the people of state X think we need to accomplish this goal; the legislature should pass a bill matching these broad parameters”. But policy should be designed by elected policymakers.

          • Justin Runia

            Yeah, I’ve gone pretty far down the road of automatically voting no on Cali props that call for expenditures, particularly those that don’t bundle in a tax increase.

            But Prop 14 (top-two primaries) was pretty good, there’s some worthwhile stuff that breaks through all of the money-backed attempts to monkey-wrench the state government. What we need is reform.

            • SatanicPanic

              I pretty much do this myself. leave the money decisions to the legislature, unless it’s something like when Jerry Brown asked for tax increases.

          • Darkrose

            The CA ballot initiative system is a fucked up mess. Legalization is great and all, but the initiative system also gave us Prop 8. We still have capital punishment because there were two different, confusing initiatives on it. I shudder to think what would happen if single payer was o. the CA ballot.

          • nixnutz

            I automatically voted for all taxes because I knew there were millions of assholes automatically voting against them. I’m really glad I don’t have to put up with the ballot questions anymore, and especially the advertising for them.

    • CP

      Which is why government spending priorities should never be constitutionalized. It’s way too inflexible and basically locks the structure of the budget into whatever it looked like when the amendment passed.

      Correct.

    • NewishLawyer

      I’m against the Proposition system but we have it and I don’t see it going away.

      • gleeb

        Someone should put a proposition of the ballot about it.

      • Just_Dropping_By

        Well, sure, I know it exists, but the problem is something people should keep in mind when voting. I vote against all state constitutional amendments that purport to set specific percentages, ratios, dollar figures, etc. even if I otherwise agree with the general goal of the amendment.

    • Micheál Keane

      Most of California’s problems can be traced back to dumb initiatives. (Washington State has its share of problems from them too)

      Fortunately, they’ve slowly started unwinding things (redistricting reform was a good start) but it’ll take time and probably more initiatives.

    • Denverite

      Cough, cough, TABOR, cough.

      • Michael Cain

        I worked on the Joint Budget Committee staff. TABOR, Amendment 23, the Gallagher Amendment… Unemployment insurance is now a quasi-independent state agency so that it’s out from under TABOR debt limits. Much of state support for higher ed is structured as pseudo-scholarships in order that it not count against TABOR spending. The “negative factor” creativity on the part of the Dept of Ed, the General Assembly, and the state supreme court in order to get around the plain language of Amendment 23. Residential versus business property tax valuations are increasingly distorted to stay within the Gallagher Amendment. Increasingly, taxes are tied to specific spending reducing the flexibility of state/local government to make decisions.

  • Aaron Lercher

    One idea for proposed taxes for the California plan would amount to income redistribution from the top 20% to the rest. This study is revealing about the subsidies enjoyed by the top 20%.
    https://www.peri.umass.edu/publication/item/996-economic-analysis-of-the-healthy-california-single-payer-health-care-proposal-sb-562

    In addition to the opposition by insurance industry and other parts of the healthcare industry, and the annoying little problems caused by federalism , healthcare politics comes down to income redistribution. So if there’s a factional fight over that in the California Democratic Party, it is partly about that.

  • MariedeGournay

    Sirota, I hate that guy.

    • DN Nation

      I once responded to some ridiculous logical stretch he made on Twitter by referencing the old “didja know Hitler was a vegetarian” chestnut. He responded by calling me a violent anti-Semite, then blocked me. It’s almost like he’s not fond of arguing in good faith!

      • MariedeGournay

        I remember seeing on MSNBC scolding someone for not taking the supposed Clinton Foundation ‘pay to play’ rumors seriously. He’s a preening ass.

        • FlipYrWhig

          Of all the self-made pundits from the early days of the blogosphere, Sirota has always seemed to me the one who most wanted to be a famous media personality.

      • Micheál Keane

        He has a great schtick of citing himself in support of his arguments.

    • Micheál Keane

      Sirota supported John Edwards as the “only moral choice” in 2008.

      • DN Nation

        Edwards was talking about poverty in a way that no major candidate was, I’ll give him that. I’ll also note that I’m originally from the Triangle and everyone there knew he was a total sleaze years before the affair.

  • DN Nation

    They’re completely wrong. What’s more, they know they’re wrong. They’re perfectly aware that SB562 is a shell bill that cannot become law without a ballot measure approved by voters. Rather than committing to raising the millions of dollars that would be needed to overcome special interests and pass that initiative, they would, apparently, rather deceive their supporters

    See also: “A true leftist would’ve won in GA-6, also we didn’t bother putting one up because reasons. Georgia is icky.”

  • Xer

    C’mon. Math is for neoliberal sellouts. The structure of American Democracy and the existence of an opposing party are only relevant if sellout Democrats let them be. The words “single payer” are a magic incantation, and there’s nothing to really be learned from the diverse, and sometimes public/private, systems that work in the rest of the developed world.

    Quite honestly, the problem isn’t really the structure of our health care payment and delivery system. It’s the prices. Obamacare would be dandy if we paid the same prices for drugs and services that people do in France, Canada, Japan, etc. Any plan that doesn’t have real controls on price is going to fail.

  • dmsilev

    If the California bill had been basically a statement of principles or an aspirational goal, it would have made sense. Unfortunately, it was presented as an actual serious attempt to get single-payer, despite the fact that the bill was far from serious. If your proposed funding mechanism for obtaining a couple hundred billion dollars is “gee, I dunno, we’ll figure that out later”, you’re not serious. Republicans do that sort of nonsense, and I’d kind of prefer that the Democrats don’t.

    • nominal

      That’s exactly what it was, though, and it made and makes a lot of sense to push it.

      It shows that the biggest state in the nation supports single payer. It pushes the overton window quite a bit to the left. And it’s changed the opposition to single payer from “It’s Communism plus Fascism plus Clinton” to “Man, that costs a lot and you need federal help.”

      That’s far from nothing. Pushing unlikely legislation isn’t nonsense. It’s how you get to the sensible legislation.

      • nemdam

        No, it’s that opposition hasn’t even had to say it’s Communism because the plan is so ridiculous.

        If Obamacare had no serious funding mechanism, and no viable plan to achieve one, we would never have heard about death panels. The opposition doesn’t even have to attack the plan because its ridiculousness collapses on itself.

        • nominal

          Fact is, California considered a single payor health care bill and not a single person said it was communism. That’s the fact. As in, that happened.

          Why do you think that’s a nothingburger?

      • DN Nation

        Hey, right on, but then you’ve got to ixnay on the “whoever attempts to make our pie in the sky a workable solution is a FRAUD who should be MURDERED” stuff, no?

      • SatanicPanic

        And the politicians pushing it were very upfront about what the obstacles were. People are making California pols out to be some sort of cranks without bothering to understand what was going on or even listening to the pols themselves. It’s a cudgel to complain about the Bernie left.

        • Hob

          If they were very upfront, they weren’t upfront enough to get through to any of their supporters. Literally everyone I know in California and every writer I’ve read on this has been taking one of two positions: 1. the bill is unworkable and pushing it was a dumb idea, or 2. the bill is AWESOME and could definitely be passed if only we had the willpower. The nuanced point of view you’re talking about seems to be entirely absent from the broader discussion, and I think that has to count as a political failure; whether that’s the fault of the bill’s sponsors or not, I don’t know, but it is a failure.

          • SatanicPanic

            Seeing as I can’t even get people on this blog to consider it, I sympathize with the pols who pushed this. It’s not an easy job getting people to think beyond binary positions sometimes.

      • stepped pyramids

        It pushes the overton window quite a bit to the left.

        The “Overton window” doesn’t really exist. To the extent it does, it’s way too early to know if this specific proposal would have any effect on the parameters of the greater health care debate. It’s equally plausible that unachievable, failed proposals like these would weaken the position of advocates of single payer/guaranteed universal coverage.

        • Scott Lemieux

          Exactly. The Overton Window is just back-of-a-cocktail-napkin bullshit used to pretend structural constraints don’t exist. There no actual evidence it’s a thing, and the example is was developed for (bush’s Social Security push) did the opposite of what Overton predicted.

          • Brien Jackson

            Well it’s at least better than its corrollary: The theory that you can get 110% of what you want in a negotiation if your first ask is astronomically high enough.

            • Scott Lemieux

              In related news, the Mariners would like to offer the Yankees Jarrod Dyson for Aaron Judge and Gary Sanchez, therefore ensuring that we’ll get Judge,

              • ColBatGuano

                Could we throw in Leonys Martin to get both Judge and Sanchez?

  • Rob in CT

    It’s fine to have slogans. But you also have to have an actual workable plan. Both are needed.
    I had some hope because if any one state could pull it off, CA is the one. I really wanted to see something good come of the effort. So this is disappointing. But the problems raised – Prop98 & the waivers issue – seem insurmountable to me. We need to do this at the federal level or, failing that, it has to be done by a state like CA while the federal government is run by sympathetic people.

    • SatanicPanic

      Absolutely. I think the first step for any supporter of this- myself included- is getting people on board to vote for a Democratic White House.

  • aab84

    For a lot of DSA types, the goal isn’t so much to provide universal health care, as it is to strike a blow against capitalism while also providing universal health care. Not that there’s anything wrong with blows against capitalism, but it doesn’t seem quite as important as ensuring that an additional 20-odd million people get to see a doctor.

    • nadirehsa

      I don’t think that’s quite right. It’s that we don’t think true universal health care is possible through capitalism.

      The massively oversimplified version of the logic is this: 1) Capitalism by its nature creates gross inequalities. 2) The money needed to properly fund the social safety net is currently tied up in billionaires’ bank accounts 3) Only a system which removes the existence of billionaires (and millionaires and probably somewhat below that as well) is capable of liberating those resources so they can be used for the greater good. 4) Therefore we need to propose generous single payer plans and tie the funding of that plan to ever higher levels of taxation on the wealthy.

      So you can’t separate the max income taxation scheme from the true universal health care scheme. People who point out that the country is not ready to support the level of high-income taxation needed to support these very generous single payer plans are, sadly, correct at this time. But I do think we can get there (Maybe not in my lifetime.)

      • MidwestVillager

        Doesn’t every other capitalist developed country have universal health care?

        • nadirehsa

          Capitalist developed? Sure. But in their efforts toward universal health care, they took money from the wealthy to care for everyone, so they’re on their way to social democracy, and are further along than we are.

        • Scott Lemieux

          Exactly. Almost every other liberal democracy has shown that universal healthcare is possible under regulated capitalism.

          • nadirehsa

            “Regulated capitalism” and social democracy really aren’t that different, if they’re different at all. I will gladly adopt the term “regulated capitalist” as a signifier if it helps the politics.

            • Brien Jackson

              NEOLIBERAL SELLOUT!!!!!

            • Scott Lemieux

              France, Sweden, Demark, Germany — these are all capitalist countries. They have a better model than the American one, but they haven’t abolished capitalism, and yet they all have universal healthcare.

  • nominal

    This is absolutely right, but I don’t think the point of aspirational legislation can be overstated.

    What happened here is that the legislative body of the biggest state in the nation almost passed (came close to? seriously considered? pick you poison, doesn’t matter) single payer health insurance. And the main opposition was not a combination of this is communism or this is fascism or death panels, but (1) this is costly and (2) this is impractical because it requires unreliable federal assistance. That opens up a lot of room for expanding health care. It gives moderate Democrats a lot more room to make proposals, even if they’re short of single payer. It gives someone like “reasonable conservative” David Brooks a lot less room to attack Democratic health care proposals.

    It’s incredibly important to bring the debate down to money and practicality. Once we’re down to counting pennies, we’ve won. No non-gerrymandered Republican can take the position that cutting taxes is more important than giving chemo to a dying mother.

    This proposal brings us closer to that day.

    • stepped pyramids

      “Even a supermajority in loony liberal California can’t pass a single payer program, because it would triple the state’s budget!”

    • nemdam

      They demonized Obamacare as Communism with death panels. To think the opposition won’t attack a center-left proposal because a far left proposal also exists is naive. It’s like thinking the right wouldn’t demonize Hillary because she had to defeat Bernie in the primary.

    • The Lorax

      It also outlawed private insurance. Which is bananas considering how invested people are in their insurance–both those who have it and those who work for it.

  • nemdam

    Examples like this are why I don’t take single payer advocacy seriously anymore. It’s simply an expression of wish fulfillment. The dream of single payer has been out there for decades and gained a prominence it did not have since (NEOLIBERAL!) Hillarycare because of Bernie Sanders. Yet, its advocates still have nothing in the ballpark of a viable plan. When you advocate for something for so long, then get a real opportunity to express your views to the mainstream, if you still don’t have a viable plan, you’re not interested in actual implementing the policy and are simply preening.

    This also ignores the fact that the goal should be universal healthcare, a goal which is already shared by the Democratic party, and not a specific version of universal healthcare which is used by virtually no other countries. It would be a mere annoyance if single payer advocates merely had this position. But to then use it as a litmus test to attack the Democratic party especially with Trump in the WH causes me to question how much of an ally these people actually are.

    • Steve LaBonne

      There’s certainly no question about that in my mind.

  • NewishLawyer

    Test? I can’t see comments.

    • Nick056

      It’s reverted to WordPress. My precious precious upvotes!

      • Probably just a glitch in the Trump/LOL program running in the computer simulation we are all “living” in.

    • CP

      Yeah, it’s weird. It’s like Disqus just died, and bumped us all back to the old system. (Go back to old articles from a few days ago and all the comments we posted there are suddenly visible again).

      Glad it’s not just me…

      • Brett

        Maybe they were getting flooded with trolls. The new Disqus comment sections seemed troll-ier than usual.

      • nixnutz

        I’m still using my WordPress login, I was looking at the Disqus comments and as soon as I logged in it switched and all the comments disappeared. Are some of you guys using Disqus logins or are is this now a fork and there are two sets of comments? Although I did log out and they didn’t return so that theory probably doesn’t check out.

        • Are some of you guys using Disqus logins or are is this now a fork and there are two sets of comments?

          And which timeline is darker than the other? (Also, who slipped that ferret into the Trousers of Time?)

    • Murc

      … are we suddenly back on WordPress?

      • wjts

        Hooray!

        • Murc

          Part of me is super-duper thrilled, but another part of me says this is like celebrating that you’re suddenly warm because the building has caught fire.

          • wjts

            My thought was the Christmas Football Truce.

      • WordPress is a neo-liberal sellout, I want my single-payer Disqus back!

        • wjts

          WHY WON’T THE DLC LET US HAVE A REAL LEFTIST COMMENTING SYSTEM LIKE JS-KIT?

    • ploeg

      Well there go my detailed plans for a perpetual motion machine that would solve all of our energy problems forever.

  • The Lorax

    Yes! This was a terrible plan for our state, especially if you care about our university system. And I wish people would stop equating universal coverage and single payer. Bernie did this constantly on the campaign trail.

    Also, people are going to have to disentangle their desire to punish insurance companies from the desire for universal coverage. The former is not a worthy public policy goal.

    • Murc

      Also, people are going to have to disentangle their desire to punish insurance companies from the desire for universal coverage. The former is not a worthy public policy goal.

      While disentangling our desire for universal coverage from our desire to punish insurance companies may be desirable from a political standpoint, from a policy statement you are dead wrong.

      For profit-insurance companies are hideous death machines whose entire purpose is to extract money from people while providing them as little health care as possible. Punishing them for behaving like sociopaths and then destroying them is absolutely a worthy public policy goal. It might not be possible, but it is certainly good policy.

      • nadirehsa

        Amen.

        • humanoid.panda

          For profit-insurance companies are hideous death machines whose entire purpose is to extract money from people while providing them as little health care as possible. Punishing them for behaving like sociopaths and then destroying them is absolutely a worthy public policy goal. It might not be possible, but it is certainly good policy.

          And so are hospital chains, most specialist clinics, the pharma industry and so forth. And the evidence is quite strong that when it comes to the problems of the American healthcare system, those guys are about twice as deadly as health insurance firms.

          • humanoid.panda

            The truth is that, hard as it is to accept, when it comes to the failures of the American system, your kindly doctor is more at fault than the insurance CEO. But that’s not a truth many people want to hear.

          • Murc

            Your ideas intrigue me, Panda That Walks Like A Man, and I wish to subscribe to your newsletter.

            • humanoid.panda

              I am not sure if this a sarcasm or not, but among health economicsts, it’s an universally accepted fact that a central problem of American healthcare is that insurance companies are much weaker than providers, and thus have to pay them much more than Medicare/Medicaid, and vastly more than other health systems pay their providers.

              • Murc

                It absolutely was not. I’m familiar with the phenomenon of which you speak.

                I recognize it as a problem, but I think I take a softer line on it than you do. Providers definitely need a haircut, and they definitely do some shitty things (my Dad has stories about billing shenangians he’s seen his colleagues engage in) but… hrm.

                Providers actually provide care. Like, they actually, you know, heal people. I am less outraged at them extracting value for their labor than I am at insurance companies for running what I view as shitty protection rackets.

                ETA: By providers I mean actual physicians. Not so much drug companies or for-profit hospital chains and the like.

                • CP

                  shitty protection rackets

                  +1

                • We don’t call them “shitty protection rackets”.

                  We call them the new “fecal transplant maintenance regime”, and charge $5000/month for it, minimum.

                • nadirehsa

                  Right. Doctors, through their labor, directly benefit others. They deserve to be compensated for that, and I’m fine with, even supportive of, paying them well. There’s a limit, obviously, but “healing other people is a lucrative pursuit in life” is an overall societal good.

                  Your average pharma or insurance exec? Parasites.

                • BiloSagdiyev

                  Some wise commenter of blogs years ago at sadlyno, probably Davis X. Machina (because if it’s great, it always seems to be him) said that when you put vampires in charge of the blood bank, don’t be surprised when you come up a few pints short every week.

                • humanoid.panda

                  Providers actually provide care. Like, they actually, you know, heal people. I am less outraged at them extracting value for their labor than I am at insurance companies for running what I view as shitty protection rackets.

                  But insurance companies do provide value: their job, in theory at least, it to reduce the vast power/information asymmetry between providers and patients, and thus reduce the overall overhead in the medical system. I agree completely that the structure of the market means that their incentives a misaligned, but there is no reason why an equitable system can’t include insurance companies.

                  In other words: in a world without no intermediaries, any doctor can charge any price, and the vast majority of people will do whatever they can to meet his demands. Heartless bureacracies, whether private or public, are required to tell providers: “to this point, but no more.” The problem in the American system is that our heartless bureaucrats are both too weak (can’t set prices), and too strong (can pick their own clients.)

                • BiloSagdiyev

                  MWUHAHAH! I can comment in WP now, and still haven’t had to type in my password! I’m a two system low-effort commenter!

                  In a world… with password fatigue… this tickles me.

                  Thank you for using the word “parasite”, nadirehsa. I really think it’s technically accurate to describe what Wall St. and the medical biz have done to our society.

                  Alas, while it’s technically fine, I know we can’t use it too much, because there are Nazis running around, and you know they they like to abuse that word for their favorite subject. : (

                • humanoid.panda

                  There’s a limit, obviously, but “healing other people is a lucrative pursuit in life” is an overall societal good.

                  Here’s the thing though: limit setting is not some magical procedure. Someone has to set them ,and setting those limits is an enormous societal good.

                • JKTH

                  The way I think of it is that insurance companies are a lot more unnecessary than providers, but less of an issue when it comes to the cost of health care.

      • The Lorax

        I get the opprobrium. But getting the policy details is hard enough without making the destruction of insurance companies one of them.

        • nadirehsa

          I think a good public option will achieve the destruction of insurance companies, or at least a significant diminution. It doesn’t have to be a stated goal of the plan; just a nice side benefit.

        • Murc

          That’s an entirely fair point, but is a significant walkback from your initial position.

      • CP

        Interacting with them over the last few years has pretty much caused me to label them an organized crime racket.

        It’s certainly not my priority, but I can’t pretend that I’d be terribly bent out of shape if they got stomped on.

        (My wingnut uncle has had the bright theory for years now that the purpose of the ACA was to bankrupt all the insurance companies so that the nation will have no choice but to embrace public health insurance. To which I can only say, “if only.”)

      • Brett

        Someone on another board I hang out with used to be in management at Blue Cross Blue Shield. She said BCBS’s fall-back plan in case the country was seriously moving towards Single-Payer was to try and preserve a role in managing the administration of it, like how states will contract management of Medicaid out to private insurers.

        • CP

          Oh, fuck no. Let them manage Donald Trump’s casinos or something. We’ve got enough crooks in the government as it is.

    • SIWOTI

      I think people would stop equating universal coverage and single payer if we had any easily understood workable examples of what universal coverage without single payer would look like.

      It is easy to explain how single payer would work (everyone would get Medicare/Medicaid), what the transition would be, and how it covers everyone. It is not as easy to explain other non-single payer universal coverage systems.

      Since NFIB v. Sebelius precludes the government from forcing people to buy health insurance, that precludes a German or Swiss style system where everyone has to buy health insurance and the government subsidizes premiums for those who can’t afford it. So that universal coverage model can’t work.

      While I *heart* the UK’s NHS, there is little chance that Republicans will ever agree to a national system of government run (or contracted) health care providers that are free (or mostly free) to every citizen (and available at cost to anyone else who needs it), so that model of universal coverage won’t pass.

      And from there, every universal coverage model that exists gets more and more complicated to create and explain, including the ACA. Which doesn’t necessarily make them worse as universal coverage, but it does complicate the political messaging.

      If I was running for office, I would say the goal is universal coverage, and single payer is one way to do that. Since we have two working programs (Medicare and Medicaid) that are single payer, it makes sense to use them as a starting point to achieve universal coverage. An NHS style system, which we have an example of in the VA system, is also something that could achieve universal coverage.

      NFIB v. Sebelius would put severe roadblocks in the way of a German or Swiss style universal coverage system, and the end result would be that they would almost certainly not be universal. And to get around those limitations would require explanations that would exceed the bounds of this comment box. Which make them poor political policies to campaign on. And conflating universal coverage with single payer increases the support for single payer, which almost certainly increases the legislative leverage for enacting both universal coverage and single payer. “Don’t like socialized medicine? Well, don’t help us on universal coverage and see what you get.”

      • Foster Boondoggle

        “NFIB v. Sebelius precludes the government from forcing people to buy health insurance…” I though it held the opposite. “By a vote of 5–4, the Court upheld the individual mandate component of the ACA as a valid exercise of Congress’s power” (Wikipedia). But IANAL. What is the US roadblock to a German/Swiss/Singapore/Australia style of mandated mixed public/private provision of care? (If it’s “the current composition of Supreme Court”, that’s a political constraint in the same fashion as “the current composition of Congress”.)

        • humanoid.panda

          Yep. Legally speaking, there is no reason why Congress can’t hike the mandate x3 and make it an actual, German style, obligation to enroll. The politics though..

      • sk7326

        https://www.vox.com/2016/2/3/10899790/single-payer-americare

        Yglesias talked about the Americare idea which would work from the current system

        Step 1: Instead of a mandate, create a baseline level of universal coverage, possibly an option which is publicly funded. Everybody who has a social security number has it. Premiums are funded via taxation (of some form). Lower income folks pay less or none. This plan reimburses providers at a lower rate than private industry – although maybe not quite as low as Medicare/Medicaid (though that would be nice).

        Step 2: Anyone can get a tax CREDIT by showing s/he has procured qualified health insurance via other means.

        Step 3: Employers can purchase this coverage for their employees and receive the standard tax break – as long as they provide for at least 75% of the premiums.

        Federalize medicare – while Roberts’ monkeying makes it impossible to coerce states, it does not preclude simply taking the states out of the process.

        Do this, and it does not destroy for-profit health insurance – but it deeply imperils the value proposition.

        Obviously all of this is hard, and impossible with a Republican congress.

      • JKTH

        It’s not really that big of a barrier. NFIB does preclude us from literally forcing people to buy insurance, but it’s not hard to design a system with high enough subsidies/penalties that would get pretty much everybody except politically-motivated RWNJ hold-outs insured.

        I do agree though that it’d be useful for there to be more detailed non-single payer proposals out there. Most discussions seem to just gesture at ideas without fully considering a workable system.

  • Brett

    Why are we back on WordPress? I liked the transition to Disqus. Oh well . . .

    The budget costs are getting all the press attention, but I think the legal problems Drum identifies (and you highlight) are a far bigger obstacle. California would need a waiver for Medicaid, a separate Innovation Waiver to get out of the ACA requirements, and they can’t even touch Medicare funding without an Act of Congress (assuming they want to – presumably having California Medicare-For-All and actual Medicare in separate systems wouldn’t be too much of a problem). It’s quite unlikely that the Trump Administration and Republican-held congress will go for any of these.

    What they need to do is put up a separate bill that just establishes a Public Insurance Plan (a “public option”) with a premium schedule that varies with income, and let any resident and resident children under 18 enroll in it if they choose. That gets you effective Medicare-for-All*, without having to jump through a ton of hoops.

    * I don’t think it will actually be Medicare for all, per se. Making Medicare a universal single-payer system would require some extensive changes to it, and probably an increase in the payment rates to providers to make it somewhat palatable. I wouldn’t expect huge savings and cost reductions in the present from that, just in going forward (and a gradual decline over time in the share of GDP going to health care expenditures).

    • nadirehsa

      This is basically my preferred option as well.

    • Redwood Rhiadra

      “assuming they want to – presumably having California Medicare-For-All and actual Medicare in separate systems wouldn’t be too much of a problem”

      Actually, it would be a HUGE problem. Because the California single-payer plan is more generous than existing actual Medicare. So seniors would actually LOSE HEALTH CARE BENEFITS when they hit 65 and end up on federal Medicare. At least without that Act of Congress allowing them to access the Medicare funds and take over administering Medicare.

      • nadirehsa

        Having a bunch of consistently-voting seniors about to lose some of their care as they transition into the federal system sounds like a fantastic way to get that federal system to provide more generous care.

      • Brett

        I thought the plan for California Medicare-for-All was to simply use the Medicare payment schedule. Although I guess they’d have to shift over to paying for Medicare Advantage as well (the state could reimburse them, or offer its own Medicare Advantage replacement plan).

  • MattMinus

    What if I told you that insurance companies aren’t actively trying to kill patients?

    • Matty

      I would ask you what that has to do, as they say, with the price of tea in China.

    • Murc

      I’d call you a downright liar. I’ve seen insurance companies actively try to kill people with my own two eyes.

    • CP

      What if I told you that insurance companies aren’t actively trying to kill patients?

      “Well, I didn’t mean to.”
      “Didn’t mean to? You put your sword right through his head!”
      “Oh dear. Is he all right?”

    • Lost Left Coaster

      Before Obamacare, they would kick any patient off their plan if they found a pre-existing condition that hadn’t been reported, sometimes things as trivial as acne or some long-resolved condition. This often came when the patient had been diagnosed with something serious. They’d leave the person to die in order to save money.

  • stonetools

    The so called California single payer plan isn’t really a plan if it doesn’t have a realistic funding mechanism. You can call it an aspirational wish list, or moving the Overton window, or whatever fool thing you want, but it’s not a plan and not something you should put forward as a bill. A bill is something you intend to pass into law, so it should look and work like a law. Somewhat OT,but Jeff Stein has interviewed 8 Democrats asking them how they would fix the ACA if the Senate bill fails. The 8 don’t have anything but some vague proposals.I think the congressional Democrats need to be working an alternative that they can present as a clear agenda that all Democrats can sign on to. Needless to say, it has to be something better than an unrealistic single payer proposal or a just a grab bag of ideas.

  • CrunchyFrog

    Yeah, funny how some people will jump on a liberal’s rejection of something that purports to be universal health care, but in fact is a chaotic, unintelligible mess of a proposal that makes ACA look straightforward by comparison, as proof that the liberal never really wanted universal health care anyway.

    Kind of like how they said that because we didn’t support the brutal and illegal invasion and occupation of Afghanistan and Iraq we didn’t really care about women’s rights in those countries.

    We got this same shit when we rejected the bozo health care measure in Colorado in November. I don’t know who drafts these – I figure it’s either secretly done by an ALEC-type group that is trying to sabotage the universal health care movement or is done by one of the many artsy-fartsy liberal factions that can’t be bothered with the boring process of actually learning about how things work and how it should work (you know, like Consumer Reports used to be and may still be) who are funded secretly by the ALEC-like group.

    • BiloSagdiyev

      First legalized weed, now health care for Bozos? Colorado is on the cutting edge!

      • CP

        With the Midwest going the way it is, there are more and more vacancies in the “heartland, but not fascist” department. Somebody has to fill them, and why not Colorado? The mountains are pretty.

        • CrunchyFrog

          I thought the trend was irreversible, but now I’m not so sure. Too many nominal Democratic voters still like to split their tickets and they seem to think putting the daddy party in the SoS office is a good thing. So the GOP keeps winning the SoS office, and with actions from the Trump admin’s DoJ I would not at all be surprised if they suppress enough of the Latino vote here in CO to regain control of the legislature and governorship. All the GOP needs is one term to change voting rules (CO has one of the best, most flexible voting systems in the country to encourage the highest participation possible) and gerrymander to gain a permanent state majority. After that, the state will be as fucked as Kansas. But with nice mountains, true.

          Ironically Utah is that funny mix of ultra-conservatism but with a strong community orientation and support of gov’t programs. Of course, that survives only because of the intense whiteness of the state population, but for now except for the strange drinking laws it’s still tolerable.

  • BiloSagdiyev

    A long, long time from now, Kevin Drum and all of us here will be labelled premature single payer advocates.

  • Lost Left Coaster

    This morning I learned from a guest on Democracy Now, from the Nurses’ Union, that the whole reason this bill was shelved was due to big money insurance companies buying out the Assembly Speaker. Not one word was mentioned about these additional complications that make it impossible to do right now.

    There is so much wasted time and energy right now! And once again ire from the grassroots is directed at the Democrats for no good reason.

    ETA: Some of these Democrats clearly do deserve ire. They’re posturing through this bill that they know could never actually work. But they’re using it to score political points anyway. Ugly ugly.

    • humanoid.panda

      ETA: Some of these Democrats clearly do deserve ire. They’re posturing through this bill that they know could never actually work. But they’re using it to score political points anyway. Ugly ugly.

      But that’s the whole point: the posturers are now heroes, and the people who had to swallow the bullet are the corporate demons. Everyone profits!

  • CP

    Aaaaaaaaand we’re back to Disqus! Just like that.

  • stonetools

    Seems the switch to Disqus ate my comment. Oh well, it wasn’t wisdom of the ages.

  • Brett

    Hey, Disqus again! Although I’m a bit sad that my comment is gone.

    As Drum says, universal health care — whether single-payer or another
    variant — is going to have to be implemented federally, not on states
    that have to have annually balanced budgets and depend on federal
    spending.

    You can’t get full single-payer at the state level, but you can get close. If California were to pass and create a Public Insurance Plan (a “public option”) that was open to all residents and their children for enrollment, and funded out of however they decide to fund this, then that gets you on the way to single-payer even if it’s not technically there.

    As for the California bill, it’s not just the Medicaid waiver. You need a separate waiver to opt out of the ACA, and an Act of Congress to get control over California’s share of the Medicare funding (as well as a system to channel their FICA payments into the California plan instead of the federal one). This is all totally implausible in the present political environment.

    • TheBrett

      Oh, and by “pass” a Public Insurance Plan, I mean “put it a referendum that also includes exemption from the Proposition 98 education formula”. Without that, it just won’t work for the same reason that a state congressional bill won’t (and which Dayen describes pretty well in that eye-opener of a piece).

  • There isn’t any European model that works with for profit insurance companies providing basic care. Scott keeps pretending that the corporatist health care he apparently favors is what they have in Europe, but it isn’t.

    • Scott Lemieux

      This is incredibly dishonest on multiple levels.

    • IM

      There is Switzerland. ACA without it flaws.

  • Michael Cain

    The folks behind the Colorado single-payer ballot initiative that went down in flames last November had looked at the funding in considerable detail. The major revenue streams that were needed to make it work were: federal and state Medicaid money (waiver); the ACA subsidies (waiver); capturing a certain portion of the Medicare Advantage market (waiver and/or statutory changes); workers’ comp premiums; and a substantial progressive payroll tax intended to capture much of the money currently spent on employee health insurance premiums.

  • ASV

    I have started to think that some of these people believe in some sense that there’s a draft bill that just says “Single payer,” and the spineless Dems won’t even put it forward. Indeed, “single payer” is not a policy proposal! For that matter, “regulate, mandate, and subsidize” is not really a policy proposal, which is part of why it took so long to craft the actual ACA.

  • Jeff Ryan

    David Sirota. Now there’s a credible source…

  • Mr_Six

    Prop 98 has an uncodified section that allows the Legislature, with a vote of 2/3 of both houses, to amend the measure to further its purposes. It wouldn’t be simple because Prop 111 followed 98 and there are multiple parts of the California Code that have to be considered, but it is just a drafting exercise to figure out a way to carve the tax revenue necessary for single-payer out of the funding included in calculating school funding. It’s possible that a court would rule that another ballot measure is necessary, but Drum et al. should stop saying that Prop 98 clearly requires one. The California Legislature has done similar things in the past with no more clear legal authority than the uncodified section of Prop 98 provides. Just in the education funding arena, ERAF is an example. If people want to poo-poo single-payer in California, the waivers are a much bigger obstacle, IMO.

  • Brien Jackson

    I mean, when David Dayen says your single payer plan is garbage…

  • Chaz

    If we can’t get a Medicare waiver, can we just leave the Medicare recipients on Medicare and exclude them from CA single payer? And do the same for the VHA?

    These people are already getting near-free single payer healthcare from very popular federal programs, so it’s not like they’d be left in the dust. Healthcare for old people costs a ton, so leaving these folks out of the program would massively reduce that $400 billion cost estimate. People over 65 who happen to not be Medicare-eligible could be rolled into the new CA single payer system along with the under-65s.

    I know that this would be more messy than just having one single payer system, but is there some rock-solid, unquestionable reason that this is not feasible? Leaving all those old voters out might seem to kill the bill’s political viability, but I don’t think so. People receiving VHA or Medicare have no need for newfangled state single payer anyway, so you’re not going to win votes by giving it to them; they might even prefer to be left on the existing systems. You could maybe sweeten the pot by giving a state subsidy or rebate to reduce Medicare’s copays and deductibles.

    If we can’t even manage a Medicaid waiver then we’d need to do the same for Medicaid. In that case we’d definitely need to find a way to supplement Medicaid to make sure the benefits and provider availability match the vanilla CA single payer, and we’d need to create an incentive/inducement to get eligible people actually signed up for Medicaid rather than the vanilla CA plan.

    I imagine the economics of this don’t work out as well as absorbing Medicare. I haven’t read the detailed assessments but I presume the CA plan included some decent cost control (although I’ve also heard the opposite?)? Medicare on the other hand has piss-poor cost control (but still better than the private sector). It may be that the planners were hoping they could get $x from the feds through Medicare waivers and cover the former Medicare patients for a lower cost, using the remaining cash to cover other people or reduce copays. You don’t get to do that if you leave Medicare out of the plan. But you do still get a large savings.

    As for Prop. 98, that’s a big obstacle but not a dealbreaker. If it means we need a ballot measure, well, the legislator is able to create ballot measures. Alternatively create some goofy publicly-owned healthcare company that’s off-budget, and empower it to collect “healthcare fees” in the form of income and sales taxes. That’s really stretching the law but I’ve seen posters saying that CA’s unemployment insurance is already done that way?

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