Home / General / What Might Single Payer Look Like?

What Might Single Payer Look Like?


I am definitely not the LGM health care wonk, but I wanted to point out to you all this proposal about how to get to single payer. The left always says, “Let’s have single payer!” but the conversations rarely go into any depth at all. What would that look like? How would we get there? What about the insurance industry? Etc. So I won’t really comment on the overall quality of this proposal, but rather want to point it out so that commenters can work off some kind of proposal in order to hone their ideas.

Our plan, the Medical Insurance and Care for All program (MICA), is a public health insurance program based on Medicare but open to all individuals. Employers will be required to buy their employees MICA or equally good private coverage. If one does not receive employer coverage, they will automatically be enrolled in MICA and charged for it in their taxes.

ny serious move toward a more rational universal health care system will face strong opposition from hospitals, doctors, drug makers, and insurance companies. That’s because they rely on the byzantine nature of the health care system to charge significantly more than providers and insurers in other highly industrialized countries.

There is no way around this financial reality. Consequently, for any plan to be politically viable, it must aim to reduce opposition from outside the health care sector as much as possible while still achieving universal affordable health care.

The Affordable Care Act (ACA) was designed as a large transfer of wealth from the rich and a segment of healthy middle class individuals to the poor, the sick, and importantly, the health care industry. MICA is primarily a transfer of wealth from the health care industry to everyone else.

The guiding political principles behind this plan are intended to make it politically viable by minimizing disruption, making the transition feel voluntary, and ensuring everyone outside the health care sector is noticeably better off (and at least not worse off).

There are two primary approaches to transitioning to single-payer that minimize disruption and the number of losers outside the health care industry.

The first is to slowly lower the Medicare age and/or slowly add specific groups to Medicare. The second is to find a way to transition our current employer coverage system towards single-payer-like health insurance.

This plan does the latter by strongly encouraging the private dollars currently spent on health care to be redirected toward a new, much cheaper, and better quality government program. MICA will be an attractive option for all companies, as the program should cost 20-30% less than what employers are currently spending on insurance.

The existence of a universally better government program will compel the remaining private insurance industry to perform better.

The reasons for this approach over slowly lowering the Medicare age are multifold. First, is the issue of financing. Lowering the Medicare age would need to be combined with a new tax structure while this plan relies on mainly redirecting employer current spending on private health insurance.

This route is also quicker and more difficult to reverse. MICA would be available immediately to all companies and they would steadily start choosing it.

Additionally, one fear with lowering the Medicare age slowly is that opponents could simply freeze it when elected, ending up with our same system—except Medicare now would start at age 59.

Lowering the Medicare age is likely to be disruptive. There might be some point, for example, when the eligibility age reached 45, where larger companies might stop dropping employer coverage en masse, creating a need for an emergency fix.

There’s a lot more detail at the link.

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  • twbb

    What I’d really like to see is massive government investment in health infrastructure: Create giant radiology centers and labs and leverage economies of scale, and provide support for cheaper primary care options like RNs, DNPs, PAs, etc., by giving them access to expert diagnosis systems (which already outperform physicians).

    • Procopius

      Question: do we have evidence that these things gain economies of scale? Because hot everything does. Banks, for example. It’s been shown that the TBTF banks are actually much less efficient than mid-range banks. They have access to some markets that smaller banks can’t get into because they don’t have enough access to capital, but certainly their operations costs are much higher. Also, the medical specialties you mention are already barred from “practicing medicine.” The AMA has tremendous blocking power. I’m so old I remember when I had measles and the doctor came to our house (in Akron, Ohio) to treat me. The AMA is one of the reasons they don’t have to do that any more.

      • Imaging…maybe? The equipement is expensive to buy and maintain so when every small centre has an MRI machine they tend to over use it. OTOH, I don’t know if you can get enough from scaling up to offset transit issues.

        For care, volume definitely improves care. Going to a hospital that specialises in say colon cancer will get you far better care. So there’s good reason to try to concentrate care in that way. Of course to really do this you need job protection and transit and housing coverage. I wouldn’t be surprised is that paid for itself in cheaper facilities and better outcomes.

        • Richard Gadsden

          This is what the NHS has been doing for some time – each hospital does A&E, of course (transit is a big issue in emergency cases; don’t increase ambulance distances) and they all do generalist care but then there are a bunch of specialisms and you’ll get moved to the nearest hospital that covers your specialist problem.

          I’ve had my back looked at at Salford Royal, my sleep apnoea is Withington and my heart issues were at MRI, because that’s where the specialist care is for those.

          If a doctor sees five patients with suspected X every week, they’ll be much better at spotting the atypical case that turns out to be Y than the doctor that sees five patients with suspected X a year, so this is a quality-of-care issue as well as a cost issue.

        • Pat

          Our hospital, which is well-run, has been buying up local hospitals and networks. So we’re now responsible for around half of the health care provided in our metropolitan area. All the expensive scanning machines have a single electronic scheduler. This gives any doctor in the network access to all of the scanners and has significantly cut down wait times.

          What I mean is that you don’t need a big facility with a bunch of machines. You need cooperation from the groups that have them.

      • twbb

        I think the things I mention will scale, not just in terms of operating costs but capital expenditures.

        As for the AMA, DNPs/PAs are already started to bite into their monopoly, and while it’s a powerful lobbying group it’s not omnipotent.

  • Joe Paulson

    Universal coverage is my concern. Not sure if “single payer” is necessary there.

    Let the wonking commence!

    • NeonTrotsky

      Single payer has basically become short hand for universal healthcare at this point honestly, even if thats not technically what it means.

      • Steve LaBonne

        Well, that needs a lot of pushback. Sloppy thinking on these matters is the difference between political success and failure.

        • percysowner

          Because Hillary Clinton’s pages and pages and huge website of meticulous plans for, well, basically everything won over Make America Great Again? People care far less about sloppy thinking than you give them credit for.

          • Steve LaBonne

            Proposals are one thing. Actually passing legislation is quite another.

            • percysowner

              Political success IS getting elected. Once elected THEN you have to worry about the details, but right now Medicare for all is a slogan people understand.

              • Steve LaBonne

                How’s that working for the Republicans?

            • so-in-so

              See the current GOP Congress… trying to pass SOMETHING after 7 years of slogans. They may (probably) succeed, but nobody can pretend it is pretty or looks organized.

          • JMV Pyro

            It’s more accurate to say they don’t care until they either think the sloppy thinking will effect them personally or it actually does effect them personally.
            Then they start really caring about all those details.

            • SpiderDan

              It’s even more accurate to just say they don’t care.
              See: the last 40 years of Republican economic policy.

          • awarre

            This is true, and for me its a damn good reason to NOT use the term Single Payer. There are so many SP plans out there with gigantic scary price tags that the GOP can point to. Saying “universal health care” instead sells the principle of, well, universal health care, without attaching the party too closely to any one plan.

        • Procopius

          You have a point. However, I think most people understand that “single payer” has become code for, “Everyone, man, woman, and child, gets appropriate medical treatment without thinking about paying a bill. They pay, but whether it’s through taxes or ‘premiums’ is something we have to work out.” If there are still people who don’t understand that, we need to find a way to educate them. The MSM is our biggest obstacle.

          • FlipYrWhig

            IMHO the problem is that “single payer” as a phrase is meaningless. It doesn’t even say who the payer _is_. And the way the phrase seems to work in practice is that it’s supposed to mean “people like me should get free medical treatment, whatever the doctor says we need, and people richer than me should pay for it.” It hand-waves all the thorniest issues like triage and the supply of providers. Which in turn makes it seem amateurish. YMMV.

          • Right here on this very blog, there are regular commenters who are quite clear that “single payer” means single payer only and not universal health care, because universal health care that is *not* single payer does not accomplish the primary goal of destroying the health care industry. Or, in Murc’s own words, “SMASH CAPITALISM”.

            Single Payer advocates have a goal *beyond* simply providing health care. And they are all very well aware of that.

            • Procopius

              OK, I can sympathize with that, but destroying the health care industry is not my goal unless it’s necessary to get to universal care with no immediate payment demanded. I wouldn’t mind destroying the health insurance industry, but it’s not something I want to work for.

        • Hmmm. Meh. If people confuse “single payer” with “universal heavily govt funded and regulated health care” I doubt it matters. I mean I care because that’s how I roll, but I’m not sure it’s a political or messaging problem.

          To a first approximation, if you’re worried about messaging wrt policy details then you’re probably over worried.

          • so-in-so

            The politician has to think clearly, the message may be somewhat more fuzzy.
            Of course, the RW will always equate “Universal Coverage” with something like the NHS, and follow up with mushy horror stories. Remember how Stephen Hawking would be dead under NHS (according to some GOP hack).

            • Even the politician doesn’t have think all that clearly: their staff does ;)

              But I think the standard poly sci point holds: to a first approximation no one cares at all about policy detail. Even well informed lay people tend to ignore most details. And you can’t shield yourself from negative attacks via policy details, cf death panels. The prompt for death panels was *funding discussions with your doctor about end of life care and directives*. This is about as benign a policy provision (and as minor a policy provision) that you can imagine. And yet it was raised into death panels.

      • SpiderDan

        Not really. If you are in favor of any universal coverage plan that ISN’T single payer (read: you aren’t all-in on single-payer) then you are instantly branded a neoliberal shill by the single-payer crowd.

        • DamnYankeesLGM

          Well, sort of. If you were to say “I oppose single payer, and prefer X”, you’d get that reaction.

          But I’d bet if you said, “Single payer is the only way to go, and we should structure it like X” you wouldn’t get that reaction.

          Even if X is the same in both sentences.

          • stepped pyramids

            I can confirm that I have repeatedly been accused of being a neoliberal for suggesting that single payer isn’t the only option for universal health coverage.

            Unless you’re suggesting that people should just lie and call things that aren’t single payer “single payer”.

            • DamnYankeesLGM

              I’m not saying they *should* – I’m just saying if you did I bet you’d get away with it. Because I think a lot, if not most, of the people who really care about “single payer” in the sense you are talking about care about it as a matter of political position – as staking out a “pure” position uninfected by corporate interests or political compromise. They care less about the actual nuts and bolts policy.

            • It’s not a lie if the language shifts.

              Just say “modern universal system like in Europe” ;)

        • ForkyMcSpoon

          Can confirm. When I pointed out some of the political obstacles, I was told I don’t give a shit about the poor. One thing I said was that doctors in the US are paid significantly more than doctors elsewhere, which might mean that single payer costs a lot if you don’t go after their pay…

          My friend’s response: “Fuck the doctors.” Somehow I don’t think this will be a winning slogan, but what do I know, I’m just a neoliberal shill.

  • Steve LaBonne

    As with most “Medicare for all” proponents I don’t think this person understands very much about the Byzantine complexity of actually existing Medicare and in particular the massive financial exposure of Medicare recipients absent a lot of supplementary private insurancem

    • stepped pyramids

      This plan is not a “Medicare for all” plan and is specifically contrasted with such a plan. This sounds more like Pete Stark’s “AmeriCare” plan, where the government offers an affordable public plan available both to individuals and businesses, with automatic enrollment and heavy discounts for lower-income people. Instead of the IRS just levying a fee if you don’t have insurance, they charge you the premium for the public health plan.

      • Scott P.

        As described, employers could opt for the Medicare plan, lower their costs, and end up providing worse insurance for their employees. So those with employer-based health care are at risk of ending up worse off.

        • stepped pyramids

          That of course depends on how good the public plan is. Most of the better employer-provided plans out there are a result either of union negotiation or a company with otherwise well-compensated employees offering a perk. If there’s a significant gap between the public plan and the best private plans, I believe those employers are likely to keep the private plans or replace it with supplemental insurance or just higher salaries.

          I can say that I’ve had really shitty employer-provided health care and really great, and there’s definitely a point where the difference between good and better is just how much of the premiums the employer pays for you.

      • JMV Pyro

        It essentially is an updated version of that plan, they say as much. Vox had an article about AmeriCare being a good potential path forward as well a few months back.

        Honestly, I’m pretty amiable to the the idea myself. It seems like the best path to get around the whole employer-based insurance/loss aversion thing.

    • mch2

      Yes. After over 40 years on an excellent employer-provided plan, on recent retirement I have been amazed (sad to say) at the reality of Medicare. Insurance companies control most of it. Not necessarily bad (cf. Germany, France). Just saying that Medicare is mostly insurance-company managed. Do people realize this?

      • StellaBarbone

        Medicare parts A and B are still run by the federal government. Medicare part C, the “Medicare Advantage” plans, and part D, the pharmaceutical benefits plans, are insurance-company managed. Medicare A and B picks up 80% of covered medical costs and most people who opt for A/B vs. C buy Medicare supplements unless low income makes them eligible for Medicaid as the secondary provider.

        France operates exactly like Medicare parts A and B with employers providing or individuals purchasing supplemental insurance to cover the 20% not covered by the A and B equivalents. Both Medicare parts A/B and the French health insurance system provide healthy markets for private insurance companies. France, of course, gets really good outcomes despite not being a single payer system….

      • Pat

        I recently lost my aged mother due to cancer. She had had Medicare Advantage for years, but as the bills set in she was enrolled in Medicaid. They took almost $800 a month – half – from her SS for the privilege. Comparable insurance off the exchanges for someone with less than $20,000 annual income would not have cost $9000.

  • DamnYankeesLGM

    Isn’t the easiest way to do something like Medicare for all to just do two pretty simple reforms – (i) let everyone buy on the Obamacare exchanges no matter what and (ii) produce a public option which by law provides coverage no worse than the best plan available on the exchanges (maybe the best silver plan or something) and is priced at the cheapest price on the exchanges?

    That way, people would be voluntarily signing up to government health care. They wouldn’t feel like they were *forced* on to the system. And people would obviously sign up since its the best deal. And then over time private insurance would just die on the vine for anything other than supplemental coverage.

    Seems easiest. No?

    • stepped pyramids

      That’s a way toward universal coverage, but it’s not “Medicare for all”, all forms of which I’ve seen prohibit any kind of private plan that covers the same things as the public plan.

      • DamnYankeesLGM

        Well, it’s not Medicare for All at first. It’s the path *to* Medicare for All. It’s how you go from here to there in the least disruptive way. That’s how I was thinking about it.

        • stepped pyramids

          I mean, even “Medicare for all” is a misnomer because most of the proposals for it actually eliminate the current Medicare program and replace it with more comprehensive coverage.

          • JMV Pyro

            I figured they’d just call the more comprehensive program “Medicare” and call it a day.

    • Steve LaBonne

      Yes, I think building on ACA in some such way is the path forward.

      • Pat

        I think a key aspect will be getting rid of the income cut-off for subsidies. People who make more money should still have the cost of their insurance limited to 3-5% of their income.

    • rm_rm_rm

      Although I don’t know policy, I think I do know consumer/voter responses to branding. This seems to make a ton of sense to me. This is the public option we all wanted, right?

      ***But brand it like it’s another private plan.***

      Americans need to think they just got a great deal on an insurance plan, because they are such smart bargain hunters. Do not mention that it is the federal government public option.

  • Azza

    Australia had the most contested route to universal healthcare of the existing single payer schemes, which was established in 1975 by a Labor government, then repealed (contrary to promises of maintaining it) by the Coalition in a series of steps between 1976 and 1983 and then re-enacted in 1983. The same groups opposed to universal care in the US were opposed to it in Australia, as they were in Canada, New Zealand and Britain. The opponents of universal care in the US are not going to suddenly start singing Kumbaya and withdraw their opposition because a universal scheme is nice to them.

  • SpiderDan

    I, for one, think it would be much better to have the Supreme Court fully-torpedo a law implementing single-payer than it was for them to simply undermine a law increasing coverage.

    SCOTUS nominees don’t matter, both parties are the same, etc.

    • Joe Paulson

      Jill Stein is intriguing.

    • Paul Thomas

      Not a lawyer, I take it. The constitutional argument for single-payer is a lot more unambiguously correct than the argument for the mandate was.

      (Also, one should note that the two aren’t mutually exclusive. All you have to do is put in a severance clause that reverts the law to ACA in the event a sufficiently large portion of single-payer is struck down.)

      • SpiderDan

        Not paying attention when Bush v. Gore was handed down, I take it.

        The idea that partisan SCOTUS justices would be unable to strike down single-payer because it’s just too constitutionally sound is comically naive. The ACA was significantly crippled because SCOTUS decided that forcing states to participate in Medicaid expansion was too coercive, and you’re saying that they have no choice but to uphold a law forcing every state to participate in single-payer? Absurd.

  • stepped pyramids

    I’m not sure this plan is technically single payer because it doesn’t entirely eliminate private health coverage that provides the same benefits as the public plan. But in practice, my understanding is that instead of offering “Cadillac” plans that are better than the public plan, instead insurers are likely to provide supplemental plans that just cover things the public plan doesn’t.

    • Note that by that definition the UK does not have a single-payer system. In fact the only country I know of that does would be Canada.

      The trouble with adopting the Canadian system would be making people give up their private insurance. The Canadian system was adopted before private insurance plans became entrenched the way they are now here. So I wouldn’t recommend going that route in the US.

  • applecor

    We may not even be able to hang on to ACA with the entire healthcare industry FOR it, yet somehow we are supposed to be able to pass MICA with the entire healthcare industry AGAINST it.

    US providers are not going to suddenly wake up one morning saying “You know? We take too much of the economy. Based on what other industrialized countries do, we aren’t entitled to what we make.” There is already going to be a supply shortage with the current level of healthcare funding. Meanwhile insurance companies supposedly earn their keep by putting downward price pressure on providers. They try, but ultimately the providers have the power.

    Like twbb says, if we want to cut the share of GDP taken by healthcare we have to attack the government granted monopolies on care (licensing) and drugs (patents). However it is not clear to me that we have to, or can, cut the healthcare GDP share at all to get to universal coverage.

    • njorl

      I think the strategy would be to pass a version of MICA which isn’t that threatening when a political opportunity presents itself. Then, when another opportunity presents itself, make it better, and so on. Ratchet up the coverage whenever possible. When it’s clearly outperforming other forms of insurance, it can be adopted as a baseline single payer system.

  • As far as I can tell (I only skimmed the article, so I could be wrong) this single payer plan would gradually create a universally accessible government health plan. It would not outlaw private insurance. In fact, private health insurance exists in so-called single-payer countries such as Canada and the UK although its scope is limited by law in Canada and by the dominance of the NHS in the UK.

    As I understand it, a health system where there is a universal public plan that covers what is generally acknowledged to be essential health services is a single -payer system. One flaw in Canada ‘s system, though, is that drugs are not covered by the single payer plan. There, some people are covered by public plans while others buy private insurance, like in the US.

    • Azza

      Australia allows private insurance, but we also cover drugs and some things most single payer plans neglect like psychiatric services.

    • JMV Pyro

      Is there any example of a universal healthcare system that outright bans private insurance these days?

      • stepped pyramids

        Conyers’ Medicare-for-all bill bans any private plan from covering the same things the universal plan covers.

        • JMV Pyro

          Should have probably specified that I meant existing universal systems. Like the ones in other countries.

          • stepped pyramids

            Yeah, actual single payer is pretty rare.

      • djw

        Canada, I think, is the only one.

        • TheBrett

          Canada and the Scandinavian countries’ systems, and maybe some others I can’t remember. The latter have co-pays but no private health insurance IIRC.

      • Gareth

        North Korea.

  • mongolia

    not a health care wonk by any means, but wouldn’t it be better to say “medicaid for all” instead of “medicare for all”? medicaid has the advantage of being for anyone at any age, whereas medicare is for older people, so for issues that only arise for younger people (i.e. childbirth and related issues), medicaid would presumably have administrative infrastructure to deal with this currently, whereas medicare does not, for obvious reasons.

    pedantic point, but genuinely curious as to why “medicare for all” is the formulation SP advocates prefer as opposed to “medicaid for all”, other than medicare and medicaid sound similar, and that medicaid is for the poors

    • JMV Pyro

      I think it goes back to the branding idea that “Medicare = popular program” and “Medicaid = unpopular program”.

      Medicaid is of course pretty damn popular these days, but the brand name has stuck.

      • applecor

        If it’s all about branding, I recommend “Trumpcare”.

        Half the people will be for it on substance, and the other half will be for it because it contains the word “Trump”.

      • Howard_Bannister

        Medicaid has the whiff of ‘health care for poor people,’ while Medicare is ‘something everybody gets because they paid for it.’

        So Medicare as a name will probably stick, even if it’s really Medicaid.

    • randomworker

      I’m in the Medicaid as the default option camp. It’s a little lean, but it gets the job done.

      If the default is Medicaid, then you can layer other coverage over it and keep a “private” sheen, that seems to be important to a majority of voters. Like employers could offer plans that pay for private rooms, less efficacious and more expensive drugs, etc.

    • ForkyMcSpoon

      Campaign on Medicare for All but give people Medicaid for All for all I care. I don’t think eliding the differences between the two will cost Democrats anything, as long as the features of the program are good.

    • stepped pyramids

      “Medicare for all” usually doesn’t actually mean “Medicare”, it means “a new comprehensive public health plan called Medicare”. And the reasoning is just that Medicare is a popular and well-known program.

    • Denverite

      There is a big philosophical difference between the payment structure in Medicare and Medicaid. Medicare envisions the providers making a reasonable profit. Medicaid really is supposed to be a “reimbursement” structure, where the provider gets paid what it cost to provide the service and nothing more. In practice, most services are reimbursed a flat fee, so if the provider can provide the service for less, then she can pocket the difference. But there are some types of services that still set rates retroactively based on the cost to provide the service. Nursing facilities literally tally up what it cost to provide services to their residents, prorate that over how many were Medicaid (most), and then set the rates retroactively on a cost-reimbursement basis. (If your next question is “how in the world do they make any money?”, the answer is that they also provide much more lucrative Medicare rehab services, which are only short term, but a bed’s a bed.) Basically, nursing homes are using the Medicaid patients to keep the lights on, and the Medicare patients to make bank.

    • BloodyGranuaile

      As a matter of branding, I think it’s because Medicaid is a means-tested program and Medicare is fully an entitlement.

      As far as what I understand of actual health care policy (which is not a lot, although the discussions here have been very informative and I follow them with interest), Medicaid seems like it would be a better program to build a universal system off of.

  • JMV Pyro

    Overall I like the idea behind the plan, although I’d still need some clarification about how the “Funding” works. I get that the plan is to shift costs from private to public, but I’m lost on the specifics.

    Also, that “Doctor Immigration” section is 100% necessary, but oh man would the AMA go ballistic at the sight of it. Realize the entire plan is prefaced on “they’ll hate us anyway, might as well go all-in”, but still.

  • Denverite

    When you fill out your taxes, you provide your health policy number. If you don’t have one, you are auto-enrolled in Medicaid or whatever you want to call the new government-provided insurance. (I’d probably envision something a little more generous than Medicaid and a little less generous than Medicare, but it doesn’t matter.) You get charged 3% of your income (or whatever the surcharge rate would be to zero out spending — probably not that high because most people who auto-enroll would be young and healthy). If you show proof of private insurance at any point during the year, you can go off the government plan. Voila.

    • Murc

      When you fill out your taxes, you provide your health policy number.

      As long as we’re dreaming, why not dream of a world where most people aren’t filling out their taxes?

      This is possible. There have been numerous proposals along the lines of “for most people, the IRS has all the information they need to calculate your tax burden and your refund-slash-amount owed. There’s no reason they can’t just send you a fully or partially completed return, and then you sign off on it. This would save both the government and individual tax payers money.”

      So if we’re dreaming of better policy, why not a world where your insurance company is already reporting your policy number and it is already being factored in?

      • StellaBarbone

        That’s how taxes are done in most of Europe. A pilot program in California was very popular with taxpayers, but for some reason the tax prep services lobbied hard against it.

        • Rob in CT

          Buddy of mine described the process in Finland to me and I was green with envy.

      • rm

        Another nice thing conservatives won’t let us have. They want people to hate taxes, so making the filing impossible to do correctly helps them.

        • FlipYrWhig

          It’s not even THAT hard to prepare and file your own taxes for the way most people live, so conservatives have spread a mythology of a rapacious IRS lurking to jack you up on small mistakes and run you into the ground. See for instance daytime cable-channel advertising. It’s disproportionately medical devices, personal-injury lawyers, and tax-debt resolution services.

    • TheBrett

      I like that idea – Medicaid as the Insurer-of-Last-Resort, and the one you get auto-enrolled in. It might be wise to couple that with some laws to make sure private insurers don’t just skim the cheapest patients, and then use the extra costs of Medicaid having all the sickest ones as a rationale to cut the program.

      Pretty much any state could theoretically do that now, with a waiver from the federal government (although fat chance of getting that from the Trump Administration right now specifically).

  • Brian J.

    This is not a proposal. This is a speech that any Republican senator could be giving at this very moment.

  • TheBrett

    If you’re going to create a true public insurance plan to go along with private plans (while also serving as the Insurer-of-Last-Resort), it would be best to set it up as quickly and efficiently as possible. Not so fast that the implementation is a mess, but fast enough so that it could be done inside the two terms of a Democratic President.

    Trying to do it more gradually than that is probably going to fail. It will stall out once it has added more stakeholders and faces a change in party control of Congress.

    • JKTH

      Yeah I don’t really see the need for this specific proposal to be phased in. Maybe give it some lead time like the ACA did but no need to drag it out. It’s not all that disruptive and to the extent that it is, it’s in a positive direction.

  • Eli Rabett

    What is coming in health care are defined payment systems where employers provide a fixed amount of cash for employee health benefits and you have to find your own from some private marketplace that they have selected. (For example Mercer Marketplace). This has all the advantages of defined payment retirement systems (for the employer of course).

  • it will look like ponies shitting rainbows over the heads of happy children, forever.

  • Rob in CT

    There is no way around this financial reality. Consequently, for any plan to be politically viable, it must aim to reduce opposition from outside the health care sector as much as possible while still achieving universal affordable health care.

    The Affordable Care Act (ACA) was designed as a large transfer of wealth from the rich and a segment of healthy middle class individuals to the poor, the sick, and importantly, the health care industry. MICA is primarily a transfer of wealth from the health care industry to everyone else.

    The guiding political principles behind this plan are intended to make it politically viable by minimizing disruption, making the transition feel voluntary, and ensuring everyone outside the health care sector is noticeably better off (and at least not worse off).

    Well, right off the bat they acknowledge the hurdles. That’s a good sign.

    • Rob in CT


      Sections 13-16 – Employer-provided insurance is one of the top sources of funding in our health care system, but most people don’t realize what their benefits truly cost them. Instead of trying to fully educate everyone about this and how a whole large new tax would on net leave them better off, it is politically easier to just build on top of this funding source. It also technically puts the responsibility of moving people from private insurance onto MICA on the employers instead of the government. The hope is most companies will accept this change because signing up with MICA would dramatically reduce their health care costs.

      The employer mandate is roughly based on the employer mandate in the Hawaii Prepaid Health Care Act, which successfully gave the state a very low uninsured rate before the ACA was enacted. It also resulted in some of the lowest health care costs for working Americans.

      In general, economists believe employer contributions to benefits, such as insurance, mostly come out of an employee’s potential wage. As a result, this employer mandate would indirectly function like a minimum wage increase and a payroll tax for companies that don’t currently provide insurance. This is an acceptable way to deal with financing health care since the federal minimum wage in the United States is too low and a payroll tax is how many countries finance their public health care systems.

      That all makes a certain amount of sense, but I don’t know that it defuses opposition at all (which is the reason for building off of employers instead of going straight to purely tax-funded SP). Employers – low-wage/small employers in particular – will scream bloody murder.


      Part H – Cost Control

      The bill is aggressive with cost controls at multiple levels because there is no way a true universal health care bill is not going to face strong industry opposition. Any attempt to keep the industry on board will result in a bloated, complicated mess full of holes that will keep the country on a path of health care bankrupting businesses and the government.

      Since you can’t win over the health care industry as a whole, you might as well go strong on cost controls to produce real noticeable benefits for the rest of the economy to gain their support. The bill uses both market approaches and direct government control to bring down costs.

      Needless restrictions on foreign doctors dramatically increase health care prices for businesses and individuals.

      So the medical insurance industry & providers (not *all* providers, I know – I’d expect a fair number of primary care docs to be supportive) will be lined up in furious opposition. Add to that employers screaming about the employer mandate, and the Right-wing propaganda machine turned up to 11 screeching about the death of freedom or whatever.

      And maybe they’re right. Maybe the plan should be “fuck those assholes (providers, insurance companies), they’re ripping us all off/are bought (political opponents)!” and damn the torpedoes. My confidence in my ability to predict politics is shaken enough that I’m willing to accept it might work, or work about as well as any other plan…

    • Rob in CT

      If you click through to the more detailed plan, they have this:

      Part H – Cost Control

      Section 30 – Doctor immigration – Doctors and dentists from countries, such as Canada, France, Japan, UK, Ireland, Germany, and other highly industrialized countries with comparable health care outcomes are immediately allowed to practice in the United States. The Secretary will also create a more streamlined process for all other countries on a country-by-country basis that would allow sufficiently trained doctors to practice in the United States without needing to go through an American hospital residency.

      Section 31 – Scope of practice – The Secretary will study and implement ways to eliminate unnecessary scope of practice restrictions on other healthcare providers. The issue should be reviewed every 4 years based on new technology and research.

      Section 32 – Health care monopoly prevention – The Secretary will be charged with the power to deny any health care industry merger or acquisition if it would reduce the quality of care or increase cost.

      Section 33 – Ending abuse of patents – The Secretary will have the power to revoke any patent or exclusivity for a drug or medical device if the patent holder is found to engage in abusive pricing. The Secretary also has the power to allow individuals to directly import specific drugs or devices from other countries where they are cheaper if the manufacturer is engaged in abusive pricing in the United States.

      Section 34 – Fair pricing – No medical facility that offers emergency services or individual practicing at such a facility at the time can charge anyone more than 200% of the MICA rate regardless of their insurance status.

      I have two thoughts here: 1) how much the medical industry will hate this; and 2) this is actually kind of weak, isn’t it? If your plan is to say fuck ’em, go hard or go home, this is underwhelming.

      • Richard Gadsden

        In the EU we have mutual recognition of qualifications (as part of the freedom of movement of labour) but doctors whose medical training was performed in a language other than English have to pass a medical English (or Welsh) test before they’re allowed to practice in the UK (and there are definitely German and French tests in those countries; I assume the same applies elsewhere).

      • Aaron Morrow

        “how much the medical industry will hate this”

        I assume they will prefer the Medicare-level payments in this plan than the Medicaid-level payments in one of my plans. I’ve often thought that on “Day 1” of Democratic unified control we might be able to pass a simple expansion of Medicaid eligibility before we start haggling over the details of DemPresCare. Depending on our caucus unity, raising it again and again could be Plan B.

        • JKTH

          I assume they will prefer the Medicare-level payments in this plan than the Medicaid-level payments in one of my plans.

          That is one of the less talked about advantages of basing universal on a Medicare-like system than Medicaid. If you’re really concerned about health industry opposition (I’m not but some are), they’re gonna like the former a lot better.

      • JKTH

        A lot of the cost control is probably just in paying providers at Medicare rates. The doctor immigration part can help with costs too…not really sure about the patent stuff since it would depend a lot on how they defined abusive pricing.

  • Rob in CT

    I’d like to see David Anderson (Balloon Juice) go over this.

  • JamesWimberley

    Part of the political problem with American public health provision is that it is funded by very progressive *federal* income and corporate taxes. (US taxation is not very progressive as a whole, because state taxation through sales taxes is regressive). In countries with single state provider health care funded from taxation (UK, Sweden, Spain..) the tax system is centralised. Bismarckian social insurance (France, Germany) funds health care through flat or slightly regressive payroll taxes, like Medicare as I understand it. This could be replicated by making the Medicare-for-all funding largely based on a payroll tax, with an exemption for companies offering equivalent plans privately.

    • Rob in CT

      This proposal kind of does a bit of both. It uses payroll taxation, but there are caps on % of income an employee can be charged. There is other help in there for low-income people too.

      Section 19 – Reduced premiums for low income individuals – Premiums charged on taxes will be reduced for low income individuals so that they do not exceed this percentage of their income using this sliding scale:

      1% income for those under 150% FPL

      2% income for those 150-200% FPL

      3% income for those 200-250% FPL

      4% income for those 250-300% FPL

      5.5% income for those 300-400% FPL

      6.5% income for any individual over 400% FPL up to the full cost the premium

      Section 9 – Help for low income individuals – For individuals below 300% the Federal Poverty Level (FPL), the Secretary will create reduced co-pays and out of pocket limits indicated by the smart MICA card. Co-pays and out of pocket limits would be reduced by:

      80% for those under 100% FPL

      60% for those 100-150% FPL

      40% for those 150-250% FPL

      20% for those 250-300% FPL

  • pseudo-gorgias

    It’s going to look like nothing because democrats cannot win elections, and there is no indication they are going to start doing so anytime soon.

  • JKTH

    The proposal seems pretty thought out. I can kinda quibble with a few details, like having people below the poverty line paying premiums or cost-sharing at all. They don’t have to pay premiums on Medicaid so I don’t see why they should in this system. The summary said that Medicaid would still exist as supplemental coverage but it’s not specific on how that’d work.

  • Veleda_k

    This may simply reveal my ignorance of a complicated subject, but one thing I’ve always been concerned about in this discussion is that unless we truly eliminate private insurance and have only one government plan (which doesn’t seem feasible to me), I have to wonder whether I’ll be able to use my government insurance to get the healthcare I need. Which is to say, is there a mechanism to ensure that doctors and hospitals will accept our new public insurance? Not every provider accepts Medicare or Medicaid. And while I’m deeply grateful to the ACA for providing me with healthcare I couldn’t otherwise access, many providers don’t take my exchange plan, and I’ve had difficulty accessing even some basic health services. Luckily, I have access to community health clinics, but not everyone does, and even for those of us with access, it’s not a perfect solution. (The clinics are overworked, so you may be waiting a long time for an appointment, which can really suck depending on your needs. Also, so much of what they can offer is dependent on what funding they can get.) Have solutions been offered for this?

    (Also, related to the proposal in the link, I see that it counts dental care as supplementary, and I don’t think that can be allowed to stand. Dental care is health care.)

  • Tracy Lightcap

    I think Scott has covered the big obstacle here: this would cost too much. Taxes would have to rise and the opt out provisions could make that worse. Besides, I think the plan is hand-waving when it comes to resistance by the “healthcare industry”. As people never tire of pointing out, this is 1/6th of the economy whose ox is getting gored here, They’ll resist it and probably successfully.

    I think Scott is right: what we need is a Dutch/Swiss system combining an individual mandate with highly regulated required non-profit plans sold by insurance companies and with a variety of premium/coverage options. The companies get to sell supplemental insurance to the people they sign up, so there’s an incentive to sweeten the offers beyond what the government mandates. And the employers are off the hook. This would have problems here due to the already exorbitant costs built into the system, but it wouldn’t break the bank and we already have models that work that we can imitate. And if you offered the insurance companies a deal where they suddenly have 300 million new customers that they can sell for profit supplemental insurance to, provided they get their clients signed up, you build in a system where the profit motive works for you. Finally, this would leave the doctors harmless in the short run, although their long term income prospects would be implicitly controlled. We’ll probably end up doing something like this and calling it “Medicare for All” so it’s more sellable.

  • Brien Jackson

    Designing a single payer plan as a matter of policy isn’t all that hard. What makes it difficult is that proposals that disrupt existing plans or raise taxes to pay for it are unpopular, and the response of single payer advocates is generally to either deny that or insist opposition will melt away in the face of single payer awesomeness. Plus they’re a lazy bunch with no interest in organizing or doing work beyond yelling at other people to get on the single payer uber alles train.

    • Free Fries

      I always ask if women will still have to pay for abortions out of pocket, is it really single payer/universal health care?
      Answer is always some form of the following “of course abortions will be covered”

      Well silly me for not hand waving the Hyde Amendment!

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