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Institutions Matter


This article about how a doctor’s strike nearly killed the single-payer system that Canadians are now (justly!) proud of is good and useful.  There are a couple of important takeaways here, namely 1)practitioners, not insurance companies, are likely to be the most powerful and influential opponents of universal public insurance, and 2)if the system is implemented, people will really like it.

As a political scientist, though, the concluding grafs are really, really wrong:

A Medicare-for-all fight would be hard because that type of system requires massive change. That was true in Saskatchewan in 1962, and it’s true in the United States. But hard and impossible are two quite different things, and there isn’t much that convinces me that we fall into a different category.

I asked Marchildon how he felt about this comparison: Is it fair to compare pre-single-payer America to the pre-single-payer Canada of the 1960s?

“I think it’s quite similar,” he said. “I don’t think the interests are, quantitatively, so much more powerful in the US than they were in Canada. What’s missing in the US is the federal government being willing to pull the levers in a way that allows states to innovate with their own solutions.”

This really couldn’t possibly be more wrong:

  • There’s a huge difference between the veto-point ridden American system and a parliamentary one. The more opportunities vested interests have to stop legislation the more powerful they are.
  • When most countries implemented universal healthcare, they could offer doctors a good enough deal to mitigate opposition. Implementing single-payer in the 21st century U.S. not only doesn’t making stuffing mouths with gold impractical, single-payer to be viable will require practitioners to take a substantial haircut.
  • The idea that the path to single payer in the U.S. lies in states being permitted to “innovate with their own solutions” ignores some…really critical differences between the countries.

That’s not to say that achieving universal healthcare in the U.S. is impossible. But it does no good to ignore these critical institutional differences that have shaped everything about the development of the American welfare state. The next Democratic government should go as far as they have the votes to go, but practically the path to universal public insurance in the U.S. is much more likely to be gradual than one-fell-swoop.

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