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Who Compromises?

Ezra Klein's efforts to sketch out the details of some kind of mish-mash of universal health care and Health Savings Accounts is a good time for some further thoughts on the question of "political feasibility" and health care. Obviously, this is a major concern for the sort of single-payer ideas I like. And not just a concern. A stopper. There's no chance this stuff could pass the congress. The interest-group opposition would just be too vehement.

Nevertheless, it's not clear to me that the alternatives are any more feasible. It's important to note that the feasibility metric here isn't that by taking a more moderate position you swing more of public opinion around to your side. Instead, the point of things like Clinton's plan, Haase's plan, New America's idea, etc., etc., etc. is that you can successfully convince some substantial bloc of interests out there to support rather than oppose your plan, and some other bloc to stay on the sidelines. I don't think that sort of "negotiating with ourselves" makes sense. It amounts to trying to guess what kind of plan you make be able to get insurance companies, or the AMA, or General Motors (or what have you) to support.

My preferred progressive strategy is to keep the short-term focus on preserving and expanding Medicare, Medicaid, SCHIP, VHA and other public-sector programs. For the long term, focus on talking up the virtues of single-payer and making it clear that this is what liberals in our hearts know to be right. At the same time, we should always make it clear that we recognize that any such program would do immense damage to powerful interests in the United States and we'd be willing to take half a loaf if it were offered to us. But the onus here to find a way to make a deal should remain on them. If AHIP or the AMA or the NAM wants to put some kind of managed competition on the table and bring some conservative politicians along with them, great. We should be happy to sit down at the table and make a deal. But they need to move toward us, we're not going to guess randomly at what it is they want. The reality is that the employer-based health care system is crumbling, and it's dragging some very large businesses down with it. Our responsibility is to plant our flag and try to rally as many people around it as possible. When some of the big players get interested in a compromise, they can write one up, and if it's halfway reasonable, we'll deliver our support.

May 25, 2005 | Permalink


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Exactly, you guys aren't running things, so why should you go around acting and thinking like you do.

Posted by: Chad | May 25, 2005 1:39:14 PM

The precedent for single payer health care rolls down your street every day. Metrobus. There were private bus companies in greater Washington, but they were taken over by a government funded agency because they were all going broke.

Well, hospitals are going broke. Rural and urban hospitals are closing down and suburban ones will be next. Doctors have uncollectible bills and an administrative nightmare coping with insurance companies. And health insurance ain't has as profitable as it used to be. Just check out their stock price over the last 10 years, or just look at their corporate bond rating.

We are not far from the health care industry collectively begging the government to take them over.

Posted by: Alice Marshall | May 25, 2005 1:45:43 PM

I don't think it's about running things, in this case. It's namely, trying to come to a compromise with the insurance/medical industry to keep them from going ballistic on any plan WHILE designing it.

Personally, as far as I'm concerned this is a do or die situation. Either the changes are made to the health care system or the entire American economy gets dragged under by those costs.

The situation is getting more dire by the hour...

Posted by: Karmakin | May 25, 2005 1:45:55 PM

2006 Congessional Contract with America pledge:
All Children under 12 will be covered by health insurance.

Posted by: theCoach | May 25, 2005 1:46:09 PM

Sounds kind of like the Democrats' Social Security Plan: let's not propose anything ourselves; when they want to do something, they can come to us. To my mind, that's very good for the status quo. Since any "fix" to the health care system will inevitably lead to a massive increase in the size of government, that works for me!

Posted by: Al | May 25, 2005 1:58:04 PM

To get a feeling for how financially dysfunctional our health care system is you have to read the trade press, this is but a sample-


better examples of the financial breakdown abound, but I don't have time right now to hunt them down.

Posted by: Alice Marshall | May 25, 2005 2:07:55 PM

Dunno how to tell you this Al, but the federal government presently pays for most health care. Between Medicare, Medicaid, the Veterans Administration and the military health system we already pay for most of it. We just do it in a way that insures the greatest cost for the least service.

Posted by: Alice Marshall | May 25, 2005 2:10:12 PM

In addition to having interest group opposition from small businesses and insurance companies, it's quite likely that a single-payer system ould also face some opposition from within Democratic fundraising circles. The med mal systems in France, England, Germany, and Sweden are all very, very, different from the United States, and all of them (except Sweden) have fewer successful claims and give out dramatically lower payouts medical errors (Sweden basically gives out pocket change to a whole lot of med mal victims). Now, part of the reason for this phenomenon is that workers also have some other form of disability compensation that is more generous than its American counterpart. But controlling med mal costs is one part of decreasing the costs of single payer health care systems. ATLA would almost certainly oppose such reforms, and ATLA represents a non-trivial chunk of the money that the Democratic party receives.

That said, you're right; hold it out there as a principle and let everybody else meet us half-way, not the other way around.

Posted by: Electoral Math | May 25, 2005 2:10:20 PM

Dunno how to tell you this Al, but the federal government presently pays for most health care.

Actually, not quite correct. The United States' public expenditure on health care (at all levels of government) is about 45% of total expenditure on health care.

Posted by: Al | May 25, 2005 2:38:20 PM

I think if you want a public sector solution, then it will be not only in the interests of public sector types, but essentially their responsibility to come up with at least the broad outlines of a solution. Leave it to the private sector interests, and I will bet you dollars to doughnuts that you get a private sector solution, one that will probably do less, cover fewer people, and be focused mainly on private sector profits. It's the quasi-public insitutions - non-profit hospitals and MCOs - that probably would come to the table with a public/private hybrid (since they're the ones getting fairly heavily slammed), but I'd also expect their solution to be more problematic than useful. To the extent that there is a solution - and I think on a systemic scale, there probably isn't - it's a public/private partnership driven by the public interests. And I think that means it's driven by public sector.

Posted by: weboy | May 25, 2005 2:46:45 PM

um, Al, are you counting the tax breaks for employer provided health insurance in that figure?

I think Matt makes some good points here (though I think some of them are better applied to other issues, like, say, taxes) about Democrats and compromise. But I actually think that if we made the right "compromises," using existing structures like SCHIP and employer provided health insurance, coupled with ideas like an individual mandate and tax credits, we could probably get to a place where all children would be covered, and I'm including the politics here. Now, I suppose that universal coverage for children is a "compromise" if one sees single-payer as the ideal, particularly if it includes the existing system, but I tend to see covering all chidlren as a moral issue in its own right, that if we can do, we should, and as long as it works I don't give a rat's ass how we do it. Then we can talk about expanding coverage to parents, and up the age spectrum as children "graduate" from insurance, and eventually we'll get somewhere.

Posted by: flip | May 25, 2005 2:48:53 PM

Yeah, why propose a plan at all? Let them come to you. So what if tens of millions of people sit there with no insurance and deteriorating health, if hundred of billions of government debt is accrued, it's all about showing the conservatives who's boss and not "negotiating with ourselves".

And, when the current system does crumble, as you so eagerly anticipate, what makes you think they will come in your direction? The health care policy debate does not exist along a linear spectrum. When the status quo changes, it could well be in a direction completely orthogonal to your desired single payer insurance.

Posted by: QuietStorm | May 25, 2005 2:54:44 PM

Exactly. The job of a minority party is to criticize and obstruct the ruling party while aclaiming an alternative based on broad principles. The goal is not to pass legislation, but to shape what legislation you can towards your principles and try to convince the public that you vision is superior.

Offering details only alienate potential allies, so its best to nail those down when you are in the majority and better placed to offer deals and compormises in exchange for support.

Posted by: catfish | May 25, 2005 2:57:31 PM

I lived in Canada for many years and have extensive experience with their system. I paid $54 dollars a month for full coverage. No co-pays. No caps on payouts. I picked my own doctor.

Specialist care can be problematic. A few years ago I needed some varicose veins on the back of my legs treated and it took about 3 months to get the procedure done (the system is triaged so emergency cases go to the front of the line. If I'd needed an emergency haert bybass, that would have been done immediately.). I'm getting to the point now where I need the other leg done, and of course that's not covered in the US as a 'pre-existing condition.' It'll probably cost me about $11,000.

Canadians, like people everywhere, bitch about their health care, and these complaints are often used by advocates of the status quo in the US as proof that 'socialized medicine' doesn't work. But it's a fact that an often used method to smear one's opponent in Canadian politics is to accuse him or her of wanting to bring "American-style" health care to Canada. They know what a mess our system is down here, and they don't want any part of it.

Send a few million American voters to Canada, let them live with that system for a few years, and we'll have single-payer universal health care here in a heartbeat.

Posted by: John Doheny | May 25, 2005 3:11:53 PM

Why would small business object to a single payer system? We are getting killed under the present system. My premiums are soaring and I don't even have the assurance of security. What if my insurer notifies me some day that they are no longer interested in selling me insurance? How can I compete for employees with larger companies?

When we get single payer it will be in part because of the collective power of freelancers and small business.

Insurance companies will scream, until the feds tell them that in exchange for going out of business the feds will be responsible for their debts. Health Insurance is less profitable every year, that is partly why insurers are resorting to ever more unscrupulous practices.

Posted by: Alice Marshall | May 25, 2005 3:13:21 PM

You know, maybe the AMA needs to be broken first. Truth is it doesn't represent all doctors. I'm sure what the percentage is, but I think less than 25% of doctors actually belong.

Posted by: praktike | May 25, 2005 3:42:26 PM

Re: I paid $54 dollars a month for full coverage.

I assume this does not imclude the taxes paid to support the system?

Re: I'm getting to the point now where I need the other leg done, and of course that's not covered in the US as a 'pre-existing condition.' It'll probably cost me about $11,000.

How long have you had your current coverage and did you have previous coverage within two months of obtaining your current coverage? If the latter answer is “Yes” and that previous coverage would have paid for your surgery then you need to remind you insurance carrier of the HIPAA act (and hire a lawyer if they still refuse you). Also, if you have had your current coverage for more than a year then any pre-existing condition should now be covered.

Posted by: JonF | May 25, 2005 3:42:44 PM

Advocates for universal coverage need to be able to say how their plan will be better than what we have now. If they're convincing, some of the people involved in what we're doing now will be better off. They need to see why they should support change.

Reforming the system can't please everybody. 'Everybody' in the current sysem are why it's not working well. Some of them have to go. "By their acts, ye shall know them."

Posted by: serial catowner | May 25, 2005 5:40:32 PM

I wear a ~$12k artificial leg. Even if I maintain coverage, many plans don't cover prosthetics, so I would have to pay that bill myself every 2 years (or have even more difficulty walking).

Now this disability didn't occur because I rode a motorcycle, or because I didn't watch my health --I was born with it.

What's worse is that if I can't keep up with this expense, my mobility is at risk and therefore, my employment.

You can't control the genes you are born with and you can't determine the disabilities you're born with either. The market is allocating health care resources more poorly each year, providing care to less people at greater cost. Where the government provides (or pays for) care here in the U.S., most people are more satisfied than under totally private (especially individual) health plans.

Posted by: david | May 25, 2005 8:13:58 PM

Both the short term and long term strategies Matt mentions will fail because the other side does not see any problem with the health care system - their profits are all up. And the rate of expansion for existing programs is glacial.

Rather than treating the current special interest obstacles as fixed givens in the arena, progressives should be more creative in trying to bring them around to our point of view. Providers and small businesses are getting the shaft in the current system and they will be more open to a single payer system just for simplicity and stability's sake. GM seems to almost be at that point for competitiveness reasons. But we have to make the case, and do so vehemently.

On the policy side, most progressives are in agreement that a single payer system would avoid many of the inefficiencies of the current private health insurance system. The VA is a good example of a mini-Canadian system right here in the U.S. that is ranked higher than all the private alternatives.

Posted by: Rogue Progressive | May 25, 2005 8:18:41 PM

How long have you had your current coverage and did you have previous coverage within two months of obtaining your current coverage? If the latter answer is “Yes” and that previous coverage would have paid for your surgery then you need to remind you insurance carrier of the HIPAA act (and hire a lawyer if they still refuse you). Also, if you have had your current coverage for more than a year then any pre-existing condition should now be covered.

Gee, what a great system we have. The only thing separating this poor chap from a needed medical procedure is a ten hour seminar on health insurance regulations and several thousand dollars in legal fees.

It really is getting Kafkaesque, ain't it?

Posted by: P. B. Almeida | May 25, 2005 8:54:47 PM

Of course, PBAlmeida, you're correct only if the care managers at the insurance company think varicose veins are medically necessary.

For a rough outline of what single payer might look like, I recommend going to


which has the text of the proposal PNHP published in JAMA in 2003.

Posted by: muste | May 26, 2005 7:16:10 AM

Re: Gee, what a great system we have.

I was not claiming that we have a great system. I was trying to give some useful advice to someone who needs it right here, right now. If his insurance company is screwing him over, there may be legal recourse.
And don't think for one minute there won't be bureaucratic nightmares even under the best designed single payer system.

Posted by: JonF | May 26, 2005 8:44:28 AM


Why would big business object to a single payer system? Look what just happened with United. Now project forward and tell us what is going to happen when the boomers retire and the big three auto-makers have to pay their insurance premiums? The day that a signficant portion of corporate fat cats decides that health premiums are killing their bottom lines is the day we will see genuine reform. Oh how quickly the party line will change.

Posted by: Diana | May 26, 2005 12:34:50 PM


I lived outside the US for 30 years. When I last resided here fulltime (in the early 70s) I was a freelance musician and so of course had no insurance at all. My current coverage is through Tulane university in New Orleans, where I am visiting professor of music.

Taxes: One of the prevailing myths in Canada is that US taxes are lower, consequently many Canadian friends are disappointed to learn that my taxes in the United States are not significantly lower than in Canada. The fact is, tax rates here are only really favorable to those making over $100,000 a year or so, and that ain't me, or the vast majority of Americans, for that matter. Also, tax rates would have to be awfully low to make up the approximately $800 a month I'd have to fork out for comparable coverage as a freelance musician.

In any case, as someone points out further up this thread, about half of health care costs in this country are already shouldered by the government. In absolute dollars, our system is more expensive. One way or another, we pay, unless we're willing to just let people die in the streets.

As for the "bureaucratic nightmares" inherent in any system, my own personal, totally subjective and non-expert experience has been that the Canadian system gave me excellent (for the most part) care promptly when I needed it, and the American one is a Kafkaesque, hideously expensive nightmare. Honestly, I don't give two shits about ideology. I just want a system that treats me when I'm sick.

Posted by: john doheny | May 26, 2005 8:06:16 PM

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