A lot of well-meaning people don’t understand single-payer healthcare

I see a lot of sentiment from American liberals and lefties that the United States needs single-payer healthcare, e.g.:

Now, I understand being frustrated with the American healthcare system. But I think – as a person who considers themselves to generally be a member of the left side of the aisle – that one of the reasons I am left-wing is because I think facts are important and it is likewise important that my political opinions be based on factual output. And a lot of liberals – like this guy here – use the phrase “single-payer” like it means “a solved healthcare system” or “what most of the modern world uses” and neither of these things are true. And I say that as someone who lives in a country with an actual single-payer system!

So, let’s go question-and-answer for a while.

What is single-payer healthcare?

It is a healthcare system where either the sole or primary provider of health insurance and/or healthcare is the state. If you get sick, you go to the doctor, you flash your health card (a card that confirms your enrollment in the single-payer healthcare system) and you get treatment. Some systems may require you to purchase supplemental healthcare insurance for certain elements of healthcare provision.

And this is basically what everybody but the United States uses, right?

Oh, heavens no. Canada, the UK, Norway, Sweden and Finland are about the only countries that use anything close to the mental conception most Americans have of “single-payer,” and even all of these countries have some digressions from how single-payer traditionally works. Speaking as a Canadian, here is a short list of things our “single-payer” system doesn’t cover: prescriptions, dental care, vision/optical care, home care, ambulance use, and doctor’s notes. You will note that those are some pretty big gaps there.

Most first-world countries have a sort of mix of private and public care to achieve universal healthcare:

• Japan pays for 70% of everybody’s healthcare expenses up to an individual limit, but it’s on individuals to pay the other 30%. (Japan historically manages this by strictly limiting user fees, but Shinzo Abe seems determined to rework their system entirely so this summary may be out of date within six months of its writing.) It also requires citizens to have personal health insurance, although it maintains an insurance fund for those who cannot afford their own.
• Italy has a system of public hospitals which everybody can use, but also a system of private hospitals which require insurance. Spain does much the same thing.
• France achieves universal care by requiring all citizens to enroll in health insurance plans, which are provided by a small number of national-level non-profit private insurers who deduct their fees from your paycheque and a national fund for the poor/elderly/indigent/etc.
• Germany has about 130 government operated “sickness funds” – government-regulated insurers – which cover about 90% of the population, including everybody who makes less than 50K euro per year, and a system of private insurers who cover the other 10%, who are mostly the upper-class.
• Australia and New Zealand have fairly explicit two-tier systems: medicare-for-all, but better-medicare-if-you-pay-for-it systems.
• The Netherlands requires everybody to get private insurance, which is highly regulated so as to avoid insurer abuse.

…some of those sound sort of like Obamacare. But Obamacare seems sort of bad. What’s the difference?

Well, a few things. (And we’ll continue to call it “Obamacare” rather than “the ACA” because, despite the inaccuracies, why not.)

Firstly, Obamacare was designed to have a Medicaid expansion for poorer people who couldn’t afford insurance on their own. Many states, however – mostly controlled by Republicans – decided that they didn’t want to expand Medicaid but that they still wanted the for-profit insurance subsidies, and sued over this. The Supreme Court sided with the states, because it had a majority of partisan conservatives on it. This created an insurance gap in a lot of states where it was least helpful to have one.

Secondly, Obamacare’s general principle was “for people who make too much to be eligible for Medicaid, even post-expansion, we will subsidize people who cannot afford insurance so they can buy insurance that is decent.” The subsidies were, bluntly, not quite high enough, and as a result some people (although far less than the media might have you believe) have resorted to buying near-worthless high-deductible plans.

Third, Obamacare does nothing to create true cost controls on healthcare expenses. A lot of healthcare in America costs more for no reason other than it costs more. Obamacare did not attack cost controls for a lot of reasons, most notably because Republicans weren’t willing to agree to any such thing, and because Obama couldn’t get some Democratic Senators on board for even minor cost controls – most notably Joe Lieberman, a strong contender for being one of the worst people alive, who utterly refused any “public option” (i.e. a government-run insurer who would force private insurers’s costs downward by offering lower prices) up to and including the idea of expanding Medicare to become a buy-in option for anybody who wished to do so (a position he had previously endorsed, because Joe Lieberman is a terrible person) and as a result Obamacare was forced to pass without a public option.

It should also be noted that any push for cost controls would provoke holy war with both the insurance lobby and doctors (whose salaries are part of the reason prices are high). And people generally like their doctors.

But why didn’t he just go with single-payer –

Because it was not feasible. There’s been this meme created among the left that Obama didn’t try hard enough to pass single-payer, but he didn’t try hard enough to pass single-payer because he had exactly 60 votes in the Senate for approximately nine months, exactly the number necessary to pass a filibuster, which meant that he needed every single Democratic vote to pass anything since the GOP were not going to vote for anything he proposed (up to and including proposals they helped draft, which was the entire point of the “Gang of Six” negotiations in 2009 – getting the GOP to help draft a new healthcare law so it would pass, except they then admitted they wouldn’t vote for it even under those circumstances). Which meant, in turn, that conservative Democrats like Lieberman could hold the entire process hostage. Which they were more than happy to do.

But we should go with single-payer now, right?

Speaking as someone in a single-payer system, it is not all bread-and-roses. Single-payer systems mean that every medical concern can become political drama because the government ultimately decides which treatments it is willing to pay for. This means that anybody dying of, say, some horrible cancer can suggest that the government refusing to pay for a given treatment which might still be considered experimental can turn it into a wedge issue. It doesn’t have to be life-or-death stuff either; last year in Ontario parents of kids with autism successfully lobbied for extended treatment schedules for their kids.

Single-payer also means that the government has to guarantee a given standard of coverage geographically speaking. That means patients in rural areas need service guarantees. That gets expensive too. And, of course, because single-payer usually means stretching care dollars as much as possible, it does generally correlate with increased wait times for services. Not perfectly and not so dramatically as a lot of American conservatives pretend – but it is a pressure more or less inherent to the system.

What Americans should do is recognize that Obamacare mostly does what it set out to do: vastly expand healthcare coverage, most of which is reasonably good coverage. Most of what it does is politically popular. The problems with it are relatively straightforward: the subsidies aren’t large enough, the system is still somewhat byzantine and some states are interfering with the Medicaid expansion. Neither of these problems are unsolvable in and of themselves: increase the subsidy level, for example (and offset it with a new tax of some kind) and you’ve fixed 90% of the problems with coverage, and then can turn your attention to cost controls as the next issue to resolve once everybody has their insurance and is all “this is pretty great.” (Well, except for the bit where most of the anti-Obamacare animus is actually racially driven. Good luck with that.)

But for crissake, The Left, stop insisting that single-payer is the only way to go. It isn’t. Most of the countries with the best for-dollar health outcomes don’t even use single-payer. “Single-payer” has become a sort of meme rather than anything meaningful, a way for progressives to show their lefty bona fides by being Against The System, Man, and isn’t Obamacare just a sop to insurance companies by making us pay for insurance? Well, yes, but insurance mandates aren’t a new thing: most non-single-payer countries have them, and even most single-payer countries which just take the money out of your taxes directly are usually paying private healthcare providers anyway so it’s almost always a transfer of public money to private concerns. What matters is how well that transfer is regulated and the quality of service received. “Single payer” doesn’t really move that needle at all.

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