Sunday, March 15, 2009

Why conservatives should not rule out a single-payer system

583 words

It appears to be an article of faith among conservatives that a single-payer medical insurance system (“national health insurance”) is a terrible idea. Often, the “socialized medicine” label is stamped on it and it is rejected out of hand. More thoughtful conservatives will recite a long list of disadvantages, some of which are real, and rest their case.

The problem with these thoughtful conservatives is that all public policies have both advantages and disadvantages. The disadvantages and costs of a proposed policy do not necessarily mean it is a bad idea. (The converse is also true: the mere fact that a policy has advantages and benefits does not prove it is a good idea.)

Serious medical policy discussion requires us to consider both the advantages and the disadvantages of each of the many possible policies. We must seek the policy producing the most benefits with the fewest downsides and costs. Simplistic analyses which assume that some proposals are all benefits and no costs or all costs and no benefits must be avoided.

Conservatives bring many useful perspectives to the table. It would be a shame if they allow their preconceptions to prevent them from contributing actively to the forthcoming national discussion.

Conservatives, for example, have long been critical of “unfunded mandates,” under which the national government imposes duties upon state or local governments but does not provide the funding needed to carry out these duties. This in effect increases national taxes, but in a way that gives Congress the credit for the benefits while state or local governments incur the blame for increased taxes. However one of the alternatives to a single-payer medical insurance system funded through federal taxes is an unfunded mandate: imposing a duty on individuals to purchase medical insurance. In effect, such a mandate is still an increase in federal taxes.

The “anti-tax” argument against single-payer is therefore invalid since many other systems would also increase taxes, one way or another. And a tax increase for single-payer would be offset by elimination of insurance premiums paid by individuals, either directly or as the reduced wages occasioned by premiums remitted by their employers.

A second example: Many conservatives favor decreasing governmental complexity in order to render it more understandable and thus controllable by the electorate. But any medical insurance policy short of single-payer will probably increase governmental complexity and impose an impossible range of choices on individuals who will be forced to decide what insurance to buy without having the information needed to decide intelligently.

Conservatives also value efficiency. This should make them suspicious of the present insurance system under which large amounts of money are spent by insurance companies trying to avoid paying for particular treatments for particular patients. A certain amount of such “transaction costs” would be necessary even under single-payer, since automatically paying for all conceivable treatments for all patients would bankrupt any system. But experience with Medicare indicates such costs would be much lower than is the case with private insurance.

Conservatives should remember that a single-payer system will not automatically bring with it a governmental monopoly on the provision of medical services. Some of the problems associated with single-payer systems in other countries result from governmental monopolies in providing treatment rather than from the fact that government is the single payer.

None of this is to say the case for single-payer is clear and obvious, but it does suggest that conservatives would be very unwise to rule it out without a lot more thought and conversation.

1 comment:

  1. One continuing problem with ALL means of sharing risk re health costs, via insurance or government action, is the reality of rationing. Government systems of health care are frequently tagged with the stigma of "rationing" care, which they DO do. There is only so much medical care available, so any systemic approach should recognize that prioritizing the $$ and medical man-hours available will happen. One solution to the stigma is openness, which too many government programs avoid.

    Example: The current VA treatment system promises care for ALL eligible veterans. In reality, the total care allowed ( by the $$ allocated to the system ) is way short of demand, particularly in psychological help. The VA effectively "Rations" health care by having several un-acknowledged barriers. Their facilities are sited physically in places remote from the largest populations of veterans in need. Their admittance criteria are time consuming & records intensive, with minimal assistance for the needy vet. While the VA itself publicly claims to want to treat vets, the vets who need treatment see a huge maze, which effectively blocks & delays their access to the treatment they need. THIS is the system I expect to find when their is only one source for all health care.

    While the current Insurance system does have costs, which I would like to think can be reduced, it does have ONE singular advantage: the public has the government on IT's side in disputes with the insurance industry. With a single-payer ( Government ) system, it is ME, alone, against the entire government when I need access to the system. There will be no independent forum to argue my needs in. If you think I am wrong. the OTHER example of government managed care is Medicare. Try getting a change to their rules for care-givers!!

    ANY new system of cost allocation needs to start by understanding and discussing the rationing which WILL occur. The new system must have some explicit PUBLIC forum for continuous review of both individual cases, and systemic reforms. This system MUST be quick to review & decide: Medical care delivered late is NOT caring! British medicine has long depended on delaying expensive treatments to decrease their total costs: their incidence of Heart bypass operations & Kidney transplants is tiny compared to ours, and most of their candidates die waiting!

    I spent my childhood & 7 years after college in the active military medical care system. I am now stuck in Medicare for the rest of my life. Both systems can do a good job, with the right assets. Both can be totally non-functional in individual cases. I worked for 30 years in the employer paid insurance system, which has it's own negatives: Lock-in or non-insure-ablity being one major issue.

    None of those systems is what I want for my grandchildren ( when they arrive).

    John T Myers PE


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