Responding to Political Attacks on Single Payer

By Lambert Strether of Corrente.

Single payer polls very well (“81% of Democrats” are positive), despite the Obama administration’s attempt to destroy it, and has for years (although it polls better when called “Medicare for All”). And so it should, considered as public policy.

Therefore, one of the most of the many entertaining spectacles of this year’s election season has been to see the Democratic Establishment — as I hope we can, albeit with irony, designate the neo-liberal and as yet dominant cadres of the Democrat Party — sprint away from single payer as fast as they can. Even more entertainingly, the fleetest of foot — hold on to your hats, here, folks — were the self-styled Establishment “wonks.” But then, their sprinting orders come from the top:

(Let’s remember that Clinton only mentions single payer under duress; see here for her views on “evidence-based” heatlh care policy. So credit due to Sanders for shoving the Overton Window left by putting single payer into his platform and forcing the discussion[1]).

So, with this post I want to present this entertaining video “webinar” from the excellent PNHP (Physicians for a National Health Care Program). Here’s the video, from PNHP’s Dr. Stephen Kemble. I advise you to watch it in full.

Up until 8:38, we have a detailed analysis of the various cost estimates put forth by Gerald Friedman and the Sanders campaign, followed by a job application shockingly dishonest paper from Kenneth Thorpe, as well as the CEA’s Gang of Four, and Henry J. Aaron of Brookings. Following that, there’s a brief dissection of Clinton’s (not shocking) claims. This is followed by pro-single payer talking points, summarized here:


I don’t think I can add a lot of value to the video by making screen dumps and going through each talking point in detail; if you want to see the points, start at 8:38. What I’m going to do instead is focus on the the question and answer question that follows, starting at 17:22. What follows is a partial transcript, with a comment from me after each answer from Kemble.

* * *

When we talk about how difficult, cumbersome, expensive this would be to implement and we talk about implementation of medicare 50 years ago Wouldn’t it in fact be more complicated now because medicare was implemented in more of a vacuum and there is more that has to be dismantled in order now to implement single payer? I get this question a lot when I speak; it kind of surprises me when people say “Wouldn’t this be hard to implement?” and the other thing they say is “Aren’t the other countries that have done it successfully smaller?”

KEMBLE: That is a question. I think that it really depends on whether or not you can eliminate the insurance model for financing health care, that you actually could say, “OK, we’re eliminating health insurance and starting a single payer program,” you would would be starting it from scratch, and you would obviously do the infrastructure for the single payer program before you eliminated the insurance system and then just switch over. The problems is that it would be met with massive resistance from the health insurance industry because they would be about to be bumped out of health care. And that’s really the problem. If you could overcome that problem there is a political will to say we can no longer rely on the insurance model to finance health care, then it becomes just as easy to implement as Medicare was. That’s the if. That’s a big if.

Yeah, but even if we did that, and I would be very happy to get rid of all insurance, you still have the problem of what to do with the insurance industry, the people it employed, all those things.

KEMBLE: HR 676 does include job retraining for the people employed by the insurance industry but it would be more expensive now than it was when HR676 was proposed because the amount of bureaucracy has escalated markedly since. There’s a lot of people you have to retrain.

Lambert here: What the questioner and Kemble describe is insane: We have what is in essence a make-work jobs program (the insurance industry) whose purpose (beside rental extraction) is inflicting suffering on people, and even killing them, by denying them health care. However, I’m skeptical of the “retraining” argument, for a few reasons: (1) I’d assert that “training” is often walking around money for politically connected trainers, and the hoped-for jobs rarely materialize; (2) neoliberals keep urging training as an answer to the “skills mismatch” problem that supposedly causes unemployment; and (3) a Jobs Guarantee would be a better answer than training. Because when you think about it, there are a lot more parasitical systems that ought to be purged than the health care industry: The F-35, for example. Or much of the FIRE sector. Better to treat the whole patient, perhaps. On the other hand, there are no doubt jobs to be found or invented in the actual delivery health care, as opposed to health care meta-jobs like billing and coding.

I have a concern with the comparison to all of the European single payer systems since they all seem to be running out of money and the second layer of private insurance seems to be out of all of those system so I’m concerned when we just pointed that, we’re not being completely open and honest.

KEMBLE: Well, the thing about that is that when you say they’re running out of money already spending much less than we are, so the only reason that they’re running out of money is their reluctance to fund their system. But it’s not a matter of their systems being less cost-effective. It’s a matter of people don’t want to pay more taxes so there’s a tendency to skimp on money for their helath care systems. And also the efforts to privatize some places like the Netherlands have resulted in increased costs, not savings. You’re still left with the most cost-effective model is single payer, and all the experiments trying to veer away from that have resulted in increased costs.

Lambert here, translating: The neoliberal assault on the delivery of all public services is global. Britain’s NHS is a prime example; the Tories are in the process of gutting it as you read this.

I’d like to ask about the former single payer supporters who are now coming out against single payer. Do you feel like this is strictly because they’re clinton supporters it’s political in that way or is there any other reason that they’ve now turned against single payer? And is there any hope of reversing that?

KEMBLE: there is a probably a possibility of reversing that, but I can see no other plausible reason because many of those really did detailed analyses of single payer proposals and they just changed their assumptions to eliminate all the savings that single payer could gain, and I don’t see any other reason for doing that then they want to support Clinton, and therefore they want to discredit Sanders. And unfortunately even people like Paul Krugman who I always thought was above that sort of thing, have fallen into it.

Lambert here: Bitter lesson learned, on wonks of negotiable affection[2].

On staying with the Affordable Care Act and muddling through… I calculate $45 trillion dollars spent in 10 years compared to the Sanders plan being $14 trillion over 10 years. Is that what you get?

KEMBLE: I think that sounds plausible and I do think that we have really not seen the net fallout from Obamacare, both in terms of cost and in terms of disruptions to care delivery. We now have a 55% burnout rate among American physicians, we have escalating amounts of money being siphoned out of health care into new administration and I just don’t see how this can continue without collapsing.

Lambert here: This, and everything above and below, is ancien regime stuff. It seems impossible to divert the flow of rents!

We had a question earlier about whether it is still accurate to say that about 20 to 30 percent still goes [to] insurance company profit. Is that number still accurate?

KEMBLE: [P]rofit is probably less than that, but administration is the other question because ObamaCare requires 80 to 85% actuarial value depending on the, or I mean medical loss ratio depending on the size of the insurance plan, which means that supposedly 80-85% healthcare dollar goes to health care and the rest can go to administration and profit and other things. The problem is that Obama negotiated with the insurance industry to count medical management as health care, not administration. And medical management is pharmacy benefit managers, utilization review, prior authorizations: all the things that are obstructing health care and those things have escalated dramatically in the last five years, and they’re all being counted as health care and not administration. So nobody knows. They can spend as much as they want on obstructing health care and they can call it health care. So the whole medical loss ratio thing is just really messed up.

Lambert here: So that’s how Obama worked the scam. Frankly, I’m gobsmacked. I wasn’t cynical enough! And so much for the “capped at 85%” pro-ObamaCare talking point!

There’s also plenty of other good information on Taiwan and the Netherlands, so again, be sure to listen to the whole thing. However, I felt the above questions


I’m not on the road for single payer taking questions from skeptics, so I am holding forth from my armchair at 30,000 heet. However, returning for the moment to Kemble’s summary slide:

It strikes me forcibly that these talking points are, one and all, crafted to appeal to what I’ve been calling the 20%: The credentialled class who manage the rest of us, the 80%, with varying degrees of brutality, corruption, deception — and even sometimes courage and compassion — and hence who massage capital on behalf of its owners, the 1. And All Kemble’s talking points — but especially the “cost” argument — are very much 20% arguments, focused on academics, managers, policy makers, and implementers; in a word, technocrats. There’s not one single talking point that presents concrete material benefits for patients (i.e., all of us, at one point or another). And what happened with the cost argument? The single payer advocates had the analysis on their side, no question. But their former allies in the political class — Operative K is the classic example — simply rejiggered their numbers, and cost became he said/she said.

If I had to create some bullet points on the concrete material benefits that single payer provides the 80% whose families live on wages, I’d put together something like this[3]:

  • Health care when you need it from the doctor of your choice
  • More money in your pocket
  • No paperwork

And then frame the health insurance industry CEOs as the deadly parasites that they are. Dr. Kemble, I recommend a dietary treatment: more red meat!


[1] A single payer program can be designed to appeal to Republicans, as Laurence Kotlikoff, chairman of Reagan’s CEA, shows in Forbes. So whatever reason Clinton has for her intransigence is likely to have little to do with politics, let alone policy. Ka-ching.

[2] Reminding me forcibly of Clive’s point that, increasingly, to stay “middle class,” you have to close your eyes to corruption, or be corrupt, as all of these turncoats are.

[3] Of course, if you’re lucky, or somewhere north of the uppper 20% — ka-ching — you already have those things. So you see why single payer has no real appeal to Operative K, the Acela bois, et al.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. grayslady

    I listened to this when it was posted the other day, and it’s an honest assessment of the situation. However, with regard to people being unemployed after the changeover, when has anyone cared about all the people who lost their jobs from mergers? Banking mergers, grocery chain mergers, airline mergers–the list goes on and on–not to mention factory closures.

    One interesting point made at the end of the presentation was by someone (a doctor?) who mentioned that Taiwan was already using its single payer system to analyze epidemiological information to prevent major disease outbreaks by determining areas of the country where problems seemed to be developing. This is the first time I’ve heard someone mention this important aspect of national health care, namely, better prevention tools and efforts.

    1. tegnost

      “However, with regard to people being unemployed after the changeover, when has anyone cared about all the people who lost their jobs from mergers? Banking mergers, grocery chain mergers, airline mergers–the list goes on and on–not to mention factory closures.”

      My first thought as well….

      1. kimsarah

        Provide those displaced workers with the same bogus job training programs that the rest of those who have been laid off have been offered — programs that provide technical trade and burger flipping skills to help them compete in the new worldwide economy — for less pay and no benefits.

    2. Carla

      Yes, better prevention is a MAJOR advantage of a functioning public health system. (And I hope it is evident to sane people by now that we cannot have a functioning public health system without single payer. It’s probably the most important item after clean water and food safety.)

      This has been pointed out many, many times in the past by single payer advocates and activists. However, no one was listening.

    3. auntienene

      Yeah, why are these jobs sacred? I’ve heard this so many times.Why should sick people be sacrificed for them?

      And all that crap about choices? My choice is healthcare that I need when I need it.

    4. Devamitta

      A a truly national “health” plan rather than a health “insurance” plan can promote more healthy lifestyles and illness prevention (as seen in the system in England and shown in the Michael Moore movie Sicko). And, after analyzing a number of nation’s health care systems, Taiwan modeled its system on our Medicare system seeing it as comprehensive and efficient. Incentives could easily be (and have been) built into the system so that doctors and hospitals get rewarded by reducing illness and promoting healthier lifestyles,

  2. hyung nam

    I’m part of Health Care for All Oregon working for single payer state by state and we’ve had Friedman out to do a tentative study for us. One of our advocates who is also in PNHP, Dr Sam Metz uses the simple talking point- better care for more people for less money. And yes, we need to think about our audience and how we address people – “Narrative power analysis is based on the recognition that the currency of story is not truth, but meaning. That is, what makes a story powerful is not necessarily facts, but how the story creates meaning in the hearts and minds of the listeners. Therefore, the obstacle to convincing people is often not what they don’t yet know but actually what they already do know. In other words, people’s existing assumptions and beliefs can act as narrative filters to prevent them from hearing social change messages. A narrative power analysis seeks to unearth the hidden building blocks of these pernicious narratives, so that a narrative of liberation can better challenge them.”

    1. kimsarah

      It’s no surprise who is behind the movement to crush hopes of a single payer system — the greedy pharmaceutical, insurance and health care systems and the politicians they own.
      When light was shed on who has been behind the anti-climate change campaigns, public support for taking more drastic action to slow climate change increased substantially.
      Anyone who thinks Hillary will stand up to her puppet masters is woefully misinformed. Of course, a lot of her supporters don’t want too much change because they have their eyes fixed on cashing in someday from the corporate-beltway revolving door system.

  3. Katharine

    The notion that you have to retrain clerical workers because the exact types of jobs they held cease to exist is absurd. The skills–data entry, matching information with selection criteria, producing form letters and reports, etc.–are fully transferable. That these supposedly sophisticated experts do not understand the difference between specific job functions and skills is a deplorable commentary on their ignorance. What Color Is Your Parachute? and other job hunter’s aids have been explaining the distinction for decades.

    1. Yves Smith

      While I agree that retraining programs generally fail in terms of equipping candidates to get jobs, you are showing how desperately out of date you are in invoking What Color is Your Parachute? which might as well have been written in the era of stone knives and bearskins for its relevance to the modern job market.

      Employers today spec jobs incredibly narrowly. They want only to hire someone who has done precisely the same job somewhere else so as to not have to train them. From the modern employer perspective, you “general clerical skills” argument is bollocks. Someone who has been in say the accounts payable department at Macys would not have a snowballs chance in hell of being hired to handle patients’s records at a major hospital chain (unless someone has a personal connection so the job was never posted at all). The hospital chain would limit its search to people who’d worked with medical records, ideally at a hospital.

      1. Carla

        Agreed, Yves. But I would go farther: Employers today don’t really want to hire at all. If they can contract the work out, they will. And while specs are ever tighter, crapification reigns.

    2. Devamitta

      And, business don’t blink an eye when cutting jobs and their claim that is is just good business sense ought to apply to healthcare. In Germany, health insurance companies exist and employ many people; the companies are not allowed to be for-profit and compete against each other,

      1. Devamitta

        And, all businesses don’t blink an eye when cutting jobs and use as their claim that it is just good business sense. Why shouldn’t this concept apply to reducing healthcare costs? There will still need to be administrators, and the ones who lose jobs can be retrained to take jobs in the burgeoning health care systems. In Germany, health insurance companies exist and employ many people; the companies are not allowed to be for-profit and compete against one another,

  4. ScottW

    In 2013, military/healthcare constituted 13.9% of France’s GDP, while in the U.S. it was 20.9%. The U.S. figure is low because it does not include all of the “security spending” and associated costs of war. So if you bring us in line with France our economy collapses. We are beholden to death and sickness to make our economy work. Somehow the French are figuring out how to direct labor into other areas, albeit its unemployment rate is higher.

    That helps explain why when you go to France so many people are enjoying the cafe life. More money for wine, cheese, baguettes, etc., because less is spent on bombs (they still export lots of those) and expensive medical procedures.

    My answer to what is going to happen to all of those insurance folks displaced by single payer? Just look around at all of the major problems being left unattended and put those people to working fixing them. Maybe a couple more gardeners (making a living wage) tending to a better public park? How about one on one tutoring for kids who are in high school reading and writing at a 3rd grade level? Pot hole filling? Better design, implementation and maintenance of pubic transit? The list is endless.

    1. OpenThePodBayDoorsHAL

      Kennedy’s big idea was to re-direct the Arms Race into the Space Race: get the same public dollars flowing through but without Armageddon as the outcome. So instead of building bridges in Somalia, the US Military gets to work building bridges in Nashville.
      Health care is the crisis that eventually will eat the entire US economy, I guess only then will enough people realize we are in three-alarm fire territory.
      And as a former American now living in single-payer Australia I can report the following: it’s a dream. I go to the doctor at 9 AM and my reimbursement is often in my account by 2 PM the same day. This is not hyperbole: we’re surprised sometimes when it takes as much as 1 1/2 days. Very noticeable on the ground, too, where a small US doctor’s office had one physician and 3 or 4 gals in the back manning filing cabinets, the AUS doctor just has one.
      It’s one of the main reasons we shipped out.

  5. susan the other

    The insurance industry has its tentacles everywhere. It’s like mutual insurance is America. And if any highly lucrative segment of society opts out it makes all of insurance everywhere too unprofitable to survive – similar to the health insurance conundrum when healthy people opt out. Insurance needs to evolve because it is all going to implode anyway in this brave new world. A better form of insurance IS single payer; another would be jobs guarantees in green industries. Get rid of the insurance industry altogether and eliminate the risks it promotes so it can make an immoral profit. It can’t begin to ever pay out all of its obligations. It’s just another pyramid balloon.

    1. Carla

      Thank you, STO. I’ve been saying for more than thirty years: Insurance is a criminal industry. People just smile and turn away.

    2. Malcolm MacLeod, MD

      suth: It’s always a pleasure to read one of your clear and cogent comments. With some
      exceptions, insurance is a scam.

    3. kimsarah

      Sounds like a grand ponzi scheme. It has to keep growing like the Blob to keep the top management well-paid. If they lose too many customers/patients and cuts have to be made, they just sock it to the rest of the insured with higher rates and fees.

  6. allan

    The abusive inclusion of medical administration in the medical loss ratio was not exactly a secret.
    Already in 2009, a certain Wonk was clearly proactively heading off criticism on his Blog:

    It’s also important to note that you don’t necessarily want administrative costs as low as they could possibly be. Some activities that are considered “administrative” are useful. Disease management, for instance, which accounts for some of the difference between Medicare and Medicare Advantage. Mental health counselors who are available by phone. Good-faith investigations into waste, fraud and abuse. Care coordination. Nurses who use e-mail or telephones to remind patients to take their drugs. Administration is not always wasteful.

    I wonder where he ended up.

    1. Lambert Strether Post author

      “Some activities that are considered “administrative” are useful.”

      But that’s not the same as classifying them as “health care” for the purpose of calculating the medical loss ratio!

      I see how the sleight of hand was worked, now….

  7. charles leseau

    Do I have a faulty memory? I seem to remember before the ACA was implemented, just about everywhere online I saw people arguing that it should be supported because it would “open the door to single payer.”

    That line seemed to disappear entirely after ACA was pushed through. I wonder where it went?

    1. polecat

      it flatlined————————————————————————————-

      because faux progressives

    2. EmilianoZ

      IIRC Obamacare was supposed to have something called “public option”. IIRC public option was supposed to open the door to single payer by progressive extension. I dont know of that public option thingy ever became part of ACA.

    3. Devamitta

      Well, that was when Obama talked about having a public option, which scared the bejeesus out of the insurance industry because they knew it would be their death knell. Obama, like a good corporate tool, dropped it out of the discussion, just as the Democrat Max Baucus dropped single-payer out of the discussion as chair of the committee on health care reform.

      1. Yves Smith

        That is complete revisionist history. Lambert can provide the gory details, but the short version is Obama dropped it all on his own, voluntarily. No concession demanded, much the less obtained, when someone in a negotiation gives something up that they want to get a deal done.

  8. Howard

    This is really contemptible. Gerald Friedman is an economic historian specializing in labor history. He has also published an analysis of Bernie’s plans that economists who actually knew something about macroeconomics and the US economy said was wildly off. This provoked a whirlwind of name-calling from Bernie’s supporters, which died down a bit after it turned out he’d made a basic error.

    Now it’s single-payer where we have the all-too-characteristic response from Bernie fans. A guy who actually knows a lot about health economics is smeared as dishonest and looking for a job with Clinton. Five people at the top of the economics profession are labeled the “Establishment” that, for unknown but no doubt sinister reasons, is “sprinting away” from single-payer… because they’ve gotten “orders” from Clinton, who presumably has made up with the insurance companies since they savaged her plan in the 90s. Do you really not see how insane this is?

    You ninnies, everyone likes single-payer. There’s no question that it’s simpler. The question is how we get there. You may recall that Obamacare was attacked as a government takeover of health care. What do you think they’ll say about single-payer?

    The big expansion that Bernie is talking about– no deductibles or copayments, for example, which makes it unlike Medicare– will cost a lot. You may have gotten the impression from Bernie that European health plans a cheaper because they’re single payer. No– insurance is only 6% of the cost of health care in the US. The reason Britain, for example, is so cheap is that they pay doctors a lot less. Maybe that’s justified, but shouldn’t an honest politician tell people that? Shouldn’t he tell them that in Europe, as in the US, you may have your “insurer” deny you drugs or treatments that you want?

    What’s really disturbing is the Tea-Party-like anti-intellectualism of the Bernie camp. “We are virtuous and pure, and the so-called experts are members of the corrupt Establishment.” No, these are smart people, progressives, who have spent a lot more time thinking about this than Friedman has. Why not pay attention to what they’re saying, instead of succumbing to paranoia?

    1. Yves Smith

      You are totally out of line.

      I just came from dinner with a political insider who told me in great detail how fast and orchestrated the attacks were against the Friedman piece. This was Democratic party/orthodox tribalism, pure and simple. And had you bothered reading any of the rebuttals, you’d realize 1. the current mainstream macro models are a crock because they assume an economy will naturally come to a full employment equilibrium; 2. The Romers, who led the charge against Friedman, have an abjectly poor record in forecasting; 3. the mainstream assumes a fixed limit to how much the economy can produce which is barmy (World War II disproved that dramatically and there are other less vivid examples).

      There are reasons to take issue with Friedman’s forecast, as with any single-case forecast, but you are making a pure appeal to authority case, when the authorities you cite failed to foresee the crisis and have been abjectly wrong post crisis.

      And please provide links to prove your assertion about doctor incomes. All sorts of doctors are reorganizing their lives NOW, under the current regime, to get out of taking any insurance because the insurers take 6 months to pay, require them to spend about a day a week of their own time fighting to get paid, and then their rack rates get knocked down to what the insurer deems to be OK. I’ve lost multiple doctors in NYC to this very issue, they’ve switched their practices from providing actual care to lifestyle treatment (“concierge practices”), such as my former endocrinologist who does only anti-aging (for a monthly set fee which is high, and then the stuff like human growth hormone shots is on top of that).

      Doctor incomes are being squeezed under the current paradigm and they are increasing being forced to practice corporate medicine. We’ve been covering that for years. See some examples:

      Coming Corporate Control of Medicine Will Throw Patients Under the Bus

      The Stealthy, Ugly Growth of Corporatized Medicine

      Finally, you dare to talk about intellectual dishonesty and yet act as if the only savings would be the cost of insurance industry itself? You simply wave away the fact the cost of our health care system is double that of the rest of those single payer systems in % of GDP terms, and produces worse outcomes. You ignore the costs imposed on doctors and hospitals of dealing with insurers, the fact that a single payer system would bargain not just with pharma companies but also medical device companies and hospitals, and perhaps most important, eliminate the “pay for procedure” structure of our current system, which incentivizes everyone from top to bottom to overtest and overtreat.

      In other words, you better improve your game if you are going to comment here. Recycled Democratic party hackery does not begin to cut it.

      1. frosty zoom

        ms. yves,

        you should be flattered that your blessed blog is piercing enough to get the attention of the demobot.

        perhaps it’s time to add the captcha thing.

        1. tegnost

          The beauty of NC has long been that if you can present a cogent argument you don’t get sent packing, and I haven’t witnessed anyone but some obstinate abusers of logic and language find their way to the door. Also troll hunting is kind of fun…the frequenters seem to always be interested in language and logic so lots of matadors get gored.

    2. frosty zoom

      actually, people are succumbing to premiums and deductibles.

      it seems to me that american health care is exceptionally bad. unless, of course, you just happen to be part of the exceptional set.

      and, “progressives”? ¿really?

    3. Lambert Strether Post author

      Let me clean up a few orts and scraps that Yves left behind. I don’t normally go into full snark mode, but “contemptible” deserves a response, and in any case, the commentariat likes to be entertained:

      1) “You ninnies, everyone likes single-payer”. No real need to respond here, not even to the weak ad hom. But for the record, since nobody could write what you wrote and have any real awareness of the single payer fight:

      I suggest the real constraints came from three sources, as indicated by their behavior from 2009, when battle for health reform was joined: (1) The Democratic nomenklatura, which censored single payer stories and banned single payer advocates from its sites, and refused even to cover single payer advances in Congress, while simultaneously running a “bait and switch” operation with the so-called “public option,” thereby sucking all the oxygen away from single payer;1 (2) Democratic office holders like Max Baucus, the putative author of ObamaCare — Liz Fowler, a Wellpoint VP, was the actual author — who refused to include single payer advocates in hearings and had protesters arrested and charged; (3) and Obama himself, who set the tone for the entire Democratic food chain by openly mocking single payer advocates (“got the little single payer advocates up here”), and whose White House operation blocked email from single payer advocates, and went so far as to suppress a single payer advocate’s question from the White House live blog of a “Forum on Health Care.” (Granted, the forums were all kayfabe, but even so.) As Jane Hamsher wrote, summing of the debacle: “The problems in the current health care debate became apparent early on, when single payer advocates were excluded [note, again, lack of agency] from participation.”

      In short, if single payer was “politically infeasible” — the catchphrase of that time — that’s because Democrats set out to make it so, and succeeded.

      2) “Gerald Friedman is an economic historian specializing in labor history” and “economists who actually knew something about macroeconomics.” Yes, the guys who work with italics and Greek letters always sneer at labor historians, don’t they? As for “actually knew something,” may I suggest you familiarize yourself with the details of the controversy before posting? You’re assuming (a) that the CEA economists actually did some analysis before going on their (“contemptible”) attack, and (b) that a labor historian is incapable of running an economic model. Both these assumptions are false, as Stiglitz shows here.

      3) On “sprinting orders”: I should have thought the touch of irony (cf. “marching orders”) was light enough, but I guess not; we’ll just have to agree to disagree on whether the willingness of the wonks to turn on a dime with single payer policy and jigger their numbers in a way that helped the Clinton campaign was the result of a number of individual consciences acting in parallel, suddenly, and simultaneously, or the sort of Overton Window management the political class does for a living.

      4) Friedman as “dishonest” and “looking for a job with Clinton.” On dishonest, do consider, again, familiarizing yourself with the detail by reading the slides. The phrase you will look for having done your reading is “hack job.” On “looking for a job,” when a writer who hasn’t been especially visible in the single payer debate raises his hand, clutching a paper that trashes one candidate’s plan, and the paper is then taken up and propagated instantly by the other candidate’s campaign, and its various allies in the press, what else are we to think? That’s how the game is played! The guy is yelling “Pick me!” just as surely as Corey Booker is running a campaign for VP with his book tour. Friedman did the Clinton campaign a big favor. You can bet it will be repaid.

      5) “Tea-Party-like anti-intellectualism of the Bernie camp.” No. You’re confusing anti-intellectualism with anti-credentialism (you know, the kind of credentialed “ninnies” from neoliberal economics departments who sold the country down the river over the last 40 years). Perhaps your confusion is a déformation professionnelle? I mean, this is the candidate who gives hour-long speeches on socialist policy to full auditoriums. That’s anti-intellectualism?!

      6) “The big expansion that Bernie is talking about– no deductibles or copayments, for example, which makes it unlike Medicare– will cost a lot.” No duh! The issue, of course, is how things net out for the patient, and for the country. Read the slides. You’ll see that in every case, single payer is the more cost-effective option (with no worse health care outcomes).

      7) Grab some bench, rook.

      1. Massinissa

        Man, Yves and Lambert both lambasting a troll at the same time is surreal, Ive never seen that in a long time. Almost wish these 3 comments could be posted somewhere for more people to see it.

    4. paintedjaguar

      “You may recall that Obamacare was attacked as a government takeover of health care. What do you think they’ll say about single-payer?”

      Well, this is just a wild guess, but I expect “they” will say that single-payer is… a government takeover of health care. Am I in the ballpark?

      A better question would be, why do these neolib “ninnies” think this moronic talking point is worth throwing at the wall?

    5. Knute Rife

      You really need to swear off the Kool-Aid. Nice to see what the Hillbots will be bringing to tonight’s caucus.

  9. Jim

    Lambert: the Kotlikoff piece in Forbes offers a Rube Goldberg contraption in the guise of single payer. Why put this forward as anything remotely sane?
    Single payer needs to be EASY for the citizenry: Go to medical provider, show your card, done! The idea that we’re supposed to pick and choose among Insurance Company offerings, each with a network of providers, paid for by vouchers given us by the Federal Government based on our income and preexisting medical conditions, is hardly any better than what we face under the ACA. Kotlikoff’s proposal has so many extra layers of bureaucracy and rent-seekers than a single payer system needs or ought to have.

    1. Lambert Strether Post author

      “can be designed to appeal to Republicans” <-- the politics, the optics, is what I'm addressing, not the details of the plan. And I have seen Republican single payer advocates, even today.

      1. BradK

        I have seen Republican single payer advocates

        You can usually spot them wearing Nixon/Agnew buttons.

  10. ke

    One way or the other, the majority is participating in the healthcare scam, including the remaining :-) workforce. No policy change is going to change the conditioned behavior to meet actual demand, which is a small percentage of existing, a typical reorganization problem

    1. ke

      What r u going to do with all the doctors doing unnecessary treatments an surgeries, the nurses and technicians enabling them, the crap equipment workers, Silicon Valley, all the make workers shuffled from industry to industry, breeding corruption for generations. You can’t bring in New until you get the crap out.

  11. Kurt Sperry

    The numbers hardly matter, medicine for profit is a moral abomination. The incentives are exquisitely perverse and there is no way to fix that. Even if public health care cost more (which it obviously doesn’t in the real world) it would still be the only acceptable approach.

    1. Carla

      “medicine for profit is a moral abomination. The incentives are exquisitely perverse and there is no way to fix that.”

      Really, you’ve said it all.

    2. Ché Pasa

      I’m old enough to remember when hospitals and doctors and health care in general were not considered profit centers but public necessities.

      Community hospitals, non-profit hospitals, public-funded hospitals were the norm. The idea of extracting rents or making profits from these necessary public health institutions was considered immoral and obscene. Doctors could and did make a handsome living, but for the most part they weren’t in practice to get rich (there were some exceptions); they believed in the premise that a healthy population was a worthwhile goal in and of itself. They saw their role as uplifting and securing the health of the people.

      It wasn’t paradise; far from it. Access to healthcare was widespread, but it was less available to marginalized and impoverished populations — except under compulsion for communicable diseases and so forth. Routine healthcare might or might not be available to marginalized populations. Abusive practices were not unknown — especially but not exclusively in public mental health care facilities.

      Costs were vastly lower than they are now, to be sure, and many of those costs were covered by government. Many were not, and under the prevailing system, patient cost for healthcare could be so high as to prohibit going to the doctor or being admitted to a hospital except under the most dire conditions.

      “Public health” was the driving paradigm, and “public health” led to extraordinary increases in life-span, reductions in infant mortality, control of chronic conditions and infectious diseases and so on, all of which progress has been under threat or actually in reverse since the transition to for-profit health care.

  12. Knifecatcher

    A while back I was working with the IT healthcare consulting arm of one of the insurance co big dogs (lets call them Amalgamated Health Group) and they let the cat out of the bag on the medical loss ratio scam under ACA.

    Specifically, what they said is that if an insurance co. handles its IT infrastructure for claims processing in house the cost gets counted under the 15-20% “overhead” bucket of ACA costs, which is bad ju-ju. But if they contract to a third party for IT the costs get magically categorized as – you guessed it – health care! Boom! No more pesky incentives to reduce the IT cost and complexity of processing health care claims! Because the nerds building the electronic hoops people have to jump through to get their claims paid provide EXACTLY AS MUCH VALUE as the doctors and nurses who treat them!

    This was straight from the horse’s mouth – they were actually quite proud of how the ACA was opening up new business opportunities for their IT consulting arm. I think I saved the original PPT slide that crowed about their accomplishment somewhere.

  13. kimsarah

    To me, it boils down to single payer threatening the current profit-motivated system that puts cutting costs and cheap or no treatment above the health and treatment of our citizens.
    By deciding who should get the best care and who shouldn’t, the industry is playing God by deciding who’s life is worth more than somebody else’s.
    Profit should not even be a word in our health care system.
    Notice how the biggest opponents to single payer are those who can afford to go anywhere they want to get the best care possible.

  14. dave1913

    Here in Canada our single-payer system has its faults but they pale in comparison to what I read and hear about the U.S. system. My son in Colorado (dual citizenship) keeps his insurance premium low by way of a $10,000 deductible (no issue for him since he is in the top 1% income-wise). In Canada, non-affluent people like me benefit greatly from the single-payer system. Three years ago I was wheeled into an operating room at our small-city hospital for a laser lithotripsy to blast away a tiny, extremely painful kidney stone stuck in a ureter. Pleasant music was playing. The nurses were relaxed and smiling. The surgeon was friendly. Now the anesthetic…I woke up…all better! Of course, at admission I simply showed my health card. Everything was covered (no deductible).

    I live in Ontario, Canada’s largest province, where doctors are complaining about the current income cap. I would be willing to pay higher taxes.

  15. inode_buddha

    In my experience, those who oppose single payer are those who think they will lose the right to choose…. because of black-n-white thinking, anything that is not to the right of them must be so far to the left that its full-on communism, and they are guarding against a slippery slope… at least that seems to be their thinking.

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