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The Tough Case Against Medicare-4-All

I just listened again to our episode with Adam Gaffney making the case for Medicare-4-All .

It was a fun conversation.  I think Anish and I highlighted well some of the problems with the progressive left's proposal but at the same time there's no question that many people will continue to find the single payer agenda for healthcare appealing.

The way I see it, the best arguments for M4A boil down to these two:

  1. The current US system is awful
  2. It's not so bad in _______ (Canada, the UK, France, Germany, fill in the blank).

These are compelling arguments that are difficult to counter.  The US system is indeed terrible and—on the surface—the European/Canadian examples are not so dire.

On top of that, there's the pervasive confusion that the current crony US system is a form of a market economy, or else that moving to a true free market is pie-in-the-sky and the more realistic next step we can take is the single payer "lesser evil" approach.

How can the single payer arguments be confronted?

Highlighting that a single payer will be ruinous is unlikely to convince.  Most people have become numb to the question of deficits.  Plus Medicare and the unfunded liabilities are a train wreck already.  To insist that it will be even more of a train wreck with a single payer system will likely not have much purchase.  Thirty trillion here, forty trillion there...Who's keeping track anyways?

Criticizing other single payer systems is also unlikely to persuade.  People do not have first-hand experience of them, and single payer supporters can point to life expectancy, which is similar or better than that the US.  Of course, life expectancy is primarily affected by the general standard of living rather than by medical care per se, but it's difficult to make the case that Canadians are a lot worse off than Americans, even taking into account wait times and shortages, since healthcare has become so stressful here, even for those who have decent health insurance.

One aspect of the comparison that I failed to point out, however, is that yes, European and Canadian systems are doing OK, but they are mostly practicing American medicine.  There is an unaccounted for free transfer of best practices that, by-and-large (although not exclusively), in the direction US → rest of the world.  If the entire world had adopted national health systems in 1948, when the NHS was established, I wager medical practice would look pretty grim compared to what it is now.

But that, too, is an argument that appeals to the imagination and the consideration of counterfactuals, and it probably won't have much impact.

I believe that it's important to keep reminding people that governments cannot be trusted.  In 1965, Medicare was passed with the promise that doctors and hospitals would be allowed to charge their "usual and customary fee."  Within less than a decade the HMO Act of 1973 was passed, and a few years later we had CPT codes, RBVUs and the whole mess leading into the HITECH Act and the imposition of EHRs.  Even if Congress can pass a plan that promises to reduce paperwork and hassle, what guarantee is there that hassles and drastic pay cuts will not be imposed a few years later?  Why would doctors wish to put all their eggs in one political basket?

I also think that it is imperative to counter the single payer advocates where they think they have the best claim:  on the moral ground.  It is one thing to voice a desire for universal healthcare but it's preposterous to believe that caring can only be obtained by impersonal bureaucratic means which, at the end of the day, always boil down to threats of violence or actual imposition of harm on those who disagree.

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