Monday, September 25, 2017

Single Payer? Should we consider Fifty One Payers (more or less).

As anyone following the news knows, Senator Bernie Sanders once again introduced a bill (he's done it once before) which would make Medicare the national health care single payer for everyone, extending the idea that if its a nice gift for the elderly, heck, its' nice for everyone.  Democrats, looking for an issue that doesn't sound like it comes from the Daily Worker or the Department of Scary Ideas from the University of California At Berkeley, have been signing on to the idea if they hope to run for the Presidency in 2020, the thesis being that "this time, they'll like it!"

Republicans, who have been busy with "um. . . you know we didn't really mean that whole "repeal Obmacare" thing, right? are once again attempting to do just that, although the chances of that passing appear to be pretty poor, right now.

Here's a thought.

How about . . . now stay with me. . . we repeal the Affordable Health Car Act, entirely, and suggest to the states, perhaps legislatively, that they take on health care. The Feds, for their part, can take on health care for United States territories and the District of Columbia (an interesting dynamic which, I predict, would squelch all talk of making D.C. a state, by residents of D. C., and which would suddenly cover the Republicans into ardent supporters of statehood for Puerto Rico.

What!  Are You Insane!



No.  Well maybe, but this isn't a symptom of that.

Let's think this through for a moment.

Supporters of a national single payer, i.e., the Federal Government, are found of saying that we're the only nation in the world without a single payer system and look how well they all work. The problem with that is that the nations the comparisons are made to are nothing whatsoever like the United States.

Take the example we hear about the most, Canada.

And in doing that, toss out the extremes.  People who claim that Canadians are in despair about their system and are ready to march on Toronto and hurl herring at Justin Trudeau are just flat out wrong.  But then people who claim that there's nothing negative about the system at all are also wrong.  By and large, however, most Canadians like it.

And, and here's the point, the population of Canada is about the same as . . . California.

Or take the British National Health Care system. Again, over here, you'll hear the claim that the British hate the system, and are ready to march on Toronto and hurl herring at Justin Trudeau (they can't do that in the UK as herring are banned as small arms in the UK. . . um, well anyway).  No, they like it.  And whatever its pluses or minuses the UK's population is about double that of California's.

And so on.  What's notable about these systems are that they all apply to smaller, and frankly more homogeneous, populations.

Indeed, in order to really look at a national system analogous to the that which would apply to the United States, we'd have to look at a country like India, or perhaps Russia. These aren't exactly analogous by any means, however, and therefore that wouldn't tell us very much.  And people would be quick to note that population wise they aren't even analogous.

The entire European Union would be, but that gets us back to the fact that the EU doesn't have one single payer but a bunch of national ones, so that doesn't tell us much.

Or maybe it does.

Why not have a separate states systems?

Well the biggest reason not to have separate state systems is that we quit thinking that way some time ago and think it odd. But that's no reason not to do it.  In fact, we already partially do as we have fifty-one Workers Compensation systems, just like I'm proposing for national health care.  If you have an injury in Wyoming, you are under the Wyoming system.  If you have an injury in Texas, you are under that state's system.

And these systems, while they all largely work (yes, there's complaints about them, but they generally work), are all individual.

Oh my, the critics will claim, we can't have that they'd be different from each other.

So what.  They may be, but that's working for Workers Compensation, and every single objection you can find to fifty state national health care system exists for that and it works anyway.  People move from employer to employer and state to state, and yet it works.

So why do this?

Well, much of the objection to single payer is that you inevitably get a single payer system that isn't paid for, and which pays for everything, whether it should be paid for or not.

That is, we all know that the Federal Government, if single payers is adopted, isn't going to pay for it.  It's just going to borrow for it. That's how it deals with every expenditure.

Some states would take that approach as well, if they adopted a state payer system, but other states are much more careful with their expenditures.  I'd guess we'd see California, for example, bankruptcy itself with such a system. But I doubt its neighbors would go bankrupt with their state systems.

Another reason is that it allows the people of a state to tailor a system that they're comfortable with. Some states, such as California, would almost certainly become the payer for their state.  Others would rely upon private insurance or a mix between private insurance and the state as the payer of last resort.  Most states have that latter system for their Workers Comp system.

States would also be free, with the system as I"m imagining it, to determine how much they cover.  Covering basic health, including catastrophic injury, would have to be a given.  Hospitalization for such things, medicine, dental, glasses, etc.

But beyond that, not so much.

Again, some states would likely opt to cover everything.  I could see California opting to pay for everything from hooter enhancement to veterinary care for gerbils.  Chances are states like Wyoming and Utah would cover basic health and nothing else. And frankly that's fine.  A Federal single payer system is inevitably going to be massive, massively inefficient, and massively over broad.  In the end, working folks like myself who object to paying for people's birth control pills and gender reassignment surgery are going to get taxed for it, on a Federal single payer system.  On a 51 payer system, however, I'd guess that people will have to think about this more, as they really will be paying for it, and its more up close and personal.  If residents of Utah figure you ought to pay for your own sex and sexual identity, that's their right.

Can we be certain this would work?

No, but if it will work on a national level, it will almost certainly work on a state level.  That is, if Canada can make it work there, at least California, New York and Texas should be able to make it work.  If Ireland can make it work, nearly any US state should be able to make it work.

Would it be prefect?

Of course not. We're talking about health.  If we're talking about that, we're already in the realm of the imperfect.

So how do we get there.

Well, we'd have to repeal the Affordable Health Care Act, but probably on a long target date to give states time to come up with their plan, as well as giving states and folks who wanted a really big national plan time to complain, whine and howl.

And that repeal would have to be total.

But the same act would have to provide, under the guise of the Commerce Clause and withholding various Federal fundings, that the states must come up with a health care plan for their residents that covers basic needs; ie., routine health and catastrophic injury, by the expiration period.  If they chose to go with conventional insurance, there would need to be some tweaking (cross state insurance competition for one thing).  And the system would have to cover everyone, which means as a practical matter the state is probably the payer of last resort.

Would this be better than what we have now?  Who knows? Would it be better than the old system?  Who knows. Would it be better than a Federal single payer?  Who knows.

But chances are that it would be more palatable, and on the getting it paid for end, more realistic than a giant Medicare, which would turn into a giant "let's borrow from the unborn to pay for the Baby Boomers and some others' program.

It's worth looking at.

Even if we are not going to.

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