Even while supporting universal coverage, I wrote and posted arguments against a single-payer system in June, 2005. At some point, I would expect that link to become inactive, so I’ve copied it below in its entirety. Though I might tinker with a couple of minor things, for the moment I’ll leave it as originally written. After oral argument this week before the Supreme Court on the Patient Protection and Affordable Care Act, I’ll try to synthesize what I’ve observed since, assess where we are now and where we might be headed.
Evidently, today was a pretty rough day before the Court for proponents of the PPACA. A few days ago in Universal Coverage, “Obamacare,” and the Supreme Court, I suggested that opponents of Patient Protection and Affordable Care Act (PPACA) “be careful what they wish for.” It they win in the Supreme Court, they will leave the U.S. with only one practical alternative to a fragile and failing healthcare system, single-payer, essentially a centralized, uniform system operated by the Federal government.
Anyway, here’s what a wrote seven years ago.
We do not need a single-payer system to gain universal health coverage.
Here, I made the argument for universal health coverage. For many, the solution is a single, national, governmentally sponsored, financed and administered program. I emphatically believe that this “single-payer” approach is not the solution, either programmatically or politically. Think of this notion as Medicare for all, or as Canada’s system imported to the US.
We should have universal coverage. We will never be able to eliminate many of the inefficiencies much less the inequities in today’s system unless we do. Recognizing that we might also eliminate some administrative inefficiencies with a single-payer approach, I think they’re worth the cost. Most important, the differences in access to care between those with coverage and those without are so large, so significant, and so tied to racial, ethnic and income disparities, that it raises ethical issues
that should disturb us all.
A purely market-based approach is not likely to work, and an active role for government is essential. However, a single, governmentally operated program won’t work either.
Many needlessly take for granted that universal coverage requires a single payer system. But single payer can be separated from universal coverage by distinguishing between the financing and operations of a universal coverage program, and between gathering the necessary revenues and spending them. These functions need not all be located in one governmental organization. For example, we can and do use public money to buy private insurance.
What’s wrong with the single payer proposal?
Who chooses? What choices?
Single payer systems rest on the premises that there is a uniform best health benefit plan for every individual, that public officials and organized political interests always can know what this best arrangement is, and that they uniformly will choose it. The weakness of this foundation should be argument enough against single payer.
The health care system will be even more politicized than it is today.
If the revenue of health care institutions and professionals, as well as the rules controlling the institutions and the care providers, are determined by government policies, lobbying by vested interests will be even more fierce than it is today. Key choices will be made by government, political elites and vested interests. This same political process also would determine which medical services are available, to whom and under what circumstances.
Single payer systems minimize the involvement and responsibility of individuals and families
The corollary to increasing government decision making and politicization is a diminished role and voice for individuals. In a single payer system, there is no role for the average person except to consume service. Individuals have no place in choosing systems of care and financing, little leverage over institutions that directly and significantly affect their lives, and only a faint voice when dissatisfied.
Once we establish a single payer plan, we cannot easily undo it
Some reform plans can be undone. A single payer system cannot. If we choose a single payer system, we will dismantle organizations and processes such as health insurers and plans. We will not easily or quickly rebuild them if the new system fails to satisfy us.
No guarantees on cost and quality. Some countries that have single payer systems have had lower cost-growth than the United States. However, in order to restrain cost, single payer systems require centralized government control of health care prices and use of services–and the intrusiveness that goes with it. But our experience with heavy regulation on the state level raises questions about whether central controls really are effective.
Organizational vitality and innovation
The structure of single payer systems discourages diversity and thus discourages the robustness and resilience that typically characterize diverse systems. Organizations continually must revitalize themselves lest they become moribund and bureaucratic. Diverse systems usually are better able to adapt, innovate and survive.
No single payer plan can centrally manage the formal or informal systems of care serving millions of people. No large centralized system can adequately tie together all of the diverse elements of a health care system on behalf of an individual. To do this we need organizations with motivation and means, and that operate at the local level. We can have a uniform system or we can have a system that is responsive to the needs of individuals, but we can’t have both simultaneously.
Locking the systems status quo into place
A single payer system would cement into place the worst and most inefficient characteristics of our health care system. It is based on a fee-for-service payment model and it relies on isolated individual institutions, agencies and professionals. The politics of universal coverage are tough enough. Why we in the United States have never adopted a system of universal coverage is worth a separate column, but it is clear that the individualist preferences embedded in the American psyche, and our ambivalence about the appropriate role of government, play a substantial role. With this as backdrop, getting agreement that everyone should be covered is tough enough. Seeking the consensus necessary to force everyone into a centralized system will leave the problem unrelieved for decades.
The ugly (political) facts of life
Even if a single payer system were ideal, we should sacrifice it in order to get even minimal coverage for those who have none.
There are other, better ways of covering everyone than to force us all into a uniform centralized system. Universal coverage does not demand a one size fits all solution, and single payer is not the answer.