We Need Clear Thinking: There Should Be No Clash
Between Public Option and Single Payer
By Joshua Holland, AlterNet
Posted on July 13, 2009
http://www.alternet.org/story/141238/
On the surface, there's a deep divide within the
progressive movement over how to fix America's ailing
health care system. A sometimes nasty, running food-
fight has raged between advocates of a public insurance
option and those who favor a "single-payer" system.
The rift endangers what might be the most important
domestic policy of our time. As Washington Post
columnist Harold Meyerson noted this week, while
there's extensive institutional support behind the push
for a public insurance option, there's little "street
heat" -- a paucity of grassroots pressure being
applied to sold- out lawmakers who believe that
insurance company's profits are more important than
getting health care right.
But the debate represents a false dichotomy to some
degree. That's because most systems that people think
of as "single-payer" are not. Among liberal
democracies, something approaching single payer exists
in Canada, Australia and the UK. But even in these
countries, buying supplemental insurance from private
insurers is commonplace.
Has Any Country Gotten "Profits out of Health Care"?
The reality is that virtually every advanced, wealthy
country features a universal system -- we're the
exception -- that is financed through a blend of public
and private means. See, for example, this Wikipedia
entry about the health care systems in Holland, Germany
and Belgium -- all of which are commonly referred to as
single-payer systems, but in fact have "multiple payers
but with some single-payer features." Those features
include: universal coverage, regardless of citizens'
ability to pay, heavy state regulation and either the
ability to bargain for the best prices from providers
or having prices set by the government.
So, if you're a "single-payer" advocate (like myself)
the question arises: wouldn't you be happy to have
something like Germany's system (when I lived in Berlin
in the early 1990s, I had an accident, broke a bone and
went to the ER without insurance. They X-rayed it, set
it and gave me a bunch of happy pills to take home.
Total bill: $10).
Then there is the Cadillac of health care systems --
the French model. Would we be poorly served with
something like the system that scores the highest among
industrialized countries in most measures of patient
satisfaction, access, longevity, child mortality, etc.?
Of course not.
The French enjoy guaranteed quality health care from
cradle to grave that is financed, in large part,
through tax revenues. However, it is not a single-payer
system. 35 percent of French hospital beds are in
private facilities; over 9 in 10 French citizens have
supplemental insurance and, as this backgrounder
explains, "About seventy five percent of the total
health expenditures are covered by the public health
insurance system. A part of the balance is paid
directly by the patients and the other part by private
health insurance companies that are hired individually
or in group (assurance complémentaire or mutuelle,
complementary insurance or mutual fund)."
When we talk about "single-payer" what we're really
saying is that guaranteeing access to decent health
care -- just like sanitation, the provision of clean
running water or electricity -- should be considered a
fundamental duty of the state. But from that point,
there's no reason I can see to exclude the private
sector entirely. We regulate utilities that provide
those other vital services, and limit their profit
margins, but we don't rely on the government alone to
deliver our electricity.
In France, "The State sees that the whole population
has access to care; it dictates the types of care that
are reimbursed, and to what degree, and what the role
is of the different participating entities. The State
is in charge of protecting patient's rights,
elaborating policies and enforcing them. It is
responsible for public safety."
That sounds fine to me, even though I identify myself
as a "single-payer" advocate.
And the reason that this is more than a semantic point
is straightforward: the proposal before us today would,
if done right -- and the Devil is most certainly in the
details -- achieve a hybrid public-private system with
"some single-payer features" much like what citizens of
other liberal democracies enjoy.
Put another way, the idea of getting "private profit"
out of health care, while perhaps appealing on
ideological grounds, doesn't reflect what the rest of
the world has done. A more practical goal is addressing
our shortcomings in part by shifting the balance
between the public and private delivery of health care.
Currently, the United States ranks dead last, among the
wealthiest nations, in terms of the portion of our
health dollars spent on public health.
Having a greater share of health spending in the public
sector not only results in a very large insurance pool,
and the efficiencies of scale and bargaining power that
comes with it. Countries with a higher rate of public
health spending end up with a different set of
incentives. Unlike a wholly fragmented system relying
on only private and largely unregulated insurance --
where an insurer has no incentive to make sure you stay
healthy because when you get sick it's just as likely
to be on someone else's dime -- public health providers
tend to place greater emphasis on preventing illness
rather than waiting until people get sick and seek costly treatment.
A Debate About Tactics, Not a Fight Over Fundamentals
Karen Dolan of the Institute for Policy Studies is
right in arguing that the fissure between public option
fans and single-payer advocates is shallower than it appears at first blush:
One problem in progressive circles that
contributes to the confusion is the perception,
real or not, that single-payer and public option
advocates are fighting each other, weakening
support for both. Though some of that is going on,
the greater problem is that people think that's
what's going on, and thereby try to push each
other out of the room.
There are very few healthcare advocates who will tell
you that a single-payer healthcare system is not the
correct remedy for the U.S. health care crisis. What
they instead will say is that single-payer is dead
politically, and that Obama and the Progressive
Democrats' public option is the only politically viable option.
This is a key point -- the divide that does exist in
progressive circles is tactical, not ideological. Most
of those pushing the public option would, if they had
their druthers, enact a "single-payer" system. But they
recognize that the two commercial enterprises that have
spent the most on political lobbying in recent years
are the "disease-care" and insurance industries.
Like single-payer advocates, they believe that a large
insurance pool with extensive government regulation and
some subsidies afford the greatest potential for (near)
universality and cost containment. And they think that
given the choice -- given a demonstration that this
approach works better than having a fragmented system
of private insurers -- most people will eventually opt
into the public plan, and we'll end up achieving
something approaching a "single-payer" system --
although an American-style variation -- through the
back door. They just don't think single-payer is a
viable proposal given the clout that Big Health wields
in Congress, and I'm not idealistic enough to say that they're wrong.
The reason this is an important distinction is simple:
people can differ respectfully and in good faith when
it comes to tactical differences, but arguments over
fundamental philosophical differences tend to become heated, and quickly.
Finally, the divisions over the role of public and
private insurers distract from other things that we
need in order to fix the system. We may differ on the
role that private insurers might play in a revamped
U.S. health care system, but there are other issues at
stake in this debate around which consensus shouldn't
be hard to find. We can agree on the need for payment
reforms that would discourage providers from providing
endless and often ineffective procedures; we can agree
on the need for tighter regulations that would keep
insurers from cherry-picking the patients that they
want to cover, and we can agree on the need for
investing in a secure electronic records system that
would cut down on the cost of shuffling paperwork around.
Understanding all of this leads, I think, to a lot more
agreement among progressives than appears to be the
case at first blush. It refocuses the debate towards a
more productive question: how much private sector
involvement we want, and what structure we might adopt
for health care financed through the private sector in
order to keep the insurance industry's predations in check.
It also explains why some single-payer advocates --
like myself -- are advocating so fiercely for the
legislation working its way through Congress to be done
right, with a large public insurance pool that's not
restricted from bargaining with providers or otherwise
forced to compete with private insurers on an uneven playing field.
Joshua Holland is an editor and senior writer at AlterNet.
c 2009 Independent Media Institute. All rights reserved.
_____________________________________________
![[iCopyright]](cid:image002.gif@01CA052B.0D507630){kind=small}
![[Arundhati Roy, writer, activist (a term she dislikes) kicked off the London Literature Festival-2009 with a public interview conducted by an exuberant Shami Chakrabarti, Director of Liberty (a British pressure group) and Chancellor of Oxford Brookes University.]](cid:image001.jpg@01CA0223.BD99BAC0 "roy-2.jpg")
Arundhati Roy, writer, activist (a term she dislikes) kicked off the