I went to a meeting of the “Manhattan Institute” (a Koch by any other name) to hear their take on single-payer. The good news is they are forced to respond to this growing movement, and that they have no good answers or even good questions. The bad news is they were planting seeds of misdirection in the audience members’ minds that could eventually make their way to the airwaves or to political debates. 

The US is Not Exceptional

“If there was one main takeaway from the evening,” the moderator remarked, “it would be that the US is really not very different from the other countries.” 

This is an entirely necessary misdirection for the anti-single-payer crusader, because once you take a good look at how much we enrich our healthcare industry, you really can’t look away without doing something about it. The kinds of statements they make to obscure our monumental problems would be, “every country has a mix of public and private payers,” and “95% of the French have supplemental insurance” (not mentioned: the French public system covers between 70% and 90% of costs).

Let’s be very clear: the US is absolutely exceptional. The US spends the most of any OECD country, and spends more than double the median OECD country whether measured in dollars ($9,900 per capita versus 4k) or as a percent of GDP (17.2% versus 8.9%), and more than double Canada with either measure. 

The US also spends twice as much on healthcare than we used to spend in the year 2000. Sure, there was inflation but has your salary doubled?

Each year, the US becomes more exceptional:

And yet at the same time, we do not devote more real resources to or get more in return from our healthcare system than do other countries. The US has fewer MDs per capita, fewer medical graduates, fewer hospital beds per capita, shorter average hospital stays, etc. Americans do not consume more healthcare or get more MRI tests or any of that. It’s just the prices, stupid: we spend much more and get much less. There’s a vast capitalist machinery between us and our doctors, siphoning from our incomes. 

Their Solution: Free-Market Incrementalism

Perhaps the soundest argument they made was that simply starting from scratch won’t work, instead slowly building a system over time is better because it provides the flexibility necessary to deal with human complexity (I’m making it sound more poetic than they did but the point holds). The truth is we will certainly need an ongoing commitment to scrutinizing and improving whatever system we build. We will have to resist the temptation to defend the hell out of single payer once we get it, in order to continuously improve it. But we’ll be improving it in the interest of the consumers of healthcare - which is all of us - rather than in the interest of the most powerful organization in a given transaction.

That would be my solution to that argument. Theirs, of course, was free-market incrementalism, where we would bring back exclusions of pre-existing conditions and switch over to a world where everyone buys their health insurance in the non-group individual market instead of through an employer. Nevermind that sick people need healthcare too. 

Morality, then, didn’t figure into the discussion at all, nor did access to care or equity. Anyone concerned about these qualities are fully in favor of single-payer. As are most Americans once they have the facts.