It would appear that Americans are highly tolerant of inefficiency in health care delivery, based on the ridiculous "system" we have in place now. Any purported governmental inefficiency would have a ways to go to approach the inefficiencies that currently exist, so that doesn't strike me as much of a reason to oppose a single-payer system.

Well government may work (and it works when its things we like -- like road building) but the PERCEPTION is that it doesn't work. And that's a big hurdle to overcome. I think American's have a very low tolerance for government and for anything related to perceptions of government inefficiencies. The American Revolution was our first anti-government, tax revolt. We've been fighting ever since. So while I personally don't like this, it is a perception that will impede implementation and gaining acceptance for the idea. We need to plan now for how to get around that.

Anybody else see the real con at work here? By my count, 7 out of 10 of these bullets (3-4 and 6-10) are essentially the same: government is inefficient and can't administer public programs well. But saying it seven times doesn't make it so.

Yeah, but the Republicans have been saying it seven million times, to the point that it's an article of faith.

Recall P.J. O'Rourke's apt description of the GOP (from way back in the Reagan years, yet!): Republicans claim that government doesn't work, then get elected and prove it.

Whereas, insurance companies are efficient?

Mr. Drum:

I have a question for you:
Who determines the salary of the medical community in a single-payer system?
My wife is a nurse, and the salary structure is insane to the non-medical person. In a single payer system, how would there payroll and retention be managed?

While I'm all in favor of "single payer", I believe all the countries wherein it is implemented are significantly smaller in population than the US.

What works in Canada may or may not work here, simply because of scale.

If someone has a counterexample, I'd be interested in hearing about it.

Government definitely doesn't work when Republicans control it.

"What works in Canada may or may not work here, simply because of scale."

Scale and entrenched interests are why an incremental approach on a procedural basis is necessary. Preventative medicine would be a great place to start. Small, or even mobile, clinics specializing in certain procedures are an option. 2 year degrees in those areas could be encouraged. A healthier population with easy, cheap availabity to rudimentary diagnostic tests would benefit us all. Only by proving that it can work on a smaller scale can we ever aspire to more substantial change.

"I believe all the countries wherein it is implemented are significantly smaller in population than the US."

Various forms of universal health care coverage are working in countries of populations up to 127 million (Japan) and down at least as far as 0.3 million (Iceland).

I think the burden is on you to prove that what works over such a huge range (400x) stops working somewhere between 127 million and 300 million (2.3x).

China also had a universal health care system which worked reasonably well for such a poor country with a population up to about 1 billion. See, gapminder.org and notice how china did incredibly well at health metrics for its income compared with most countries. That system is, I have read, in trouble recently, and was pretty different to begin with, however it was effective in its way at more than triple current US population.

I would go farther and say it is only 3 items not four. 1 and 2 are essentially the same, since (assuming for the sake of argument that the points are correct) single payer would lock us into fee for service, that is how the innovation in payment and delivery would be blocked

Very funny list, Mr. Enthoven. Says a heck of a lot more about him and why his ideas don't work than anything else.

Hillary's health care proposal was essentially Enthoven's plan. And to do all these cool, innovative market-based solutions it had to be extremely complicated. Which in turn meant it wouldn't work - and wouldn't sell.

Second, all this cool stuff has been repeately shown not to really work. Single payer health care is what the rest of the industrialized world uses because it's simpler and more direct way to deliver good health care to people.

Enthoven's list is simply denial of that basic fact. His ideas just don't work in the real world.

Steve: the EU is evolving toward a federal system, where the member countries are increasingly looking like US states.

The EU has a larger population than the US (about 500 million), and many European countries have a larger population than any US state.

Which country has the best system? Copy it. Our candidates are too stupid for original thinking.

If government is inherently inefficient then why are the Medicare administrative coast so substantially less than those of the private insurance industry?

Robodruid,

A single payer system means only that there is one insurer, presumably not for profit and publicly owned. Many of the folks processing paperwork for the now private insurance companies would be processing the paperwork in a single payer system.

The different in a single payer system and the Rube Goldberg system we now have is that the health insurance system would not provide profits to shareholders or lucrative compensation packages to executives. And the administrative costs would be far, far lower.

What Jen said - this man's memory about government efficiency goes back only about seven years.

Well, Government does work. SS works just fine. It has a surplus for years to come and has worked just fine for the last 70 years and by all accounts will be just fine for the next 40 years at least. I know of no business being managed that well.

Taxes for health care would be a lot less than the amount for premiums and deductables which they would replace.

It is the private sector that does not work, even MEDICARE works better.

Robodruid

In single payer systems the medical professions negotiate with the single payer.

Truly, the never-challenged assumption is that "business" is inherently more efficient, less bureaucratic, less susceptible to political agendas and capable of optimally allocating resources for best effect. Anyone who's ever actually worked with corporations knows that this is complete bullshit.

Imagine healthcare in the hands of Citigroup and Countrywide. Or Enron.

>"What works in Canada may or may not work here, simply because of scale."
>"Which country has the best system? Copy it."

Scale might not be the only problem. It's possible a collective system also leans on the culture it was developed in. Attitudes to government, etc. If Canadians took a "I'm the customer!" attitude the system would fall apart in short order.

For that reason I get doubtful whenever people make direct comparisons between specific geographic region's problems and solutions.

I think the biggest problem with government-run enterprises in the U.S. is that conservatives despise them so much that they'll go out of their way to manage them badly when they achieve office, thus making their prophecies of incompetent government self-fulfilling. It's like beating your wife so you can explain why you had to divorce her to get out of a bad marriage. Goddam conservatives.

the question in health insuracnce is whether or not the us will abandon the employer-mandate (health insurance is obtained through employers)

as it is now constructed employers have huge power in setting national health policy
\
autos are produced in canada where ford, gm, chrysler do not control health insurance

autos are produced in the us where ford, gm and chrysler do control health insurance

auto production is up in canada

auto production is down in the us

oh by the way, auto production is up in mexico too

Excellence and efficiency do not spontaneously appear without competition to goad them. Industrial monopolies and command economies both institutionalize waste and stifle innovation for the same reason.

That said, the marketplace has its own pathologies, and the health insurance industry is a fine example of competition introducing its own form of bureaucratic inefficiency.

What I want to see in a health care reform plan is something that keeps individual health care consumers engaged as purchasing agents with incentives to choose lower cost and higher quality products and services.

If anyone here is open to something like that, then perhaps we can work together. But if the point is to promote statism while deriding Economics 101 as anti-government ideology, then I guess we'll have to fight.

I suppose it's possible that American government is uniquely inefficient... - Kevin

...it is a perception that will impede implementation and gaining acceptance for the idea. We need to plan now for how to get around that. - Christopher / Inaudible Nonsense

You could start off by offering the public the *choice* to opt-in to Medicare and let them either pay the full premium (if they are self-employed), or let employers pay 80/20 of the premium similar to a private plan, etc. Then see how it goes. If everybody likes it well enough, then single-payer Medicare for all would be a hell of a lot easier to sell down the road. Just a thought.

An easy and fun answer to Enthoven's bullshit: Theories are good, but facts are better. He can dream up all the arguments he wants; but the single-payer system is tested and proved.

Theories are good, but facts are better.

LOL Perfect bumper sticker. The perfect response to nearly all libertarian whining.

Okay, as I understnad it, the single payer would be the US govt. correct?
In which case my question still stands. WHat determines the salary of the nurse staff? What about call back pay?

My wife will not go back in unless they pay her more. Sometimes a lot more.
In a single payer system will this still be alowed?

Otherwise she wont go back in.

I suppose it's possible that American government is uniquely inefficient, but what makes Enthoven believe that?

He hates America?

Sometimes the simplest explanations are the best.....

I agree the "government doesn't work" idea is bogus and should be completely repudiated by the American public over the next few elections.

However, given the idea that "government doesn't work", why don't the Republicans argue for decreasing military and spy agency spending?

#4 isn't unique to government. No single entity can correctly set prices. That's what competition does. There's a reason why there are 8 different prices for flights on the same route. Single payer eliminates the feedback mechanism. So that one is a completely different con (since it applies wether the single payer is the government or Walmart).

So Alan Enthoven doesn't think the USA can do what France can do, what the UK can do, what Australia can do, what Canada can do... why is he so down on the USA? Why do people like him think we are uniquely incompetent? I for one do not agree; I think the USA is an extremely capable country which can at least match what so many other countries can do.

It's nice to see the world is run by old high school debaters.

This is an old-as-the-hills affirmative strategy -- I remember seeing a 14-plank aff. plan once run by Lexington, MA's crack policy team in the 80's. They ran each plank three or four times, couched in different language, in an attempt spread out the neg. "See, Neg left four of our planks untouched -- vote aff on plan", and Bob's your uncle...

Unfortunately for LHS, the negative -- I believe it was Manchester-by-the-Sea -- lumped the planks together by type, and treated it as a five-plank plan, all five of which they blew up.

I enjoyed writing that ballot.....

rd again,

Your wife's compensation would be determined just as it is today, presumably through negotiations between her bargaining unit and her employer.

The only change would be in the insurance system not directly in the provision of health care services.

WHat determines the salary of the nurse staff? What about call back pay?

Uh, the hospital, or clinic, or partners, or whoever manages her organization? The government won't pay her, they will pay the organization the scheduled payments for the procedures performed. How this gets sliced and diced and ends up in her pockets is a normal internal matter.

I'm a federal contractor. My company bills the government, and the government pays us. I get paid through the normal incomprehensible review process like pretty much anyone else in the private sector.

rd again - In a single payer system your wife, as a nurse, works for a hospital, doctor, or clinic just as she does now. The government is the insurance company.

Christopher,

The American Revolution was our first anti-government, tax revolt.

Another myth I am afraid. The revolution was against taxation without representation. It was not a revolt against either government or taxes. You probably think the Boston Tea Party was because of high taxes on imported tea. Silly boy.

I'll agree it was about free trade but the Boston Tea Party happened because England eliminated their tea tax so the East India trading company could sell tea dirt cheap in the colonies. This was meant to eliminate the competition from smugglers who were importing tea from Holland.

The Boston Tea Party was because the tea tax was too low, not too high.

Re:

Thanks, for you input.
I don’t think my wife is in a bargaining unit, she is not in a union. She negotiated her starting salary at a new job. (15+ years neo-natal ICU nurse, RN, registered)

So at this point I know that there is a limit to her salary that is the profit and loss statement of the hospital. (Norman Regional Hospital)

But would there be a limit to what the one insurance provider would accept as a reasonable bill for services provided? What happens when a doctor or nurse go beyond what the govt. would accept?

The whole meme of government never working is insane. I was talking to my girlfriend's dad and he told me he gets his social security check every month on the exact same day. Keep in mind it's deliver by a quasi-governmental agency in the US Post Office!

Government does work. It doesn't work when (A) the people in charge don't want it to work (our situation the past 3 decades), and (B) when the people the program is designed to help are too poor and/or marginalized to really care (when Granny doesn't get her SS check she calls her congressperson and it gets fixed the next day, but means-tested programs like Medicaid can be fiddled with and gutted and what not because it effects far fewer, poorer, less likely to vote people). When everyone has medical care, they will make sure it all works.

RD,

The profit and loss statement for Norman Regional Hospital is affected by the payments it receives, including insurance and copays.

How do private insurers determine what to pay? Are you trying to make this difficult?

Minor correction: Not "Alan" but "Alain."

In the early 1960s, Enthoven was one of Robert McNamara's "whiz kids" in the Pentagon -- a systems analyst brought in to make defense policy "rational." He helped plan everything from the size of the US nuclear arsenal (1000 ICBMs was the magic number) to...Vietnam.

Enthoven later became a health policy expert.

Mother Jones found in 1993 that he was a paid consultant to a big HMO company (Kaiser): http://www.motherjones.com/news/feature/1993/05/yamin.html

RD, one of my clients is a large healthcare insurance company. They negotiate contracts with the providers they deal with which specify what procedures will be paid for by the insurance company, and how much the payment will be.

So, in reality, the insurers are ALREADY setting the prices. The only difference in single-payer is that the government will be the insurance company.

I've been on medicare for several years now and for part of that time have belonged to a medicare hmo (no cost). Each hmo, and there are thousands, is chartered on a county by county basis. They
offer various no cost extra services such as dental, gym, preventive, free vitamins, free prescriptions. The only hitch is that they are preferred provider which means you must get your care from doctors and clinics within their individual networks. My hmo provides all of the extras noted above and more. There is no annual deductible and 4 primary care doctor visits per year, including tests, are free. Specialists may have a small co-pay (I once had to pay $5.00 to see an Ear, Nose, Throat specialist). Hospital charges are fully covered.

Anyone can go to the Medicare web site and look up the hmo providers in their county. Each hmo will have different feature so you can pick the one that suits your indvidual needs.

I have read that the majority of health care cost occurs in the last 6 months of a persons life. The largest cost for most younger people is the cost of maternity care so preferred provider networks would make more than they do with older medicare patients and could offer all kinds of specialized extras.

Enthoven is bogus.

Well, four bullet-points is three more than Ezra usually manages with any credibility, so I guess we have to enjoy small miracles while they last, Seriously, what do you expect from a 24 year old with a BA who is simply not up to providing real analysis on healthcare issues?

Many of these same claims ALSO apply to our current system of private insurance. He needs to prove not only that government won't do these things well, but that the private companies are doing it better. In most cases, they are not.

JAL

Rodger,

Enthoven and the other Pentagon Whiz Kids had little if anything to do with Vietnam.

The Whiz Kids helped McNamara reform the Pentagon by supplying answers that were free of the institutional bias that the Joint Chiefs brought to the party.

It was Whiz Kid rationality versus backscratching (and/or knife-fighting) by the Chiefs. Even the military nowadays credits McMamara and his Whiz Kids for having improved how the Pentagon makes decisions.

Long after McNamara departed, the Pentagon is still largely along the lines he laid out.

Joshua,
My experience working for the government myself (GS-11 now) is as follows. There are serious problems with the way many programs are run. But the problems are in many cases actually CAUSED by the ideological crusades of the past twenty years of "government sucks" ideology.

The first obvious thing I see is that many government workers don't do all that much. This brings charges of "laziness" but the fact is in the vast majority of cases I have seen laziness isn't the problem, rather it is that they are not being assigned enough work or given enough of an avenue to show their initiative. Of course, the right would never admit that the problem with the government is that it doesn't have enough missions or that it is not active enough, but that's the truth. Morale suffers heavily in a bureaucracy when those on the lower rungs see no way to have a wider positive impact on how things are done. Contrast this with the situation of government workers under Roosevelt or even Johnson. Now those guys got a lot of shit done.

The other, related problem is the ever-expanding use of contractors in government work, which leads to a hell of a lot of confusion and waste. Contractors have an appropriate time and place, they should be hired for discrete jobs which do not have severe impacts on the core of a government organization's mission. What I have seen instead is just contracting for the sake of contracting, or for the sake of illusory budget-cutting at a branch or division level, which ends up getting paid in some other way, on somebody else's books. I see core government functions hired out to contractors who don't know what the fuck they're doing but who can always collect on their payment (Accountability? What a joke. Try being a COTS officer managing a government contract and see how "accountable" those companies are to their own failures!) Again, the issue is one of morale. If you put in contractors working for a firm whose ideology is the profit motive, that ideology is going to rub off on government workers. And guess what, the best ones are going to leave because the not-so-subtle message is: "we suck, so we hire these other people to do our job."

The issue is really very simple, America needs a new ethos of public service, and we need it quickly and badly. Everyone knows that the right wants the government to fail, that they in fact are gleeful when they can point to examples of government failure. The right cannot support a new ethos of public service because the right hates the public sector and only tolerates it the way we all have to tolerate the law of gravity. People do not often hear about the advances that have been made by government workers or agencies over the years, and it shocks me the level of ignorance that there is in this country about public servants, their motivations, and their abilities. Government workers are themselves to blame somewhat, I sense in most of my colleagues a self-depreciating sense of humor or modesty which is perhaps just a form of professional civility but which is in fact extremely counter-productive. The civil servants should be a little more arrogant--they should not think that the "real world" of change and innovation is in the private sector, they should insist that they also live in that world, that they also MAKE that world. Most of all, they should clamour for new assignments, push for new programs from within. Make it seem like they are the kinds of people who could actually run such programs effectively.

So, we made it into the 21st century without modernizing, because, hey, we ended WW II on top of the heap and could coast on that for quite a while.

But now the wrong decisions are coming home to roost and we'll need some changes around here. Scary, for sure, but do we really want to slide from #37 to #92?

Enthoven is just a BS artist. "Locks in fee for service"? Oh lawdy, that would be dreadful. Blocks "innovation in payment and delivery systems"? What a load of bull. The big innovation in payment and delivery systems would be for the doctor to know what he can do and how much he'll be reimbursed for, quickly.

And Enthoven rules out the idea that the US government, acting as the world's largest purchaser of drugs, could bargain for a price break. If this was a pinball game the whole table would be flashing TILT.

What we really need to do is find some way to keep people like Enthoven from sucking up our national resources. It's a tough problem to solve, but we'd sure save a bundle if we did.

As for all these doctors, let's just break the damn monopoly. Half of the patients don't need to see a doctor, and half of the doctors aren't worth seeing. If the patients can get the drugs they need, they'll find that a nurse is perfectly adequate for about 80% of the problems people go to clinics for. If they were honest, the doctors commenting here would admit that.

Murrican government is uniquely inefficient. A side effect of a nation being afflicted with libertarian disease, is they we get officials whose primary goal is to prove that government sucks. The way they try to prove this is to appoint the least competent people possible to run things. Then the result causes people to hate government and become libertarian. Engineers would refer to this as a feedback loop.

serial catowner: Of course half the time a nurse (or your mom) can do just as well as a doc. Half the time a teacher's aide can do as well as a teacher, a nurse's aide as well as a nurse, a draftsman can do as well as an engineer, a paralegal can do as well as a lawyer, and even a flight attendant can fly a 747 half the time. With the exception of the last one (up in the air and on autopilot), the trick is figuring out which half of the time the problem is easy.

ndc: The Medicare HMOs are actually pretty good. They also cost the taxpayer about 20% more per patient than fee-for-service, traditional Medicare.

Everyone knows that the right wants the government to fail

Well, economically I'm a small-l libertarian, which presumably puts me on the right in this forum despite the fact that I'm quite liberal on many social issues. As a data point, I don't want government to fail. I simply don't believe that monopolies, including government monopolies, breed excellence when compared to systems where there is competition.

that they in fact are gleeful when they can point to examples of government failure.

Hardly. It's my government, and my money. I don't want to see it wasted.

kokblok, right, exactly my point! I remember the IRS saying a few years ago that they would start to farm out tax collection to agencies (a truly scary prospect if there ever was one!). At the time they admitted it would've been way cheaper and more efficient for them to just hire more staff, but that wasn't what the bosses wanted.

It's just crazy. Ronald Reagan stood up and said that government is the problem... well if you worked for the government he was in effect your boss saying YOU were the problem! Could you imagine Bill Gates standing in front of his employees and saying, "people, Microsoft is the problem!". Insane! Yet for some reason it is now accepted wisdom in this country.

Alan Enthoven is a leading exponent of school vouchers.

If one combines "government doesn't work" with the glarinly obvious record of the past seven years of the worst administration in American history, that has sunk to hellishly abyssmal levels of corruption, mismanagement and cronyism, that has turned the overall efficiency and integrity of the previous Democratic administration into a corrupt, corporate Republican machine, then the only conclusion is that Republican-run governments don't work...at least for the overall health, wealth and well-being of all United States citizens.

Remember, Republican-run governments don't work, especially with Repubicans involved in so much lying, cheating and thieving.

While Democratic-run governments and programs have a history of working quite well.

the only conclusion is that Republican-run governments don't work...

I had a different take. George Bush turned me into a believer in limited government -- because I realized that I wanted his administration limited.

Trip et all...

No, I'm not trying to make it difficult. I'm rather serious.

Let’s say that the payroll of the hospital requires them to bill more than the insurance provider is willing to pay.

Either the insurance provider pays or it does not.
Right?

If they pay, that’s good for my wife (and me), but if the govt. wont reimburse at the elevated rate, my wife wont work.

If the hospital wont do the procedure at the rate the govt. negotiates, who wins?

Either the insurance provider pays or it does not. Right?

Right.

If they pay, that’s good for my wife (and me), but if the govt. wont reimburse at the elevated rate, my wife wont work.

Correct. This is no different from the situation faced by any other business. You can only employ as many people as you can profitably pay.

If the hospital wont do the procedure at the rate the govt. negotiates, who wins?

Presumably another hospital which will do the procedure at the rate the government negotiates and thereby takes away the business from the first hospital, and, in the long run, all those who need the procedure (because the hospital will eventually have to drop its rate or lose the business) and the taxpayers (because the cost of health care will go down).

Ok, I give up, Rd is a troll.

Hospitals do stuff all the time that cost them more than the insurer will pay. They also do stuff that costs them less than the insurer will pay.

Rd does not have a wife working in an ICU unit. I've worked in ICU units. My wife worked in ICU units. Nobody can work in an ICU unit without becoming aware that some patients will run up hundreds of thousands in costs that nobody will ever pay for.

And this situation is hardly unique to hospitals. Grocery stores have shifts where they spend more in labor cost than they make in sales. Restaurants have unsold food at the end of the night and bookstores have books they eventually send back to the publisher.

Sorry to tell you, anyone who answered 'Rd' was gamed by a 12-year-old troll.

Oh, and for the anonymous commenter who asked how you know which half of the problems can be treated by a nurse, well, you ask a nurse. One of the things nurses do is to decide which problems need to be sent to a doctor.

9:04PM:
Going by my own experience, the reason people who use Medicare HMOs cost the taxpayer 20% more is that most people who are healthy and don't go to the doctor also don't join a Medicare HMO. I didn't even know about the HMO program until I went to a doctors office for the first time in about 25 years. This was after I had been in the medicare program for several years without using any services.