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The state-based single payer strategy

"Quite frankly," Sen. Bernie Sanders said today, "we don't have the votes for single payer." That's not much of a surprise, but Sanders did outline another strategy for single payer that some liberals might want to think about. "Right now," he explained, "we have language in the bill that says that states that want to go forward with single payer can do that." He's talking about the Waiver for State Innovation, which allows states to go their own way if they have a plan that will achieve the goals of the bill at a lower cost. You could imagine a state -- say, California, where the legislature has passed single-payer bills before only to see them vetoed by the governor -- using that provision to implement a single-payer system.

Sanders thought this the best strategy going forward. "I believe the way we move to single payer in this country is to let one state like California go first," he said. And before some of my conservative readers decide this is a liberal trapdoor in the middle of the bill, the provision could be used to develop a much more conservative approach to universal health care. In fact, it's a legislative expression of the GOP's third plank for health-care reform: "Give states the tools to create their own innovative reforms that lower health-care costs."

The health-care reform bill will create a basic, near-universal system across the country. If individual states think they can do better, they're welcome to try. And if they succeed, you could imagine those reforms spreading quickly to other states, too.

By Ezra Klein  |  March 10, 2010; 3:30 PM ET
 
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Comments

This will sound like ass-kissing, and I dont care.

This is the kind of stuff that makes Ezra Klein invaluable. I have followed health-care reform pretty closely, and I had no idea about this before right now, why this administration hasnt talked about that more is bewildering.

The idea that states will be able to enact single payer and prove how much cheaper healthcare can be delivered is probably the most important piece of this I've heard yet.

Posted by: zeppelin003 | March 10, 2010 3:40 PM | Report abuse

I'd like to volunteer the state of Illinois to be the test guinea pig.

Posted by: leoklein | March 10, 2010 3:57 PM | Report abuse

I'm in favor of the referenced provision because it's a double-edged sword: if a state's innovation fails to save money, the state gets no additional funds to cover the losses (further, if Congress decides to bail a single state out, a swath of the entire statute becomes invalid due to a legal technicality). For example, Massachusetts gets no increase in funding to offset the $800 billion annual shortfall of its health care "reform" -- state taxpayers have to pay that sum instead. It's great to have cost-saving innovation and equally great to have a real, meaningful penalty for silliness.

Posted by: rmgregory | March 10, 2010 4:00 PM | Report abuse

Single payer cheaper? Really? Haven't test programs been tried before and failed miserably?

TENNCARE anyone?


http://en.wikipedia.org/wiki/TennCare

I'd love to see California and its $28 billion budget shortfall try it. Once it falls apart liberals will realize the fools paradise it is.

I can't wait until Californians are told how many prescriptions they can get. I'm sure docs would just flock to california to make sure they're in their single payer experiment. Ya, right.

It'll be like watching a train wreck.

Posted by: visionbrkr | March 10, 2010 4:03 PM | Report abuse

"I'd love to see California and its $28 billion budget shortfall try it. Once it falls apart liberals will realize the fools paradise it is."

OK.
Fine.
So will you shut up about it and let us try?

Posted by: adamiani | March 10, 2010 4:11 PM | Report abuse

So what exactly does "single payer" mean in this context? Presumably, it just means a state can create its own health insurance company. If so, what is to stop a state from doing so already? Does this really mean that the feds will subsidize and/or create special breaks for a state-owned insurance company? And if that is true, why exactly would that be beneficial?

Posted by: ostap666 | March 10, 2010 4:28 PM | Report abuse

Virginia is the first state to outlaw the individual mandate: http://leg1.state.va.us/cgi-bin/legp504.exe?101+sum+HB10

Posted by: rmgregory | March 10, 2010 4:34 PM | Report abuse

Great idea. Let California-Oregon-Washington and the Northeast partner up for single payer, and Texas-the South can experiment with catastrophic insurance + forced savings or HSAs.

Posted by: etdean1 | March 10, 2010 4:50 PM | Report abuse

So what exactly does "single payer" mean in this context?

One of two things: either the government contracts for services from private organizations (like Medicare) or the goverment owns the hospitals and other facilities and employees the staff (like the VA). I think most single payer advocates favor the Medicare approach -- they'll just pay the bills and effectively make the rules on what's covered, what's not, etc.

I don't see how this could work on a state by state basis. unless a state is fine with every uninsured, chronically ill person in the country establishing residency there.

Posted by: NoVAHockey | March 10, 2010 4:53 PM | Report abuse

Wouldn't that be "50 payer"?

Anyway, I'll be interested to see how many states take on this kind of effort. Hoping for Indiana to try an HSA approach!

Posted by: staticvars | March 10, 2010 4:57 PM | Report abuse

As described in T.R. Reid's book, this is exactly how it happened in Canada. If I remember correctly, Saskatchewan instituted a single-payer system, and it proved so popular that it was copied by all of the other provinces.

BTW, yes, visionbrkr, every single-payer system currently in place (see, e.g., Canada, France, Japan, Taiwan)is cheaper than the private system we have here. In fact, every system EVERYWHERE IN THE WORLD is cheaper than what we have here. And they're healthier, too. But let's just ignore that, 'cause we have THE BEST HEALTH CARE SYSTEM IN THE WORLD!!!

Posted by: TomServo | March 10, 2010 5:00 PM | Report abuse

TomServo,

you know why didn't I believe you before. There are no other things that differ in those countries than the US system.

Let me know when you convince doctors in California to accept this as payment and still practice medicine:

http://www.health.alberta.ca/documents/SOMB-medical-price-list.pdf


And there aren't any other factors (LIKE OBESITY PREVALENCE) that affect how our health compares. Why bring up FACTS that don't push your opinions.

Posted by: visionbrkr | March 10, 2010 5:11 PM | Report abuse

"For example, Massachusetts gets no increase in funding to offset the $800 billion annual shortfall of its health care "reform"

This is a fine example of wing nuttery. You notice no reference. Actually the entire state budget of MA is $27.5 Billion (http://sunshinereview.org/index.php/Massachusetts_state_budget#cite_note-2)

Posted by: lensch | March 10, 2010 5:16 PM | Report abuse

visionbrkr, we had this discussion before, but here goes. If there were one country that had a universal government run health care system that did better than we did, I'd say your argument had some teeth, but when all other industrialized countries (20 - 30 of 'em) have such a system & they all do a lot better, your argument falls apart. Australia, for example, has more overweight people and they drink and smoke more.

Look, all these other countries (except Germany) had a system like ours (free market) and none of them could get it to work, just as we couldn't get free market fire departments to work in colonial times and like we can't get free market health insurance to work now.

If they could make the transition to a more efficient system, if they could overcome their rich insurance and drug companies and the opposition of physicians, we can too. Or don't you have any faith in the American people?

Posted by: lensch | March 10, 2010 5:25 PM | Report abuse

lensch,

hope you're well. Heard you on c-span a couple saturdays ago :-)

I think we could make the transition to that system EVENTUALLY. But I don't think we can jump from A to Z overnight. there's a reason why a smart man like President Obama is doing what he's doing. Going directly there is too much of a shock to the system of healthcare.

now those like many on here who push that system because the current one doesn't work for them won't really care what happens to the current system. But the problem is that 80+% of those in the employer system like it. If you mess that up you've got a large bloc against you. As I've said to you before I think we'll eventually get to some form of single payer (although I prefer the private model for obvious reasons).

Posted by: visionbrkr | March 10, 2010 5:32 PM | Report abuse

visionbrkr, of course you don't make the transition overnight; other countries have done it in a few years, BUT you have to make the commitment first or you will never get there.

HR676 is an incremental step. In 1965 we gave Medicare to the mostly costly group of Americans. Now it is time to give it to the rest of Americans. It was not disruptive in 1965; it would not be disruptive today. In fact, what we did in 1965 was expensive, while HR676 would save money, so it would be easier.

Posted by: lensch | March 10, 2010 5:57 PM | Report abuse

Oh, I forgot:

Here is a question from a Washington Post - ABC poll in 2003,

"Which would you prefer: the current health insurance system in the United States, in which most people get their health insurance from private employers, but some people have no insurance, OR, a universal health insurance program, in which everyone is covered under a program like Medicare that's run by the government and financed by taxpayers?"

62% favored Medicare for All; 33% were opposed. That's pretty decisive.

Posted by: lensch | March 10, 2010 5:58 PM | Report abuse

Californians for single payer!
We just need to get rid of Arnold who vetoed single payer twice, and elect Jerry Brown(D). Single payer solves a lot of problems. It even cuts our deficit since costs will go down and businesses will profit. Not to mention extra income for our taxpayers. Are we socialist or communist? Who cares, because I will be guaranteed healthcare all my life, no matter which job a take, or business I start(that makes me a capitalist).

Will there be waiting lines or rationing? According to most healthcare studies of Europe, their waiting lines are as long as ours or shorter. Canada is a little sloppy when combating their waiting lines, but Germany isn't. If our waiting lines grow, then we just need to subsidize tuition for doctors and increase their ranks. What if healthcare costs spiral out of control because people abuse healthcare? We'll simply charge a $15-$20 copay that goes straight to the doctor's bill. This tactic has proven to curb abuse of free healthcare.

California doesn't want to own hospitals or hire doctors. They can remain the profit making private entities they currently are.

If I visit Nevada and I get sick, how will my CA single payer system pay for the bill? Simply by using the bargaining power of 40 million Californians to negotiate rates at hospitals outside of CA.

Don’t you need a big bureaucracy to oversee a single payer system? No bigger than the endless stream of paper work and red tape we see with our private healthcare insurance system. All of the billing and medical records are handled by a small credit card sized smart card which holds your medical information for all doctors and can allow the doctor to charge the single payer system electronically.

Posted by: photek00 | March 10, 2010 5:59 PM | Report abuse

lensch: Woops -- my message should have indicated $800 million (not billion). While I won't usually cite him, Jon Gruber offers supporting data, as does the Cato Institute (http://www.cato.org/pubs/journal/cj29n2/cj29n2-7.pdf), the Massachusetts Taxpayers Association (http://www.masstaxpayers.org/files/Health%20care-NT.pdf), and newspapers such as the Boston Globe (multiple articles).

Sorry for the typo! Again, the increase in taxes paid by citizens due to the Massachusetts health care reform is only $800 million!

Posted by: rmgregory | March 10, 2010 6:08 PM | Report abuse

This is a great provision indeed. I doubt single payer would spread like wildfire though. Even when it proved cheaper, the HSA/catastrophic guys would defend their system to the bitter end. If you haven't noticed, the health care debate has had many things, but not an inclusion of ideas based on rational argument. (Note the editorial by Newt Gingrich a few months ago in the NYT about how Texas was a model for health care reform - that's right, the state with the 2nd highest uninsured rate in the country).

And the guys proclaiming that doctors would never support such a system probably don't know many doctors. Single PAYER means insurance is public, but hospitals can be public, private, or academic (teaching) or some combination thereof. Most doctors in fact are in favor of national health insurance, because it means they don't have to take time to deal with insurance reps and can spend more time practicing medicine (http://www.reuters.com/article/idUSN31432035).

Posted by: kmani1 | March 10, 2010 6:09 PM | Report abuse

Great. The Pennsylvania Legislature has hundreds of members who are even stupider than Chuck Grassley. But best of luck to the rest of you.

Posted by: phillygirl2 | March 10, 2010 6:34 PM | Report abuse

lensch,

nice slanted poll question. No mention of how the poll results change if your family doctor stops practicing because of it?

and we'll agree to disagree on the incrementalism of HR676.


photek,

wait, you think $15 is going to STOP people from overusing care?

How about this as an alternative. How about letting people know where the best "deal" is on prescriptions?

https://www6.state.nj.us/LPSCA_DRUG/search.jsp

Now that's transparency we all can believe in. Its a shame only two states have this in place (NY and NJ). It certainly comes in handy for those with HSA's if people care about the true cost of care.

Posted by: visionbrkr | March 10, 2010 6:38 PM | Report abuse

teaching hospitals? Those will be a thing of the past, if this plan goes forward. Young people will have less incentive to go into medicine. But hey, take the "little red pill." (and people say the president's talk is too academic and highbrow for the public! un huh.)

Posted by: truck1 | March 10, 2010 6:42 PM | Report abuse

"No mention of how the poll results change if your family doctor stops practicing because of it?"

It also doesn't mention how the poll changes if an astroid hits the earth because of it. MedPac reports that 96.8% of physicians take Medicare patients.

What's you family doc gona do? Dig ditches. There are 6 qualified applicants for each place in Med school. If your doc wants to take his bundle and leave, there of lots of people eager to take his place.

Posted by: lensch | March 10, 2010 6:50 PM | Report abuse

Come on, Ezra, you and I both know that ERISA is the major stumbling block to state single payer, and the Section 1332 does not allow the Secretary to waive it. Sanders himself said as much later in the interview that you excerpted.

Posted by: bmull | March 10, 2010 6:53 PM | Report abuse

Massachusetts' mandated health care program is a FAILURE.

One reason? Legal immigrants piled onto the state-funded plan for lower-income...which sent the entire system into free-fall.

Massachusetts' response: remove some of the legal immigrants.

Legal immigrants' response: sue the state of Massachusetts.

OBAMA'S PLAN:

Grant citizenship to 11 million present-day illegal immigrants who will then be eligible for the "so-called health care program with free or subsidized" medical care --- Obama gets 11 million votes...illegals flood into our country for all the OTHER entitlement programs...

oh yeah - don't forget to add the legal immigrants to the totals....

Working Americans' insurance premiums will always be at the highest rates...and the companies will go out of business - because the "cost-shifting" that subsidizes the lower government payments to health care providers - - - will overwhelm private payers.

Posted by: easttxisfreaky | March 10, 2010 7:05 PM | Report abuse

lensch,

well sure that many docs take Medicare. While the reimbursements are low that's where the majority of the patients are. Volume over per unit reimbursement.


the older ones (docs) will retire. those not close enough will look to teach. You can't FORCE them to lose money and think it goes on forever (just like you can't force insurers to lose money. Or at least right now you can't). It'll also be much harder to get new docs into the system at a time when we have a shortage to begin with.


Posted by: visionbrkr | March 10, 2010 7:10 PM | Report abuse

Ezra,
You imply it so just to ask a straightforward question. Are you saying that if a state wanted to create its own program that, for example, provided universal catastrophic health insurance and mandatory HSA's, it would be allowed to do so under this legislation?
Steve

Posted by: FatTriplet3 | March 10, 2010 7:59 PM | Report abuse

"Massachusetts' mandated health care program is a FAILURE."

MA has covered 97% of its people. It has reduced ER use by 50%. It is widely popular. People claim physician's waits have increased greatly, but this is a lie, pure and simple. "The current average wait time to see a primary care physician in Massachusetts is 36 days, up from 34 days in 2007" This comes from a report by the Massachusetts Medical Society which also said, "More than 340,000 Massachusetts residents have gained health insurance since 2006 under the state’s landmark health care reform law,” said the report, which added, “Employers, insurers, providers, and patients have all done their part to make health care reform a success."

Here is MIT's Jon Gruber on MA:

"The major aspects of this reform took place in 2007, notably the introduction of large subsidies for low-income populations, a merged nongroup and small group insurance market, and a mandate on individuals to purchase health insurance. And the results have been an enormous reduction in the cost of nongroup insurance in the state: The average individual premium in the state fell from $8,537 at the end of 2006 to $5,143 in mid-2009, a 40 percent reduction, while the rest of the nation was seeing a 14 percent increase."

Posted by: lensch | March 10, 2010 8:01 PM | Report abuse

visionbrkr - Come on, you don't believe that nonsense about docs losing money. Look at any of the salary surveys. The income of docs after businesses expenses, but before taxes is huge compared to the rest of the country.

Here are some average figures:

GP $200,000+
Urologist $350,000+
Stomach guy $400,000+

Come to Princeton & I'll take you on a tour of physician's houses. If you want to take pics, you'll need a wide angle lens.

Posted by: lensch | March 10, 2010 8:06 PM | Report abuse

@VB:
80+% of those in the employer system like it.

This is pretty misleading. I wonder how many of these people have ever tried to make a claim? Probably the 20% that don't like it are the ones that have to actually make claims. I personally hate my employer based insurance. 1 plan, no choice of coverage, no HSA, or anything else. Premiums up, deductible quadrupled.

Its a dysfunctional system all around.

" we have a shortage to begin with."

The only reason there is a shortage is that the AMA restricts the number of med schools to limit competition and keep their fees high. When med schools have to start recruiting students to attend instead of competitive exams to keep students out, I will start worrying. And There are plenty of qualified doctors ready to emigrate here to fill any shortage.

Posted by: srw3 | March 10, 2010 8:08 PM | Report abuse

Bernie Sanders is So Full Of it.

The

All Congress has to do is Add a Medi-Care Buy in For Americans 27 & Up Via Reconciliation and you'd have a Single Payer System.

From what I Recall in the Senate Bill, it Contains Language that Parents Would be Allowed to Keep their Children on their Policies Up to Age 26.

All that's Needed to Drive Down Cost is to have a Medi-Care Buy In for All Americans, starting at Age 27, it would Cut & Contain Cost Far Better than the Current Senate Health Care Bill.

Medi-Care For All starting at Age 27, it would be the Best Thing for All Americans.

As Well as Getting Rid of [Medi-Caid]

Posted by: omaarsblade | March 10, 2010 8:13 PM | Report abuse

lensch,

alright maybe "losing money" was the wrong terminology. Maybe i should've stated making "less money". How quickly their incomes are reduced (and how drastic relative to the amount of training and stress) will absolutely (IMO) have an affect on the number of docs we have going forward.

srw3,

i give up if you're going to just make stuff up.

If I relent to your PO polls (though wording is affected here) will you relent to mine (given the same parameters? Can we make a little bit of progress here?

Posted by: visionbrkr | March 10, 2010 8:49 PM | Report abuse

srw3,


wait, yesterday you had an anthem individual plan? now you have an employer sponsored plan?

And you WANT an HSA? I thought all liberals hated them???

Posted by: visionbrkr | March 10, 2010 8:51 PM | Report abuse

Volunteers (except for the perv state of VT) come forward!

Posted by: houston123 | March 10, 2010 8:55 PM | Report abuse

Just what we need. More government intrusions. Tell me which institution that the government, er, governs, is in the black? NONE OF THEM!!


Yet, there are some of you who wants to permit the government to control 1/6th of the economy? Just totally RESHAPE the ENTIRE American WAY OF LIFE, because a bunch of ELITIST feel they know what's BETTER for an INDIVISUALIST society??

Wow! What they need to pass as legislation, is a MANDATED reading and comprehension test for everyone who wants to vote; because the pathetic PARASITES of our society are the ones who want this government HANDOUT!!!


When the "POOTUS" has to make deals to pass HIS legislation, there's something wrong. When the POOTUS BRIBES a Senator that previously, and adamantly voted NO to his b.s.; he goes and APPOINTS the man's BROTHER to a Circuit judgeship. At least he was transparent in his crooked, Chicago style.


http://nakedemperornews.com

http://realjewnews.com

Posted by: obamaalmighT | March 10, 2010 9:37 PM | Report abuse

BTW- don't believe the hype, that they will change things through reconcilliation IF they pass this crap. Check this out.


Beginning on page 1,000 of the measure, Section 3403 reads in part: ". it shall not be in order in the Senate or the House of Representatives to consider any bill, resolution, amendment or conference report that would repeal or otherwise change this subsection."


In other words, if President Barack Obama signs this measure into law, no future Senate or House will be able to change a single word of Section 3403, regardless whether future Americans or their representatives in Congress wish otherwise!!


Note that the subsection at issue here concerns the regulatory power of the Independent Medicare Advisory Board (IMAB) to "reduce the per capita rate of growth in Medicare spending."

That is precisely the kind of open-ended grant of regulatory power that effectively establishes the IMAB as the ultimate arbiter of the cost, quality and quantity of health care to be made available to the American people. And Reid wants the decisions of this group of unelected federal bureaucrats to be untouchable for all time.


No wonder the majority leader tossed aside assurances that senators and the public would have at least 72 hours to study the text of the final Senate version of Obamacare before the critical vote on cloture.


And no wonder Reid was so desperate to rush his amendment through the Senate, even scheduling the key tally on it at 1 a.m., while America slept.

True to form, Reid wanted to keep his Section 3403 poison pill secret for as long as possible, just as he negotiated his bribes for the votes of Senators Mary Landrieu of Louisiana, Ben Nelson of Nebraska and Bernie Sanders of Vermont behind closed doors.

The final Orwellian touch in this subversion of democratic procedure is found in the ruling of the Reid-controlled Senate Parliamentarian that the anti-repeal provision is not a change in Senate rules, but rather of Senate "procedures." Why is that significant?

Because for 200 years, changes in the Senate's standing rules have required approval by two-thirds of those voting, or 67 votes rather than the 60 Reid's amendment received.

Reid has flouted two centuries of standing Senate rules to pass a measure in the dead of night that no senator has read, and part of which can never be changed. If this is not tyranny, then what is?


Posted by: PanhandleWilly | March 9, 2010 6:16 PM

Posted by: obamaalmighT | March 10, 2010 9:41 PM | Report abuse

Now may be the time to insure against flood damage with http://ow.ly/1dZJr for your home


Posted by: sanyacada | March 11, 2010 12:53 AM | Report abuse

yes with a medical billing degree you can work from anywhere check http://ow.ly/1ggKF

Posted by: mazejhn | March 11, 2010 1:37 AM | Report abuse

"The Lifespan of the Average American is Less than that of People in Nations that Spend Far Less On Health Care. ...

To Put it Bluntly, We Spend More and Die Sooner."

Mitt Romney on Tuesday,

March 2nd, 2010 in the Book 'No Apology'
_________________

Keep In Mind Mitt Romney is in the Health Insurance Business, This Quote is Damning the Private Health Insurance Premise of being the Best Health Care-Insurance In the World, Especially when the World Health Organization says we're Rated 36-37Th in the World.

THINK

Posted by: omaarsblade | March 11, 2010 6:43 AM | Report abuse

Since [1974] Hawaii has required all Employers to provide relatively generous health care benefits to any employee who works 20 hours a week or more. If health care legislation passes in Congress, the rest of the country may barely catch up.

Lawmakers working on a national health care fix have much to learn from the past 35 years in Hawaii, President Obama’s native state.

Among the most important lessons is that even small steps to change the system can have lasting effects on health. Another is that, once benefits are entrenched, taking them away becomes almost impossible. There have not been any serious efforts in Hawaii to repeal the law, although cheating by employers may be on the rise.

But perhaps the most intriguing lesson from Hawaii has to do with costs. This is a state where regular milk sells for $8 a gallon, gasoline costs $3.60 a gallon and the median price of a home in 2008 was $624,000 — the second-highest in the nation. Despite this, Hawaii’s health insurance premiums are nearly tied with North Dakota for the lowest in the country, and Medicare costs per beneficiary are the nation’s lowest.

Hawaii residents live longer than people in the rest of the country, recent surveys have shown, and the state’s health care system may be one reason. In one example, Hawaii has the nation’s highest incidence of breast cancer but the lowest death rate from the disease.

Why is Hawaiian care so efficient? No one really knows.

In dozens of interviews, doctors and hospital and insurance executives in Hawaii offered many theories, including an active population that is culturally disinclined to hospitals, a significant military presence and a health care market dominated by a few not-for-profit organizations.

But there was another answer: With nearly 90 percent of the populace given relatively generous benefits, patients stay healthy and health providers have the money and motivation to innovate.

If true, it’s a crucial lesson. Health care overhaul efforts at the state and national levels have so far been largely confined to providing bare-bones insurance coverage to those in need. But changing the way care is provided has been given short shrift, and medical experts warn that costs could soar if overhaul legislation passes. After expanding coverage in 2006, Massachusetts is only now tackling the cost problem as expenses continue their inexorable rise.

Posted by: omaarsblade | March 11, 2010 6:49 AM | Report abuse

This bill grants the federal government new powers to set rates on insurance companies regardless of the costs they incur----in other words Obama & Pelosi can send every single Private Insurance Company into bankruptcy within the first year after passing this legislation.

http://www.nytimes.com/2010/03/09/health/policy/09rates.html

This bill is Single-Payer from Day 1.

You will not hear Ezra or anyone else dispute THIS FACT!

Its is the Democrats DIRTY SECRET! Every Democrat who wants Single-Payer can be found on YouTube Videos with Jacob Hacker claiming how getting Single-Payer directly is impossible and the American People have to be tricked into passing this intermediate legislation.

Obama based his campaign on the audacity of hope. He should of called it the audacity of cynicism!

Posted by: FastEddieO007 | March 11, 2010 7:56 AM | Report abuse

"I believe the way we move to single payer in this country is to let one state like California go first,"

Does California get to pay for their single payer out of their nonexistent finances, or do the rest of us get the honor of bailing out this nonsense as well?

Posted by: bgmma50 | March 11, 2010 9:19 AM | Report abuse

That's the way Canada finally got a single-payer system, isn't it? The most liberal province instituted such a system first, and gradually, over a number of years, all the other provinces followed.

So Ezra Klein is absolutely right. Doing something similar in the U.S., state by state, is the way to make single-payer happen for Americans.

Posted by: rjbennett | March 11, 2010 9:47 AM | Report abuse

What exactly does this language allow a state to do?

I ask because, as someone who is 100% in favor of universal health care, I've been very distressed to see how most liberals automatically equate that with single-payer. Would the legislation allow a state to implement one of the more popular (as measured by patient satisfaction) models for universal coverage -- e.g. all-payer or individual payer?

It seems to me that the key should be giving states the option to set up true universal systems that would include all federal and corporate coverage.

Will states be "allowed" to reform would more than the market for individual subscribers and Medicaid? If not, there's no real change from the status quo. After all, some states already tried to implement single-payer for Medicaid (resulting in massive debt) and others have regulated insurers into insolvency. The only thing that stops individual states legislature from introducing a private insurance mandate is a well founded fear of voter backlash.

It seems to me that the focus should be on creating a *universal* system rather than blind belief that by getting more patients into a public system will somehow get us out of the hole we're in.

Unless the provision that Sanders reference won't allow states to experiment with different types of *universal* models, it's pretty much wasted ink.

Posted by: Athena_news | March 11, 2010 11:40 AM | Report abuse

"BTW, yes, visionbrkr, every single-payer system currently in place (see, e.g., Canada, France, Japan, Taiwan)is cheaper than the private system we have here." - TomServo

FWIW, France doesn't have a single-payer system. The system there is based on the German model of social insurance funded through payroll taxes, supplemented by government for targeted populations and private supplementary policies. It is *nothing* at all like the U.K. or Canada.

In any case, the idea that transitioning to single-payer would automatically save us money is a fiction. As George Halvorson (CEO of Kaiser Permanente) noted in his interview with Ezra a couple of months ago, moving to single-payer would save the US less than 1% in total health care expenditures. It's true the money would cover everyone but it wouldn't do anything about problem of overexpenditure.

In order for a single-payer system to work, the system must control, not the payment process, but the cost of care itself. Citizens have to have confidence in the professionalism of the bureaucracy and demand that legislators stay out of the operation -- which does not describe the US at all. People here cannot accept the idea that CMS might actually know more about delivery and cost than Congress.

People keep looking for a silver bullet that can somehow get us onto a more sustainable path. There isn't one. The current bill, that seeks to tweak more coverage out of dysfunction, just makes things less sustainable. And looking to single-payer as our salvation is a fantasy.

Posted by: Athena_news | March 11, 2010 12:03 PM | Report abuse

The simple truth is that the problem with health care in the United States is cost. This country devotes somewhere around 16% of its Gross National Product to health care and other so-called advanced nations devote between 8 and 11% of the GNPs to health care. If you want real, honest, and effective reform, one can sit down and see where this nation's cost are higher than other nations and act. Unfortunately, reforms of this nature would upset the special interests that run this country and are not even on the table. Until this nation addresses the reality of cost we are not addressing the problem.

Posted by: jeffreed | March 11, 2010 12:35 PM | Report abuse

My comments are being held for approval by Klein and will likely not appear as Klein is only interested in promoting "progressive" (Marxist) SCAMS. Is he being paid by George Soros?

Posted by: AntonioSosa | March 11, 2010 3:19 PM | Report abuse

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