Prescriptions

Why Isn’t Single-Payer “Uniquely American”?

Congress says Canada’s health care system is at odds with American values. What if that’s wrong?

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Sen. Max Baucus. Click image to expand.
Sen. Max Baucus

On July 30, single-payer advocates staged a rally on Capitol Hill to demand why Congress wasn’t even considering enacting a single-payer health system. The usual answer you hear from Sen. Max Baucus, D-Mont., and others is that the United States requires a solution to its health care crisis that’s “uniquely American.”

This smug cliché, as I have complained before, encapsulates the American political establishment’s hubristic refusal to consider how other industrialized countries tackle the problem at the practical level. Health care reform, it is said, must reflect distinctly American values, and that’s why Congress resolutely ignores the single-payer model favored in Canada; the Bismarckian nonprofit model favored in France, Germany, and Japan; and the socialized model favored in the U.K., Spain, and much of Scandinavia.

Even on its own terms, though, the argument doesn’t hold up. That, at any rate, is what Allan Brett sets forth in an essay posted July 29 on the New England Journal of Medicine’s Web site. Brett makes the case that single-payer insurance (whose proponents, we now learn, include the president’s former doctor) is not only superior to America’s market-based system; it’s also superior at serving the paramount value of that system, which Brett identifies as freedom of choice. He writes:

Incremental reforms preserving the private insurance industry and employer-based insurance would probably perpetuate the restricted choice of health care providers that many Americans already encounter: private plans typically limit access to certain physicians or hospitals, and physicians often refuse to accept certain plans. In contrast, single-payer proposals eliminate those restrictions.

This is quite true. Under a single-payer system, the government doesn’t care which doctor or hospital you use because none is going to be more expensive than the others. Granted, the government may deny choice in tests and treatments, but Brett judges that reality as no more restrictive than with market-based medicine; the only difference is whether the gatekeeper is public or private.

By definition, a single-payer system would deny consumers (or, more typically, their employers) the opportunity to choose a health insurer. But choosing an insurer, Brett says, is “not an end in itself.” Rather, it’s a means to “efficient, cost-effective health care.” And single-payer has shown itself superior to private insurance in this respect as well, “[b]ecause administrative costs are consistentlylower in single-payer systems than in private-based systems.” (Brett might also have pointed out that a single-payer system can set hospital and doctor fees at whatever it deems reasonable.)

Why, then, is Congress so resistant not only to creating a single-payer system but even to creating a robust “public option” government health-insurance plan as one option among many? In the Aug. 3 New Yorker, Hendrik Hertzberg correctly identifies the obstacle not as culture but as the structure of U.S. government itself:

[A]n election is only the opening broadside in a series of protracted political battles of heavy artillery and hand-to-hand fighting. A President may fancy that he has a mandate (and, morally, he may well have one), but the two separately elected, differently constituted, independent legislatures whose acquiescence he needs are under no compulsion to agree. Within those legislatures, a system of overlapping committees dominated by powerful chairmen creates a plethora of veto points where well-organized special interests can smother or distort a bill meant to benefit a large but amorphous public.

Other industrialized democracies typically favor a more streamlined parliamentary approach. Hertzberg goes on to point out that in one of our legislatures (the Senate), “one member may represent as little as one-seventieth as many people as the member in the next seat,” and a minority of members may block any action through the filibuster. (These are two hobbyhorses I happen to share with Hertzberg. See “Abolish the Senate!” and “Abolish the Filibuster!”) Harold Pollock, faculty chair of the University of Chicago’s Center for Health Administration Studies, noted last month that the small, bipartisan “coalition of the willing” writing the Senate finance committee’s health-reform bill while it munched on chocolate-covered potato chips represented a combined population of fewer than 11.2 million, which was less than that of greater Los Angeles. Since Pollock wrote, Sen. Orrin Hatch, R-Utah, has dropped out, reducing the coalition’s membership from seven to six and lowering its collective constituency to 8.5 million souls, or less than that of the Chicago metropolitan area.

You can reconcile Baucus’ argument with Brett’s and Hertzberg’s by identifying the structure of American government as an expression of American values. But it isn’t the only one, and it’s far from the best. It just happens to be the one that decides how laws get written.