I would never claim it was easy or that it can be done quickly, just that it's not "logically impossible", no matter of how many hurdles one can throw in the way. The hurdles are clear and many, and indeed, regardless of the will of the people (which nowadays appears to be more lip service than real or crucial), or who just happens to do the polling of this supposed will, I can see that the chances are slim in the current climate (as pictured earlier).
As for cost, you already pay way more than you likely should in this area, and with poorer quality (if one can afford it at all). In a more general sense of cost, plenty of trillions are wasted or disappear down other rabbit holes, unaccountably so. The question w.r.t. government spending should always be the most obvious one: cui bono? Of course if the ideology is such that spending should (selectively) be kept to a minimum in certain areas then that pretty much rules out many possibilities.
Life quality isn't just determined by the amount of wages, but aside from ineffable things, also the real cost of living. Clearly many areas are subsidized to keep the cost of living (and wages) down or, depending on one's view, to keep business profitable. However, "unhealthy outlooks" are a great source of potential trouble, no matter where you look.
Here's a fuller quote from the "logically impossible" section you keep pointing to:
"Some progressives hope that single-payer could provide an attractive replacement for the grubby, path-dependent logrolling that now dominates our $3 trillion health care political economy. No viable single-payer program will replace these grubby politics. That’s logically impossible, because such a program must be produced through that very same process."
Pollack isn't saying that passing a single-payer model or Medicare for All or Sanders' plan is "logically impossible." He's saying that any such plan would still have to go through the same political process filled with negotiation, concessions, compromises, half-wins and abandonment of bigger reaches. The health care system we have now is a product in part of national and state-level actors, legislatures and existing laws. Pollack is saying that it is logically impossible for a single-payer plan to become law in its original clean-sheet form, freed from existing battle lines and vested interests. Thinking that you can create a fully functioning, uncompromised single-payer model just because a dark-horse candidate calls for it is to ignore the past and the realities of politics.
Pollack notes that in an ideal world a single-payer model would likely cost less than what we have now. "Facing the imperative of an overall budget, armed with the pricing power of public monopsony, Medicare for All is indeed more likely to control costs than any market-based approach is that relies on fragmented private payers." However, Medicare for All would cost some people a great deal more in terms of taxes and loss of existing health care plans that they like, reduced doctor salaries, reduced reimbursement rates and ugly things like denying the sick certain expensive treatments and drugs.
Pollack in general is skeptical of claims that we as a society will see major cost savings any time soon after the passage of a single payer model. "We’re not going to wring nearly one-fifth out of our health care economy while we simultaneously impose radical changes(emphasis mine) to health care financing. Such contraction is the precise opposite of what we did in establishing Medicare. It will be a miracle if we hold medical spending steady at 18 percent (of GDP) given our aging population."
Again, Ezra Klein's piece in Vox lays out in more detail the financial concerns that skeptics have with Sanders' plan:
http://www.vox.com/2016/1/17/10784528/bernie-sanders-single-payer-health-care While I like the idea of a single-payer healthcare system I don't think that enough Democrats on the Hill are going to want to plunge into an even bigger fight on the issue than the ACA was. That bill barely got passed is likely to cost quite a few legislators their jobs as public opinion about it coalesces. Bernie has a nice idea in general but its time won't come for another 10 years.
Finally, I am not sure what you are trying to say in your third paragraph.
I think you miss Pollack's main point, as summarized here: "As I have written at length in the Journal of Health Politics, Policy, and Law(and draw upon here), an American single-payer system would be more complex and kludgy than many proponents have considered or admitted. The source of these problems resides in American politics rather than the technocratic or ideological premises of our healthcare system..."
Pollack's piece in JHPPL notes that Democrats in the 70s and 80s "came to recognize that Medicare for All was unlikely to get through the U.S. Congress within our lifetimes. Our political system demanded a more incremental model, one less disruptive to the status quo, less frightening to the myriad of “protected publics”—veterans, senior citizens, and others who hold implicit political veto power over what can be done..." Pollack also writes that the ACA barely became law, even though Democrats had "the largest and most cohesive liberal legislative majority in fifty years." The public option, the first step towards single-payer, didn't make the cut.
More: "Medicare for All would require a serious rewrite of state-federal relations, radical surgery to the Employee Retirement Income Security Act (ERISA), the digestion of various Medicaid functions now performed by state governments, and a myriad of other granular details. Then there are the legal and constitutional challenges...Medicare for All would stake an even greater claim to contested views of federalism and the reach of national government."
As Pollack's Vox.com piece points out, potential winners of an established single-payer system would be lower-income Americans, a group with little organization or political clout. Potential losers would be for-profit healthcare organizations who have a great deal of lobbying muscle and money as well as richer Americans. So yes, the political playing field is heavily tilted in favor of the status quo.
"Many of the most sensitive challenges that now bedevil the ACA would be sensitive challenges to a Medicare for All system, as indeed they long have been within Medicare and Medicaid...In all of these matters, Medicare for All cannot offer itself as the replacement of our depressing health politics. It would have to arise as another product of that very same process, passing through the very same legislative choke points, constrained by the very same path dependencies that bedevil the ACA."
The road to single-payer would be torturous, and the end result would likely not be a panacea to our health care problems.
Ezra Klein's piece in Vox.com sheds good critical light on the potential costs and consequences of Sanders' plan:
http://www.vox.com/2016/1/17/10784528/bernie-sanders-single-payer-health-care As for the will of the people...Yes, Americans may want single-payer but wishing does not make it so. According to this Kaiser Family Foundation poll, released in December 2015, 58% of Americans favor a single-payer system:
According to this Gallup poll, 55% of Americans favor stricter handgun control, which I think we can agree isn't going to happen soon:
http://www.gallup.com/poll/186236/americans-desire-stricter-gun-laws-sharply.aspx Frankly, I think that if Americans knew how many expenses, legal fights, policy retrenchments and new taxes would result from Sanders' plan, they would run away screaming. In general, Bernie seems to have noble policy planks, such as Medicare for All and free college tuition. But I haven't seen realistic details about how we would pay for those goals or how we would implement them against fierce opposition.
Joe Biden was right: the ACA was "a big f*ckin' deal." I just don't think Washington is ready for the next step in the fight towards single-payer, and I don't think Americans are either once they realize what that step would cost.
I would never claim it was easy or that it can be done quickly, just that it's not "logically impossible", no matter of how many hurdles one can throw in the way. The hurdles are clear and many, and indeed, regardless of the will of the people (which nowadays appears to be more lip service than real or crucial), or who just happens to do the polling of this supposed will, I can see that the chances are slim in the current climate (as pictured earlier).
As for cost, you already pay way more than you likely should in this area, and with poorer quality (if one can afford it at all). In a more general sense of cost, plenty of trillions are wasted or disappear down other rabbit holes, unaccountably so. The question w.r.t. government spending should always be the most obvious one: cui bono? Of course if the ideology is such that spending should (selectively) be kept to a minimum in certain areas then that pretty much rules out many possibilities.
Life quality isn't just determined by the amount of wages, but aside from ineffable things, also the real cost of living. Clearly many areas are subsidized to keep the cost of living (and wages) down or, depending on one's view, to keep business profitable. However, "unhealthy outlooks" are a great source of potential trouble, no matter where you look.
It might be worth following Physicians for A National Health Program on Facebook. Some of their posts are just links, but there's also the occasional good discussion.
I think the healthcare economist is overstating his case when he calls it "logically impossible", and thereby puts it in the realm of "unreason" or "madness".
As he, and you yourself, correctly point out there are major legislative hurdles (in part because of partisanship, but also because of powerful business interests tied to the functioning of the legislative power). That might make it "practically impossible", unless there are other initiatives that level the playing field.
I think there is little doubt that the majority of the population is in favour of a solution (with perhaps some variation) as proposed by Sanders. However, in the end huge projects can only be pulled off if there is sufficient political will to make it happen.
I think you miss Pollack's main point, as summarized here: "As I have written at length in the Journal of Health Politics, Policy, and Law(and draw upon here), an American single-payer system would be more complex and kludgy than many proponents have considered or admitted. The source of these problems resides in American politics rather than the technocratic or ideological premises of our healthcare system..."
Pollack's piece in JHPPL notes that Democrats in the 70s and 80s "came to recognize that Medicare for All was unlikely to get through the U.S. Congress within our lifetimes. Our political system demanded a more incremental model, one less disruptive to the status quo, less frightening to the myriad of “protected publics”—veterans, senior citizens, and others who hold implicit political veto power over what can be done..." Pollack also writes that the ACA barely became law, even though Democrats had "the largest and most cohesive liberal legislative majority in fifty years." The public option, the first step towards single-payer, didn't make the cut.
More: "Medicare for All would require a serious rewrite of state-federal relations, radical surgery to the Employee Retirement Income Security Act (ERISA), the digestion of various Medicaid functions now performed by state governments, and a myriad of other granular details. Then there are the legal and constitutional challenges...Medicare for All would stake an even greater claim to contested views of federalism and the reach of national government."
As Pollack's Vox.com piece points out, potential winners of an established single-payer system would be lower-income Americans, a group with little organization or political clout. Potential losers would be for-profit healthcare organizations who have a great deal of lobbying muscle and money as well as richer Americans. So yes, the political playing field is heavily tilted in favor of the status quo.
"Many of the most sensitive challenges that now bedevil the ACA would be sensitive challenges to a Medicare for All system, as indeed they long have been within Medicare and Medicaid...In all of these matters, Medicare for All cannot offer itself as the replacement of our depressing health politics. It would have to arise as another product of that very same process, passing through the very same legislative choke points, constrained by the very same path dependencies that bedevil the ACA."
The road to single-payer would be torturous, and the end result would likely not be a panacea to our health care problems.
Ezra Klein's piece in Vox.com sheds good critical light on the potential costs and consequences of Sanders' plan:
http://www.vox.com/2016/1/17/10784528/bernie-sanders-single-payer-health-care As for the will of the people...Yes, Americans may want single-payer but wishing does not make it so. According to this Kaiser Family Foundation poll, released in December 2015, 58% of Americans favor a single-payer system:
According to this Gallup poll, 55% of Americans favor stricter handgun control, which I think we can agree isn't going to happen soon:
http://www.gallup.com/poll/186236/americans-desire-stricter-gun-laws-sharply.aspx Frankly, I think that if Americans knew how many expenses, legal fights, policy retrenchments and new taxes would result from Sanders' plan, they would run away screaming. In general, Bernie seems to have noble policy planks, such as Medicare for All and free college tuition. But I haven't seen realistic details about how we would pay for those goals or how we would implement them against fierce opposition.
Joe Biden was right: the ACA was "a big f*ckin' deal." I just don't think Washington is ready for the next step in the fight towards single-payer, and I don't think Americans are either once they realize what that step would cost.
Former president Bill Clinton joined his wife and daughter in assailing Bernie Sanders’ single-payer health care plan last week, saying that it would lead to “overcharging and inflation.”
But in 2009, he defended the single-payer approach, in which the government pays for everyone’s health care. During an appearance on CNN, host Sanjay Gupta asked the former president whether single-payer was “politically unpalatable, or is it a bad idea?”
“Well, I think it’s more politically unpalatable than it is a bad idea,” responded Clinton. “Because single-payer is not socialized medicine. Canada has a single-payer system, and a private health care system. Our single-payer systems are Medicare and Medicaid and Medicare is quite popular. The good thing about single-payer is the administrative costs are quite low. We probably waste $200 billion a year between the insurance administrative costs, the doctors’ and other health care providers’ administrative costs, and employers’ administrative costs in health care that we would not waste if we had any other country’s system.”
He went on to talk about mixed public-private health care systems, such as those in Japan and Germany, arguing that they also keep costs low and have merits as well. (...)
"But the goal should be clear: Our people are our greatest asset. We must take care of our own. We must have universal healthcare." ~ Trump (2000)
At at time of record national debt, nearly 19 Trillion $ and counting, Bernie's plan to up spending to 30% of national GDP in the first year and 18 trillion $ over ten years is insane.
Price Tag of Bernie Sanders’s Proposals: $18 Trillion
WASHINGTON—Sen. Bernie Sanders, whose liberal call to action has propelled his long-shot presidential campaign, is proposing an array of new programs that would amount to the largest peacetime expansion of government in modern American history.
In all, he backs at least $18 trillion in new spending over a decade, according to a tally by The Wall Street Journal, a sum that alarms conservatives and gives even many Democrats pause. Mr. Sanders sees the money as going to essential government services at a time of increasing strain on the middle class.
His agenda includes an estimated $15 trillion for a government-run health-care program that covers every American, plus large sums to rebuild roads and bridges, expand Social Security and make tuition free at public colleges.
The Sanders program amounts to increasing total federal spending by about one-third—to a projected $68 trillion or so over 10 years.
For many years, government spending has equaled about 20% of gross domestic product annually; his proposals would increase that to about 30% in their first year. As a share of the economy, that would represent a bigger increase in government spending than the New Deal or Great Society and is surpassed in modern history only by the World War II military buildup.
so the bulk of this is $15t for healthcare...and what is the cost we are already paying. My guess, $15t.
At at time of record national debt, nearly 19 Trillion $ and counting, Bernie's plan to up spending to 30% of national GDP in the first year and 18 trillion $ over ten years is insane.
Price Tag of Bernie Sanders’s Proposals: $18 Trillion
WASHINGTON—Sen. Bernie Sanders, whose liberal call to action has propelled his long-shot presidential campaign, is proposing an array of new programs that would amount to the largest peacetime expansion of government in modern American history.
In all, he backs at least $18 trillion in new spending over a decade, according to a tally by The Wall Street Journal, a sum that alarms conservatives and gives even many Democrats pause. Mr. Sanders sees the money as going to essential government services at a time of increasing strain on the middle class.
His agenda includes an estimated $15 trillion for a government-run health-care program that covers every American, plus large sums to rebuild roads and bridges, expand Social Security and make tuition free at public colleges.
The Sanders program amounts to increasing total federal spending by about one-third—to a projected $68 trillion or so over 10 years.
For many years, government spending has equaled about 20% of gross domestic product annually; his proposals would increase that to about 30% in their first year. As a share of the economy, that would represent a bigger increase in government spending than the New Deal or Great Society and is surpassed in modern history only by the World War II military buildup.
I think the healthcare economist is overstating his case when he calls it "logically impossible", and thereby puts it in the realm of "unreason" or "madness".
As he, and you yourself, correctly point out there are major legislative hurdles (in part because of partisanship, but also because of powerful business interests tied to the functioning of the legislative power). That might make it "practically impossible", unless there are other initiatives that level the playing field.
I think there is little doubt that the majority of the population is in favour of a solution (with perhaps some variation) as proposed by Sanders. However, in the end huge projects can only be pulled off if there is sufficient political will to make it happen.
The normally perspicacious Paul Krugman wrote a column on Friday entitled “How Change Happens.”
The last paragraph sums up his argument nicely:
Sorry, but there’s nothing noble about seeing your values defeated because you preferred happy dreams to hard thinking about means and ends. Don’t let idealism veer into destructive self-indulgence.
Krugman seems to think that Sanders’ idealistic stands are “happy dreams” because change happens from the hard work of compromise and settling for half-loafs. As a result, he suggests that Hillary Clinton and her pragmatism are the “adult” approach and the strategy most likely to lead to change.
He urges Sanders’ supporters to ask themselves, “When has their theory of change ever worked?” Interestingly, he leaps immediately to Franklin D. Roosevelt’s transformative presidency and characterizes it as strictly on the side of the pragmatists and compromisers.
In a response published on the Huffington Post, Professor Jedediah Purdy points out the Dr. Krugman’s take on FDR’s presidency misinterprets how FDR accomplished change. As Purdy points out, compromise was a secondary tactic, usually conducted on FDR’s terms. The two primary factors that made FDR such an effective change agent were how he wielded power, and the fact that he created a movement, the source of his power. He didn’t rely on old alliances forged in history, he created new ones. Purdy’s rebuttal is spot on, but there’s a larger point to be made about change.
Real change, consequential change, is usually the result of Black Swans, “a metaphor that describes an event that comes as a surprise, has a major effect, and is often inappropriately rationalized after the fact with the benefit of hindsight.”
The disproportionate role of high-profile, hard-to-predict, and rare events that are beyond the realm of normal expectations in history, science, finance, and technology.
The non-computability of the probability of the consequential rare events using scientific methods (owing to the very nature of small probabilities).
The psychological biases that blind people, both individually and collectively, to uncertainty and to a rare event's massive role in historical affairs.
Krugman’s criticism echoes much of what you hear from pundits, the main stream media (MSM), and the political cognoscenti, and it is no surprise that they are missing the prospect of a Black Swan where the Sanders campaign is concerned. Let’s break down assumptions embraced by conventional wisdom. (...)
So Bernie's gonna get us to the healthcare promised land when Barack couldn't, despite his high levels of support in Congress and in the voting booths?
I'm seriously glad that Bernie's running and pushing Hillary from the left. I think she needs someone to force her to listen to the needs of lower- and middle-class Americans. My guess is that if elected, Hillary will employ some of Bill's triangulating approaches to find happy compromises or realistic legislation—but to get elected, she will need to persuade average Americans that she will fight for them.
I like Bernie. I like his anger, his ability to call bullshit on conventional two-party politics and his willingness to call for blue-sky goals like a single-payer healthcare system and free college for all. But I think he would get slaughtered as the Democratic nominee (and yes, even with that prospect I would vote for him as the nominee in a heartbeat). Even if he won the election, I don't see Bernie (or Hillary) getting much traction towards attaining a single-payer system (SPS). Frankly, I'd love something like that: I've had to go through hell with some of the ACA's complexities and the incompetence of the local health exchange.
But Obama, a once-in-a-lifetime candidate, backed by majorities in Congress, didn't get the whole loaf. A President Bernie would not enjoy majority support in the House and probably not in the Senate either. I also seriously doubt that Democratic leaders would want to go back into the healthcare fight for a single-plan that would large be drawn up on the fly during the first term of a Sander's presidency.
Krugman's article links to this Vox.com piece by healthcare economist Harold Pollack that touches on the difficulty of realizing Bernie's goal. Here's the heart of it:
Some progressives hope that single-payer could provide an attractive replacement for the grubby, path-dependent logrolling that now dominates our $3 trillion health care political economy. No viable single-payer program will replace these grubby politics. That’s logically impossible, because such a program must be produced through that very same process. Barring a historically comprehensive defeat of Republicans at every level of American government, advocates for expanded health coverage will face this discomfiting reality.
...
It’s telling that no fully articulated single-payer bill was ever drafted as an alternative to the ACA. Such a bill would have been no less complicated, and would probably have been more encyclopedic than the ACA was. A huge reform that creates millions of winners creates millions of losers, too.
As with ACA, the biggest winners would be relatively disorganized low-income people in greatest need of help. The potential losers would include some of the most powerful and organized constituencies in America: workers who now receive generous tax expenditures for good private coverage, and affluent people who would face large tax increases to finance a single-payer system. At least some of these constituencies would need to be accommodated in messy political bargaining to get single-payer enacted. And states would have a role to play, too, potentially replicating the messy patchwork we got with ACA reforms.
Single-payer would require a serious rewrite of state and federal relations in Medicaid and in many other matters. It would radically revise the Employee Retirement Income Security Act (ERISA), which strongly influences the benefit practices of large employers. Single-payer would require intricate negotiation to navigate the transition from employer-based coverage. The House and Senate would be in charge of this tension, and at risk of the negotiations among key legislators and committees who hold sway.
...
Single-payer would be openly or quietly opposed by virtually the entire supply side of the medical economy. You pointed to Purdy's rebuttal of Krugman. Purdy points out that FDR's presidency "stood at the confluence of two great movements": labor unions and progressive reformers. Roosevelt also had the massive support of Americans because they were struggling in the middle of the worst economic downturn of American history. Yet almost all of his New Deal laws were passed by the end of 1936. The Conservative Coalition coalesced against him in his second term so much that many of FDR's proposals were shelved. Roosevelt accomplished an extraordinary amount in his first four years, but political opposition and his focus on an imminent world war curtailed his New Deal goals.
I don't see Bernie enjoying a similar confluence of support from deep-rooted, organized support from below. He hopefully won't have tailwind from a second Great Depression. And I doubt that many voters, even ones supporting a single-payer system, would tolerate the upheaval that would come with a rapid conversion to such a system.
The normally perspicacious Paul Krugman wrote a column on Friday entitled “How Change Happens.”
The last paragraph sums up his argument nicely:
Sorry, but there’s nothing noble about seeing your values defeated because you preferred happy dreams to hard thinking about means and ends. Don’t let idealism veer into destructive self-indulgence.
Krugman seems to think that Sanders’ idealistic stands are “happy dreams” because change happens from the hard work of compromise and settling for half-loafs. As a result, he suggests that Hillary Clinton and her pragmatism are the “adult” approach and the strategy most likely to lead to change.
He urges Sanders’ supporters to ask themselves, “When has their theory of change ever worked?” Interestingly, he leaps immediately to Franklin D. Roosevelt’s transformative presidency and characterizes it as strictly on the side of the pragmatists and compromisers.
In a response published on the Huffington Post, Professor Jedediah Purdy points out the Dr. Krugman’s take on FDR’s presidency misinterprets how FDR accomplished change. As Purdy points out, compromise was a secondary tactic, usually conducted on FDR’s terms. The two primary factors that made FDR such an effective change agent were how he wielded power, and the fact that he created a movement, the source of his power. He didn’t rely on old alliances forged in history, he created new ones. Purdy’s rebuttal is spot on, but there’s a larger point to be made about change.
Real change, consequential change, is usually the result of Black Swans, “a metaphor that describes an event that comes as a surprise, has a major effect, and is often inappropriately rationalized after the fact with the benefit of hindsight.”
The disproportionate role of high-profile, hard-to-predict, and rare events that are beyond the realm of normal expectations in history, science, finance, and technology.
The non-computability of the probability of the consequential rare events using scientific methods (owing to the very nature of small probabilities).
The psychological biases that blind people, both individually and collectively, to uncertainty and to a rare event's massive role in historical affairs.
Krugman’s criticism echoes much of what you hear from pundits, the main stream media (MSM), and the political cognoscenti, and it is no surprise that they are missing the prospect of a Black Swan where the Sanders campaign is concerned. Let’s break down assumptions embraced by conventional wisdom. (...)
Like Ralph Nader and Jerry Brown before him, the Democratic socialist believes that Americans would embrace his progressive agenda if only it wasn't for the campaign finance system.
For those who nurture an ideology that has never achieved significant electoral power in the United States, it can become all too easy to believe that only shadowy cabals and/or single-structure impediments are blocking reforms that would otherwise be broadly popular. If only we got rid of X, goes the belief, Policytopia would be within our grasp.
But enough about libertarians. (I kid, I kid.) Bernie Sanders, the Democratic socialist, is the latest iteration of a recurring political character over the last quarter century—the progressive stalwart from "the Democratic wing of the Democratic Party" who believes that progressive policies are being held back not by a more centrist public, but by a corrupt campaign finance system. Like Jerry Brown in 1992 and Ralph Nader in 2000, Sanders appears to sincerely believe that a political revolution lies on the other side of eliminating superPACs.
