October 2, 2014
Obamacare v. Single Payer: A Comparison

Jonathan Cohn has posted an article at the New Republic entitled "7 Charts That Prove Obamacare Is Working."  I’d like to take a moment to examine the benefits of the ACA Cohn points out, and draw some comparisons with the most popular legislative Single Payer alternative.

Cohn’s article is lengthy, but essentially boils down seven benefits of the law:

  1. More people have health insurance than before the law was passed.
  2. People who are getting health insurance are almost certainly better off, based on two recent studies showing improvements in physical and financial health.
  3. "Winners" (probably) outnumber "Losers" in the new exchanges, in terms of increased premiums.
  4. Premiums in the exchanges are rising slower than expected.
  5. Premiums for employers are rising slower than expected.
  6. Overall healthcare costs are rising at historically low rates.
  7. The net effect on the budget has been to reduce the federal deficit.

This is all good news.  But evidence also shows that a single payer style system could not only achieve all these benefits, but do so in a way that is vastly superior to the Affordable Care Act.  

  • While more people have health insurance under Obamacare than they did previously, there are still millions of people without health insurance.  While this number will likely fall as the exchanges continue to get up and running, the fact remains that under a Single Payer-style system, universal coverage is guaranteed.  The motto of single payer advocates has always been "everybody in, nobody out."  Even with the mixture of private and public health insurance markets we have now, millions of people still fall through the cracks.  The ACA has covered more people, but it can’t cover everyone.  Millions still get left out under the ACA.
  • Another issue affecting the ACA’s ability to extend health insurance coverage is legal challenges.  The ACA has already been hamstrung twice by the U.S. Supreme Court, and may suffer another blow as a recent statutory-based challenge to ACA subsidies works its way through the courts.  Single payer, meanwhile, is already Constitutionally sound.  Medicare—the equivalent of single payer for American seniors—has withstood Constitutional scrutiny for decades.  The U.S. Supreme Court also suggested in its Hobby Lobby decision that publicly-financed healthcare provides a solution to the Constitutional challenges posed by the ACA.  So the Constitutionality of Single Payer is not in question like it is with the complicated legal mechanisms of the ACA.
  • While it’s great that healthcare costs are rising slower under the ACA, this cost reduction is nothing compared to the potential cost savings of a Single Payer system.  Single Payer style healthcare has reduced costs relative the United States in every single jurisdiction it has been implemented.  The U.S. spends 2.5 times more on healthcare than the OECD average.  Switching to Single Payer would provide a savings of up to $400 billion per year, according to recent estimates.  And contrary to common criticism, access to healthcare in countries with universal public health insurance coverage is not the problem it’s been made out to be.  Even in countries like Canada, where critics often cite longer wait times for elective procedures, Canadians overwhelmingly prefer their system to the U.S.
  • While the “winners” may outnumber the “losers” in the ACA exchanges, under a Single Payer system, there would be no “winners” and “losers” in terms of coverage.  Everybody would have access to basic healthcare coverage.  People unsatisfied with their coverage will also have the option of purchasing supplemental private insurance, which is a very common (and eminently more affordable) practice in countries with universal public health insurance coverage.
  • The overall cost savings under the ACA are negligible when compared to the potential cost savings of Single Payer.  In New York, Green Party gubernatorial candidate Howie Hawkins is touting single payer health reform which would pay for a property tax cut for New York residents, according to a State-sponsored study.  The functional effect would be a reduction in tax expenditures for 95% of New York residents.

So it’s great that the ACA is starting to realize some of the benefits that the law’s drafters were hoping for.  On the other hand, a Single Payer-style system definitely provides an alternative that is cheaper, more effective, and won’t be subject to the endless stream of lawsuits that the infamously-lengthy & prolix ACA law has been subject to.  And perhaps more importantly, it would be guaranteed to cover everybody.

September 24, 2014

91-year Old British Man Speaks On the Importance Of The NHS At The Labour Party’s Conference In Manchester

The BBC notes that in Britain, there is presently a bipartisan political consensus on the importance of the NHS, and the Conservative-Lib Dem coalition government remains “committed to the founding values of the NHS that no-one, regardless of income, should be deprived of the best care.”

h/t Truthdig

July 7, 2014
hipsterlibertarian:


Gallup asks people in more than 120 countries each year whether they are satisfied or dissatisfied with the freedom to choose what they do with their lives. In 2006, the U.S. ranked among the highest in the world for people reporting satisfaction with their level of freedom. After seven years and a 12-point decline, the U.S. no longer makes the top quartile worldwide.

More here.

LTMC:  It is curious that Uzbekistanis report such high satisfaction with their personal freedom, given that "media outlets are tightly controlled [and] self-censorship is common.”  That being said, it is also interesting to observe that most of the top 12 countries have governments with public sectors that constitute a larger percentage of their country’s GDP than the United States.  Nearly all of them have some form of publicly financed universal healthcare.  The fact that people are self-reporting such high rates of satisfaction with their personal freedom in these countries is encouraging news for those of us who view positive liberty as a legitimate source of individual freedom under the right circumstances.

hipsterlibertarian:

Gallup asks people in more than 120 countries each year whether they are satisfied or dissatisfied with the freedom to choose what they do with their lives. In 2006, the U.S. ranked among the highest in the world for people reporting satisfaction with their level of freedom. After seven years and a 12-point decline, the U.S. no longer makes the top quartile worldwide.

More here.

LTMC:  It is curious that Uzbekistanis report such high satisfaction with their personal freedom, given that "media outlets are tightly controlled [and] self-censorship is common.”  That being said, it is also interesting to observe that most of the top 12 countries have governments with public sectors that constitute a larger percentage of their country’s GDP than the United States.  Nearly all of them have some form of publicly financed universal healthcare.  The fact that people are self-reporting such high rates of satisfaction with their personal freedom in these countries is encouraging news for those of us who view positive liberty as a legitimate source of individual freedom under the right circumstances.

June 30, 2014
Hobby Lobby Decision: Observations

Brief Primer On The RFRA & Strict Scrutiny

The Supreme Court has ruled that Hobby Lobby and similarly-situated employers are not subject to the birth control coverage mandate because that mandate “substantially burdens” the free exercise of their religious beliefs under the Religious Freedom Restoration Act of 1993.  That law provides that any law which “substantially burdens” the practice of religion must serve a “compelling state interest” and also be the “least restrictive means” of achieving that interest.  

This two-tiered test is known as “Strict Scrutiny.”  It is a standard of judicial review long used by federal courts (and state courts reviewing federal constitutional questions) to adjudicate cases involving certain categories of constitutional rights.  Congress imported this standard of judicial review into the RFRA to force federal courts to apply Strict Scrutiny to the Free Exercise Clause of the First Amendment. In doing so, they reinstated the holding of a case called Sherbert v. Verner into federal law.

The case largely turned on two questions: (a) does the birth control mandate actually “substantially burden” the practice of religion for employers like Hobby Lobby, and (b) assuming that public health is a compelling state interest (according to the relevant case law, it is), is the mandate the least restrictive means of achieving that interest?

Alito’s Confusing Analysis Of The ACA’s Self-Certification Exception

Justice Alito wrote the opinion for the court.  According to the opinion, the birth control mandate violated the RFRA because it was not the least restrictive means of achieving the compelling state interest of protecting women’s health.  As evidence of this, the Court cited coverage exceptions in the law:

HHS…has demonstrated that it has at its disposal an approach that is less restrictive than requiring employers to fund contraceptive methods that violate their religious beliefs.  As we explained above, HHS has already established an accommodation, the organization can self-certify that it opposes providing coverage for particular contraceptive services.  See 45 CFR §§147.131(b)(4), (c)(1);26 CFR §§54.9815–2713A(a)(4), (b).  If the organization makes such a certification, the organization’s insurance issur or third-party administrator must “[e]xpressly exclude contraceptive coverage from the group health insurance coverage provided in connection with the group health plan” and “[p]rovide separate payments for any contraceptive services required to be covered” without imposing “any cost-sharing requirements … on the eligible organization, the group health plan, or plan participants or beneficiaries.”

The problem here is that Alito basically explained here why the law actually meets Strict Scrutiny.  Alito points to the self-certification exception as an example of a less restrictive means the Government could use to achieve the compelling state interest in this case.  That exception is already part of federal law.  If the exception is already part of the existing law, than the least-restrictive means Alito is pointing at already exists. It’s logically absurd to state that the self-certification exception is an example of less restrictive means the Government could use to satisfy the RFRA’s Strict Scrutiny requirement when the exception is already part of existing law.  The Government has already done what Alito is suggesting it should do to satisfy Strict Scrutiny.

Furthermore, even if this were not the case, the existence of an exception doesn’t actually prove anything in terms of whether the mandate is the least restrictive means of achieving the compelling state interest at issue here.  If the Government has the constitutional power to regulate something, it isn’t obligated to exercise that power to its fullest extent.  If Congress has the power to do something, it is free to exercise that power to a lesser degree if it wants to.  This could potentially create an Equal Protection problem, but that would introduce a much different legal analysis of the issues presented here.

The Single Payer Sleeper

Secular opponents of the contraception mandate who opposed it on “limited government” grounds may wind up eating this case in the long run.  Here is a quote from Part V(B) of Alito’s opinion:

The least-restrictive-means standard is exceptionally
demanding, and it is not satisfied here. HHS has not shown that it lacks other means of achieving its desired goal without imposing a substantial burden on the exercise of religion by the objecting parties in these cases…

The most straightforward way of [covering birth control] would be for the Government to assume the cost of providing the four contraceptives at issue to any women who are unable to obtain them under their health-insurance policies due to their employers’ religious objections.

In other words, Alito’s opinion basically states that putting the Government in charge of paying the cost of services that employers refuse to cover is the easiest way to avoid First Amendment problems posed by the mandate.  According to Alito’s reasoning, the best way for the Government to meet the RFRA’s Strict Scrutiny requirement is for the Government to pay the cost of providing health insurance coverage, rather than forcing employers to cover their employees.

Single Payer advocates have been screaming about this for years.  Removing the myriad burdens of providing health insurance from employers (which includes the compliance costs as employers navigate state and federal insurance regulations) has always been one of the arguments in favor of switching to a publicly-financed health insurance system.  Alito’s opinion provides another argument in favor of that position.  The fact that many folks are touting this case as a win for limited government without any mention of this part of the opinion is evidence of the fact that nobody except lawyers and law students read judicial opinions.  It’s also an example of why  journalists and news sites really need to start linking to the judicial opinions they report on, so that maybe more of the citizenry will start doing so.

January 23, 2014

kirkwa:

And This Is Why You Shouldn’t Get Sick In America

Many believe that the US healthcare system is the best in the world. Not so according to the World Health Organization’s ranking of the world’s health systems. The US doesn’t even rank in the top 25. It ranks 37th and is the most expensive in the world. I would argue that even if we had the best healthcare system in the world, what good is it, if no one can afford to access it.

Most companies are buying 60/40-policys for their employees these days, but even if you are lucky enough to have good insurance with 80/20-policy coverage, that 20 percent your responsible for can drive you right into bankruptcy as easily as the 60-40 policy given the cost of healthcare.

Insurance cost have been going up dramatically in the last two decades, long before the new Affordable Healthcare Act has taken affect, in some cases as much as 35% per year.

But have you noticed the latest trick the insurance companies have roll out?

Yes, Higher Deductible… most averaging $5,000 per year, per person, but I have seen some as high as $10,000 per year. For those of you that are wondering, this tactic is specifically designed too stop you from using your insurance. It reduces the insurance companies out of pocket liability by shift costs onto consumers, especially those dealing with chronic illness such as diabetes and arthritis. Consequently, because consumers can’t afford the deductible they will avoid necessary care to save money.

Although insurance companies are a problem, the real crocks is the healthcare system it self. A corrupt and bloated system desperately in need of reform!

LTMC: Man.  Canadians have cheap healthcare, but they must be dropping like flies with all that socialized medicine.  

Wait a minute…

(via postracialcomments)

January 3, 2014
"We could have eliminated the income tax in 2010 had we adopted the Canadian, German, or French health-care systems."

David Cay Johnston

I think DCJ may have jumped the shark here.  I have to assume that he reached this conclusion by comparing annual revenue from the federal income tax with the cost savings differential between international healthcare systems in terms of GDP.  But practically speaking, the math doesn’t get us there.  According to his article, “Canada, Germany, and France each spend about 11.5 percent of their economy on health care, compared to 17.6 percent in the U.S.”  2013 U.S. GDP was  $ 15.68 trillion.  If we apply the GDP savings difference of 6.1% to the most recent GDP numbers, we get a savings of roughly $ 956 billion.  

That’s huge.  In fact, $ 956 billion is enough to wipe out the present federal budget deficit completely, and would leave us with a $ 300+ billion surplus…*if* that whole amount was going to the Government.  But it’s not.  Government spending on healthcare only accounts for roughly 4.6% of U.S. GDP as of 2013.  So of that $ 956 billion, we can reasonably assume that the federal Government would only receive it’s proportionate 4.6% share in savings, which is about $ 43.97 billion.  Not enough enough to put a dent in the 2013 deficit, much less eliminate the federal income tax.

The analysis doesn’t quite end there, however.  A little over a decade ago, a study by two Harvard Medical School professors found that if you include public employee health benefits and healthcare industry tax subsidies, tax expenditures were responsible for almost 60% of all healthcare spending in the U.S.  I’m not sure what the proportion would be now, but if those numbers hold true, that amount of spending alone is enough to finance a national healthcare insurance program.  As the study’s authors note, “we pay for national health insurance, but don’t get it.”

Furthermore, it’s also true that the cost differentials couldn’t be more stark.  Both out-of-pocket and total spending for healthcare in virtually every other country in the world is far, far lower than in America.  Healthcare administrative costs in the U.S. are almost double what they are in Canada.  Medical bills contribute to roughly half of all bankruptcy filings in the U.S., and three-fourths of those filers had health insurance at the time they filed.

So there is no doubt that if we switched to a Canadian, German, or French-style health-care system, that Americans would have more money in their pockets, and the U.S. Government would be spending less money.  But it’s pretty far-fetched to claim that we could eliminate the federal income tax by switching to a Canadian, German, or French-style health-care system.  Universal healthcare saves everybody money, but it certainly doesn’t leave us tax-free.

Update: The numbers I used for federal spending as a percentage of gdp (4.6%) don’t include Social Security.  But if you include all Social Security spending (which I’m not sure is accurate for our purposes here), you would still reach a similar result: there still isn’t enough in healthcare savings as a percentage of GDP to mop up the federal deficit (much less eliminate the federal income tax), if you assume a savings of 6.1% in healthcare spending as a percentage of GDP.

December 30, 2013
"My cousin died because he couldn’t afford his cancer treatment back in 2005. The bills over a 2-year period exceeded $500k, and the insurance company cut him off. I still remember my uncle pleading with the insurance company over the phone. They said he had reached his lifetime limit. He was 27. Not to get too political, but thank god this crap is illegal now thanks to the ACA."

Redditor “muscledhunter”

December 6, 2013
"[The biggest barrier to my medical practice is] The lack of a single-payer system. We waste enormous amounts of time and energy dealing with insurance companies, whose major goal is figuring out how not to cover patients."

Steven Nissen, M.D.

October 10, 2013
What Would A Single Payer Healthcare System In America Look Like?

Via Amy Goodman:

[S]ingle-payer is already immensely popular in the U.S., as Medicare. A 2011 Harris poll found that Medicare enjoyed 88 percent support from American adults, followed closely by Social Security. [Dr. Steffie Woolhandler] explained that with a Medicare-for-all system, “you would get a card the day you’re born, and you’d keep it your entire life. It would entitle you to medical care, all needed medical care, without co-payments, without deductibles. And because it’s such a simple system, like Social Security, there would be very low administrative expenses. We would save about $400 billion [per year].” Dr. Woolhandler went on, rather than “thousands of different plans, tons of different co-payments, deductibles and restrictions—one single-payer plan, which is what we need for all Americans to give the Americans really the choice they want … not the choice between insurance company A or insurance company B. They want the choice of any doctor or hospital, like you get with traditional Medicare.”

See also:

Physicians For A National Healthcare Plan

Expanded and Improved Medicare for All Act (H,.R. 676)

Medicare Overpayments To Private Plans

Taiwan’s Universal Healthcare System Provides Full Coverage For $21 A Month - Why Can’t We?

Taiwan’s Progress On Healthcare

Most Patients Happy With German Healthcare

Universal Healthcare Much Loved Among Canadians, Monarchy Less So

The British Are Surprisingly Satisfied With Their Controversial Socialized Healthcare System

Healthcare Abroad: France

Top 9 Healthcare Systems In The World

In OECD Countries, Universal Healthcare Gets High Marks

Study: 60.3% of Bankruptcy Filings Involving Medical Bills In America Were Brought By Petitioners Covered By Private Health Plans

Gul Banana on the Necessity of Universal Healthcare in America

How I Lost My Fear Of Universal Health Care

An Eye-Opening Adventure in Socialized Medicine

Close Encounters With Socialized Medicine

Conservatism And Insurance

August 18, 2013
The Power Of Experience

Think Progress highlights the story of Clint Murphy, a former Republican staffer who left politics in 2010, and discovered how hard it is to get insured with a pre-existing condition:

Clint Murphy, now a real estate agent from Savannah, Georgia, who’s been involved with Republican campaigns since the 1990s, was diagnosed with testicular cancer in 2000 when he was 25 years old. Four years and four rounds of chemo treatment later — all of which was covered by insurance — Murphy was in remission. Insurance wasn’t a problem in his subsequent political jobs — he worked on John McCain’s election campaign in 2008 and Karen Handel’s Georgia gubernatorial run in 2010 — but when he quit politics in 2010 and entered real estate, he realized just how difficult obtaining insurance with a pre-existing condition could be.

In an interview with the Atlanta Journal-Constitution, Murphy said he thought after 10 years since his cancer diagnosis, the insurance companies might cut him some slack — instead, they found something else to charge him for.

“I have sleep apnea. They treated sleep apnea as a pre-existing condition. I’m going right now with no insurance,” he told the AJC.

Murphy now supports Obamacare:

That’s why Murphy had this to say to his Republican friends who oppose Obamacare on Facebook last week: “When you say you’re against it, you’re saying that you don’t want people like me to have health insurance.”

This might be a bridge too far.  There are many problems with the Affordable Care Act, and people are opposed to it for different reasons.  Many folks on the Right tend to oppose it because they feel it adds more costly government regulation of the private sector, raises taxes, and some of its provisions are hopelessly complex and impossible to implement.  Some folks on the Left oppose it because they feel that it’s an incomplete solution, doesn’t actually insure everyone, and constitutes a handout to private insurance companies, who are now guaranteed customers by the government.  Reasonable people can come to the conclusion that the Affordable Care Act is not the best solution to covering people with pre-existing conditions.

But what Murphy’s story really demonstrates is the power of personal experience to change a person’s mind.  Clint Murphy was convinced that the health insurance system worked.  He had faith that the insurance companies would “cut him some slack” once he had to re-enter the private sector and purchase his own health insurance.  But once he had a pre-existing condition, he learned the hard way how America’s health insurance system deals with the people who need it the most.

Personal experience is a potent source of knowledge.  It is the reason, for example, why people with gay family members and friends are more likely to support marriage equality.  It’s the reason why Black Americans are more likely to have a poor opinion of law enforcement than White Americans.  It’s the reason why Hispanic Americans overwhelmingly support a more humane immigration policy.  When you or someone you know is directly affected by a problem, that experience tends to change your worldview in ways that might differ from what you might believe in the absence of those circumstances.

But it’s important to remember that this is also a conversation about empathy.  When I was younger, I spent a large portion of my youth growing up in a mostly White suburb.  Despite this, I felt like I was racially conscious.  But as I grew older, I realized that my “racial consciousness” was basically a fraud.  A large part of this growth happened in law school, where I studied the criminal justice system, and realized that it is tainted by racial injustice at every level.  Suddenly, the anti-police narratives in hip-hop made sense.  Malcolm X seemed less like a violent rabble rouser and more like a legitimate voice for the frustration of the Black community.  The realization that my history books really had been “White washed” to some extent was frustrating, but also liberating, because it allowed me to see a deeper truth that had evaded me for so long.

This is relevant to politics, because most of us inform our political positions based on personal experience.  So when a small business owner tells me that he opposes Obamacare because he genuinely can’t afford to offer insurance to his employees, I don’t just shrug my shoulders—even though a part of me is glad that people with pre-existing conditions can get coverage under the law.  If I was a small business owner in his position, I might feel more strongly about the mandatory employer coverage provisions of the law.  In the political realm, being able to understand why others might feel differently is an important part of understanding how to change peoples’ minds.

In Clint Murphy’s case, all it took to change his mind was to be placed in a vulnerable position.  All of a sudden, the complaints of people with pre-existing conditions didn’t seem quite as trivial.  Of course, Clint spent years of his life believing the opposite.  If only there was a way that the wisdom he gained from his personal experiences could have reached him sooner.

If there was a way to achieve a critical mass of empathy in this country, one which allows us to more keenly learn from the personal experiences of others, we might see a public policy revolution.  Perhaps the Executive branch would stop dropping as many drone missiles in the Middle East, weary of the blowback caused by civilian deaths.  Prosecutors might be less anxious to rack up convictions, knowing the devastation that mass incarceration and criminal records have on poor communities.  We might actually see a humane immigration policy, knowing that 11-year old girls wouldn’t be torn from their fathers.  Drug use might be treated as a public health matter rather than a criminal one, knowing that incarceration has not only failed to prevent people from using drugs, but done immeasurable damage the lives of those affected.

Will it happen?  Who knows.  It’s probably wishful thinking.  But one can always hope for the change.  With same-sex marriage and marijuana legalization on the upswing, there’s plenty of possibilities on the horizon.  We’ll just have to wait and see.

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