By Request: The Prospects for Single-Payer

Jim asks:

Paul Krugman wrote in today's column that the vote this week on Medicare (that Ted Kennedy returned to take part in) encouraged him to believe that universal health care stands a good chance of becoming a reality should Obama win and the Democrats increase their majority in both Houses. If this is true, and you can comment on this, what are the chances of us ever seeing single payer? I would think the greatest obstacles to this would be the Socialist, Government Medicine charge (gov't selects your doctor, the gov't can't run anything right) and the "loss of jobs" from the insurers.

I think the odds are really bad. And I think that the greatest political vulnerability a single-payer scheme would face is not so much the "socialist, government medicine" charge as it is desire among liberals to do something to ease the plight of the uninsured. Substantively, the most likely route to a single-payer health care system would be something along the lines of what John Edwards proposed during his late presidential campaign. That would have built upon the current system with the mandate/regulate/subsidize troika but would also have created a public sector health plan modeled on Medicare. The idea, then, is that if liberals and conservatives both have the courage of our convictions, we'll see over time whether or not people like the public plan. If they do, we transition over time to a single payer system.

I think this is a totally sound plan, but there is one problem. To get it enacted into law, liberals need to be credibly willing to walk away from the legislative bargaining table if we don't get our public-private plan. There'll be a million moving parts to a big health care reform package, and you can be sure plenty of legislators will be willing to walk away from the table if one special interest or another doesn't get its way on this or that. Will anyone walk away from the table over public-private competition? I have my doubts. Reform advocates have done a very good job of putting big-time health care reform near the top of the political agenda, and will stand a very good chance of enacting something in 2009 that makes health insurance affordable for everyone and I don't see reformers walking away from the chance to do that over the public-private issue and I don't think anyone will believe them if they try to bluff.

I have sort of mixed feelings about this. I think if I were in charge of progressive politics, I wouldn't have made this push for big reform in 2009 precisely because having done it liberals are now in the position of needing to compromise on all kinds of side issues in order to get a deal. Instead, I would have focused on expanding existing public sector programs as far as possible and then just kept coming back incrementally over and over again over a period of a few years. But pretty much nobody agrees with that, so instead there's going to be an effort for large-scale reform -- and that means saying "yes" to any package that does a reasonable job of covering everything. That, in turn, means it'll probably be impossible to drive a hard bargain over the public-private competition issue.

But see Jon Cohn for a slightly different perspective on this.