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June 08, 2005

Emanuel's Objections

Blogging over at The Washington Monthly, Ezekiel Emanuel has penned one of the most woefully unconvincing critiques of single payer health care I have ever read. In two posts, (one, two), he raises these objections:

• "Americans are simply never going to endorse a Canadian style single payer system."

• "There are also large differences beteween the USA and Canada — like 10 times the population. Another is that they are much more egalitarian than Americans are."

• "Finally Canadians believe in good government, Americans are suspicious of government. The Canadian system is not one single payer, but one for each province run by provincal governments. Do you trust individual states to be able to run a health care system for their citizens? Seen what happened to Medicaid when we tried that in the USA — do you want to repeat that?"

• Big programs only come out of Depression, catastrophe, or presidential assassination.

None of this, by the way, explains how a fairly radical restructuring of the health care system like his voucher system stands a chance of passage, but never mind that. In order: there's no reason to believe Americans will never accept single payer. Whether or not they want Canadian single payer is arguable (though polls routinely show that, in fact, Canadian-style health care is exactly what Americans want), but French style, with a supplementary insurance market? British style, with slightly higher spending? This is pure speculation on Emanuel's part, there's nothing backing it up.

Next up, yes, there are large difference between America and Canada. So what. There are large differences between Canada and France, and France and Japan, and Japan and Australia, and Australia and Costa Rica. Yes we have a large population, does that make our pension system inefficient? How about Medicare, pretty low administrative costs last time I checked.

As for whether or not states could administer public health care, I see no reason why not. It certainly works elsewhere. And indeed, Emanuel's plan puts health care under the guidance of regional boards, so I'm failing to see his argument. Unless he believes there to be something uniquely incompetent about American states, I'm lost. Further, Medicaid works badly because it's being expanded to more folks than it's funded for. And if that weren't enough, it's been punted to state governors who don't control federal funds, so they have to try and reign in costs. Fund it fully and it's a fine program. Medicare's growth, to address another portion of Emanuel's piece, has to do with new technology, as he well knows. More to the point, private health care's costs have been increasing at a far quicker rate, so Emanuel's argument here is nonsensical.

As for the last bit concerning big programs, Americans want a change in their health care system. With business sinking under the weight of health costs, the largest forces in public life are clamoring for relief. That creates a unique opportunity for reform. But Emanuel knows this, his whole plan is predicated on it. Indeed, all the arguments he makes against single payer are either fact-free assumptions regarding the American psyche or points that are equally applicable to his own proposal. If we can push through major reform of health care, there's no reason to believe that his proposal will be much easier to pass than a form -- maybe progressive HSA's? -- of single-payer. None at all. And with that said, his argument seems more like simple hostility towards single payer rather than a thoughtful evaluation of why vouchers are a better option.

June 8, 2005 in Health Care | Permalink

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Comments

Thank you, Ezra. I was absolutely whomper-jawed that Kevin let such idiocy onto his blog unchecked. It's just embarrassing, really. Emanuel comes off as nothing more than a petulant adolescent fuming that "you guys just don't understand!"

Posted by: J.C. | Jun 8, 2005 5:57:33 PM

reign in costs

For some reason, I never used to notice this mistake before, and now I see it all the time. It's "rein in", as in with a galloping horse.

Posted by: Allen K. | Jun 8, 2005 6:10:11 PM

When I saw those posts on the Kevin-blog, I immediately thought, "Wonder how long till Ezra kicks this guy's ass?"

Posted by: Neil the Ethical Werewolf | Jun 8, 2005 6:11:32 PM

Your take-down is very good, but this statement:

Unless he believes there to be something uniquely incompetent about American states, I'm lost.

shows that you just haven't spent enough time Texas. Our state government is, in fact, uniquely incompetant.

Posted by: randomliberal | Jun 8, 2005 6:34:59 PM

Emanuel really likes insurance companys too. And hates Medicare!

I've never seen a set of posts on a progressive blog (he is now up to 4) so uniformly picked apart and spat upon. And stomped on too. Vigorously.

Posted by: JimPortlandOR | Jun 8, 2005 6:40:28 PM

Yeah, there's absolutly NO reason to keep insurance companies around in such as ituation, at least for basic care. It's just beyond stupid. It's enshrining more inefficency so that the HMOs can continue to exist.

Not to mention that it opens the door to massive corruption.

It's just a terrible idea. It might even be worse than the status quo (Even though under the status quo, America can not survive.)

Posted by: Karmakin | Jun 9, 2005 1:02:10 AM

"It'll never happen."

Seems like a solid argument to me.

Posted by: Horatio | Jun 9, 2005 9:18:43 AM

Of course the American voter would accept single payer universal health care. But the American voter really doesn't have that much power. If it did we'd have univeral health care, stronger gun control, implimentation of the Gay Agenda and all sorts of progressive programs in place. Insofar as Emanual is observing that Corporations and lobbyists write laws then he is correctly concluding that we will never have universal health care.

Posted by: LowLife | Jun 9, 2005 9:34:23 AM

Not to mention that he seems ignorant of the fact that, um, we already tried vouchers with the Medicare system and it sucked!

Medicare HMOs were instituted in the late 90's--Medicare participants could choose to join an HMO instead of traditional Medicare (basically, a voucher system). The HMOs did a lot of cherry-picking and were never too popular with seniors, and became even less popular when they dropped out of many markets because they didn't like federal reimbursement rates (silly federal government thought they be held to their promise to cost less than traditional medicare!).

Now they're coming back, but only because the Medicare drug bill upped their rates significantly.

So, our experience to date with vouchers backs up what voucher opponents say--that insurance companies won't make money by competing on quality, but will instead make money by cherry-picking participants and blackmailing and/or lobbying the government for higher rates.

Posted by: theorajones | Jun 9, 2005 9:38:48 AM

Sure those bankers are cherry-picking customers for loans too. theorajones never discusses employee group plans cherry-picking who they terminate. If a woman has ovarian cancer and can't work she is put to COBRA for insurance termination. Then theorajones is upset when she is declined by individual insurance.

Come on theorajones, why do you desire employee group plans to be able to dump their liabilities onto individual insurance? It is not going to happen, sorry.

Posted by: Ron Greiner | Jun 9, 2005 10:28:09 AM

"why do you desire employee group plans to be able to
dump their liabilities onto individual insurance?"

theorajones said that? Really?

Posted by: Adrock | Jun 9, 2005 12:51:43 PM

Um.

Medicare doesn't terminate insurance, no matter how sick you get with ovarian cancer. Or any other cancer, for that matter.

Clearly, you have no comprehension of a system in which the goal isn't either to avoid or dump liabilities (also known as "sick people"). Sort of proves my argument about what insurance companies are really focused on, eh?

Posted by: theorajones | Jun 9, 2005 12:52:00 PM

I know theorajones that's why I said that.

Sure theorajones, Medicare pays 80% of medical bills with no Rx. Sounds like an old Blue Cross plan stuck in 1965. Most Americans would go crazy if their insurance was switched to Medicare. Even with the Rx in Medicare a couple would have $7,200 Out-Of-Pocket just on Rx per year. Medicare is your example of good health insurance?

Posted by: Ron Greiner | Jun 9, 2005 1:26:51 PM

So why does Medicare attract such comaratively superlative satisfactions? Why are the elderly so protective of it. Indeed, most Americans eventually do switch to Medicare and, as the surveys show, they love the program. Funny, that.

Posted by: Ezra | Jun 9, 2005 1:40:16 PM

Might have something to do with seniors realizing a)they are not immortal B) Medicine can make you sick (it's all toxic,how do you think it kills stuff ?) C)as your body wears out you have to pamper it more so as not to feel like shit. Exercise and proper diet are good for you ! d) Doctors are in business to make money. They also use the format for which they will not be sued. That's not necessarily the way an informed, intelligent person will go. So conventional medicine is good for emergency interventions. Don't expect to find a nutritionist in the doctor's office. G.I.G.O. (garbage in, garbage out) works for the result of eating trash eventually. Nobody is going to worry so much about breaking the bank keeping an old, broken body going. But it's critical to alleviate treatable chronic problems. And yes, I'm 55+ so there's some voice of experience going on.

Posted by: opit | Jun 9, 2005 2:32:49 PM

"reign in" seems appropriate commentary for problems with King George in the colonies.

Posted by: opit | Jun 9, 2005 2:44:27 PM

ezra you ask, "So why does Medicare attract such comaratively superlative satisfactions? Why are the elderly so protective of it. Indeed, most Americans eventually do switch to Medicare and, as the surveys show, they love the program. Funny, that."

If you are paying a $1,000 a month for Rx and you are on Medicare you might not like the fact that Medicare has no Rx coverage, yet.

64 year old people paying 100% of the cost of their health insurance love it at 65 when the Medicare program pays a huge chunk. Medicare couldn't have such low payments to doctors if the rest of the population wasn't paying the Doc's expenses. I personally don't think that opinion polls is the best way to determine the effectiveness of a program. You can ask uninformed people opinions with certain questions to gather any response you want. If you asked seniors in most of America paying for Medigap insurance if it's fair that in Tampa there is no Medicare part B premiums and no Medigap premiums on HMO's is this fair to you? I think your polling satisfaction would be deminished.

Posted by: Ron Greiner | Jun 9, 2005 3:52:29 PM

And yet they don't like their private insurance. You really didn't answer the question here, Ron: if Medicare is so bad, why do folks rate it so much higher than private insurance? And why, in fact, is it containing growth better than private insurance (as I note in the post)?

Posted by: Ezra | Jun 9, 2005 4:26:26 PM

I can give you my opinion if that helps. When doctors accept Medicare they automatically accept Medicare payments with no balance billing to the seniors. It is exactly like the doctor is on a PPO with Medicare. When seniors get a Medigap plan they have a zero deductible that pays 100% with no Rx. This is very simple for the senior. Of course a zero deductible that pays 100% increases utilization. Some seniors when they are lonely go down and see the doctor because it doesn't cost anything.

Private insurance that employees' have with their employer is another story. Things are always changing. They go to work and find that their Rx coverage is now different. Instead of just a co-pay for Rx they now have co-insurance as much as 50% on brand name drugs. Plus, people are always complaining that their employer has changed health insurance carriers 3 times in the last 3 years. This means that their doctors may not be on the network of the new plan and now they have to change doctors. Plus their co-pays are always on the rise. Their participation with premiums is always climbing too.

Of course sick people do figure out how their health insurance works. When people get really sick and can't work, they go to COBRA for termination. These people, and I talk to lots of them, are fighting mad. People feel uncomfortable when they are not in control. When an employer is in control of your health insurance, then the employee is not.

Medicare is an old Blue Cross plan from 1965 that is stuck in time. A different trust fund for hospitals and another for doctors. When things don't change that is good in some ways I guess. But like I said, opinions from uninformed people being asked loaded questions can produce any results you want.

Posted by: Ron Greiner | Jun 9, 2005 7:40:20 PM

As a hoser, I can assure everyone that Canadians do not trust their governments, and are not particularly egalitarian. Single-payer healthcare is iconic becuase it works. All the arguments made now in the United States were made in Canada in the fifties and sixties, and Canada did not have a bigger welfare state than the US in those days.

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Posted by: peter.w | Sep 16, 2007 10:24:28 PM

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