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Scenarios for the Adoption of Single-Payer in the US

Some have dismissed the idea of Medicare-for-all or a single-payer healthcare system in the United States as implausible (or even impossible). They see it as a bridge too far (or as one Brookings Institute reprint put it (Brookings: 26 January 2016: “The impossible (pipe) dream—single-payer health reform”), “‘You can’t get there from here.'”). I’m going to look, briefly, at six scenario-types that could (eventually) deliver single payer to our shores.

  1. Disaster
  2. Via Pharmaceutical regulation
  3. Via state experimentation
  4. Via cultural maturity
  5. Incrementally
  6. Technological


Manmade or natural, it doesn’t matter. World War II played a role in socialized medicine coming up in Europe. A major pandemic or other breakdown of the US healthcare system could largely do the same here. We continue to have tens of millions of uninsured persons, and during a big enough health crisis that would probably require a legislative remedy.

Pharmaceutical regulation

Drug prices are too high, and between insurance companies and the lack of price negotiation by Medicare, they aren’t going down anytime soon. If a combination of legislative inaction and increasing demand (in the economic sense) makes the problem bad enough, legislators may be forced (by public outcry) to come down hard on pharmaceutical companies. Were that to happen, once people saw a major regulatory success (in the form of single-payer for drugs), they might just decide they want it for the rest of the system, too.

State experimentation

In 2016 Colorado will vote on Amendment 69, ColoradoCare. Now if Colorado didn’t have some recent history to back up the idea of it going against the grain, we might just dismiss this push for a state-based single-payer system. But they do have that history, and who knows? It might work.

Vermont passed a law in 2011 for a single-payer system, but that plan proved unworkable and was scrapped in 2014.

But if any state succeeds with single-payer, others will follow. If they can actually save their state money and improve outcomes, their neighbors will want to get in on it.

Cultural maturity

With the rise of the Internet, with social media allowing people to see Europeans boggling over the state of US healthcare, people will sooner or later realize that overpaying for our healthcare is just plain dumb. Take drug prices, which the pharma companies claim sustain drug development. Either the rest of the world are freeloaders, or the US are chumps. The same goes for the rest of the healthcare system. It might take another 20 years, but at some point the culture will reach the point where it demands a single payer system. (This is, of course, the Bernie Sanders approach; whether the issue is ripe enough now remains to be seen.)


We already have Medicare, which is mostly single-payer (I’m not old enough to have the alphabet soup of parts B-D memorized, but I know that somewhere in there is some private insurance, too). Medicaid, too (disregarding the federal-state split). One of the ACA’s population-coverage improvements was via Medicaid expansion. That could just happen a couple more times, and before you know it: a single payer system.

There are other opportunities for incrementalism here. If unionizing comes back in vogue, for example, and many of the unions join up to build some gigantic insurance cooperative over time, it could be transitioned to a single-payer system.


Technology is going to be an ever-greater part of medicine going forward, just as it has been since its modern advent. The need for automation to offset labor requirements will be a huge driver in the coming decades. Depending on how fast and how far technology can go in medicine, single-payer may just come down to a sort of use tax (like that on gasoline) at some point. In this scenario the health care infrastructure may be so expensive and integrated (think the Interstate Highway System) that it requires single-payer. Or maybe it’s just mostly so cheap that the only remaining need for insurance is de-facto single-payer.

Just to be clear, I don’t think single-payer will happen short of the 2020s. But to say it’s impossible? Just use a little imagination.

This is not to say single-payer is inevitable. It may become moot. But if the US continues to overpay for healthcare, sooner or later it will become inevitable. If the interests in this field can’t or won’t work to keep prices in check until they’re on par with the rest of the world, single-payer will become inevitable.

Alternate Reality: If Obama Signed the Obamacare Repeal

Some thoughts about how badly it would hurt the GOP if Obama actually signed their Obamacare repeal.

The Republicans have again voted to repeal Obamacare (the Affordable Care Act), but this time they did so through a reconciliation measure that allowed the Senate to avoid a filibuster.

It wouldn’t actually repeal the ACA word for word, but it would merely defund it. Things like a bar against discrimination for pre-existing conditions would remain, but healthcare subsidies for everyone from the working poor to the middle-class would evaporate. The mandate would remain, but would become toothless.

What if Obama signed the bill (leaving aside the part of it that would eliminate federal funding for Planned Parenthood)?

According to the bill, some provisions are repealed effective immediately, while others like the subsidies and tax credits are only effective as of 2018. So, at least there wouldn’t be outright chaos as millions of people tried to figure out if they still could afford coverage in 2016.

But there would be a major campaign against the GOP from the medical establishment, including doctors, insurance companies, and pharmaceutical companies. If the repeal went through, it would be perhaps the best medicine (other than laughter) for the GOP: finding out what happens, Larry, when they fuck millions of strangers in the ass.

Of the many times the GOP has tried to repeal Obamacare, they have not once had any chance of success. But now, all it takes is a single signature by the president to show them all how ridiculous, how idiotic they really are.

Of course Obama will not sign the bill. And for good reason. But if he did, it would poison the GOP. They would be driving the porcelain schoolbus for the rest of the year, into 2017 and beyond. Their stump speeches would be accompanied by puke breaks with little elephant-emblazoned barf bags.

The thing is, nobody in the GOP really wants the ACA repealed. Not the GOP, who love the thing. They think it’s a key issue to voters. They think it has legs. The only thing the GOP is doing through its continuous, bizarre crusade is to force the democrats to act as though the ACA is anything more than a mediocre attempt at healthcare reform.

The ACA isn’t horrible, but it’s a far cry from what the American people deserve in reform. It’s a step in the right direction, but the race is a marathon. And the GOP is calling for America to call it quits, sit on the couch, and watch a rerun of Andy Griffith.

A Car Analogy for the Severability of the Health Insurance Mandate

Assuming that the mandate in the Affordable Care Act is unconstitutional, can it be severed? I argue that it can, by analogy with a car.

So the United States of America passed a piece of reform to try to fix its broken health insurance system.  And in that reform the congress included a mandate that all citizens purchase health insurance.  And now the Supreme Court of the United States of America has heard oral arguments about whether or not that mandate is sound with regards to the powers enumerated in the Constitution of the United States of America.

Assuming that it is not sound, and must be struck, the question then becomes whether the rest of the reform effort must also be struck.

The central question is whether that mandate serves as a chassis or an engine for the car that is the reform law.

If it is the engine, while important to the car, it can be removed (possibly removing a few other components in the process simply as a matter of convenience to pull that sucker out).  The remainder can be rolled across the street to the Capitol and then Congress can decide if they want to put a new engine, disassemble it, or something else (maybe they will convert it to an electric car).

If it is the chassis, well, everything is attached in some way.  It would be overly complicated to remove everything and still return the parts to the Congress of the United States of America for reuse.

An engine clause is one which provides a necessary resource to the remainder of the law, allowing the remainder to operate.

A chassis clause is one which provides structure upon which the other provisions rest.

It seems plausible that the mandate is an engine, and that it is not a chassis.  Without the mandate, some of the other provisions may lack the economic powers to function, but a new engine could fix that.  The mandate does not provide a framework or structure that the provisions intrinsically rely upon.

So what, then, would a chassis clause look like in a law?  I’m not entirely sure, but my guess would be something like a law requiring all citizens to purchase and maintain firearms, and then requiring a variety of activities premised upon that.  You must march around your house every Sunday, firing shots in the air at a forty-five degree angle toward the four corners while singing the national anthem.

A variety of such dependencies, all relying on the premise that you own and maintain one or more firearms and ammo caches, would be strictly dependent upon that one clause.  Without that clause, the remainder would be like a jellyfish, just a bunch of dead weight.

What do you think?  Is the mandate a chassis or an engine?