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When an Experiment is Unneeded

The Republican-championed laboratories of democracy, the states, could be used to figure out what’s needed for healthcare in the 21st century. Let the states tinker, find out what works, and then we’ll see it spread.

But those experiments are not needed. We have scores of experiments conducted all over the world. We have all these examples of healthy healthcare in all these other countries. We just don’t have the political will to enact the sensible and sane in the USA.

Now, in Europe each state has its own healthcare system, and the US might still divide a universal system into per-state systems. But the Europeans also have the EHIC system, which allows for dependable treatment when traveling (both unplanned care and for chronic treatment).

The US might still do things different than Europe and the 58 countries with universal care. But the idea that we can’t figure out a problem that 58 other countries have? The amount of denial required to reach that conclusion could only be described as gross negligence.

We don’t need to experiment with allowing states to ignore real insurance in favor of slimmed-down plans that will result in financial burdens on the infirm. We don’t need new work requirements that undermine the definition of universal. We might make some minor use of high-risk pools, but we know the basic shapes that universal coverage come in.

It is high time that any party that seeks national recognition in the US would have a plan for universal coverage. That is a low bar for 2018. The Democrats currently seek a single-payer medicare-for-all style system. If the Republicans do not answer with a 50-states-plus-DC alternative, it will only be a matter of time before CMS is charged with overseeing healthcare across this nation.

We don’t need an experiment. The time where an AHCA or a BCRA might have reflected something the US would do is gone. The cardboard reads “Universal Healthcare or Bust!”

Mandate Alternatives

The Republicans probably can’t replace Obamacare without some form of mandate.

Donald Trump will personally ask everybody to buy insurance, really really nicely. And if they push back, he will offer them $7 million in tax incentives.

Or maybe everybody who has coverage will be entered into an annual lottery where someone will win $big$bucks$.

Or we can bring back the draft and weight selection against those who do not have coverage.

Not talking electoral mandates—those are apparently a dead concept, circa 1980s. Talking about the health insurance mandate.

So, first we should understand that the Obamacare mandate is meant to serve two purposes:

  1. Avoid having too few young and healthy people so that the pool can pay for the care of the sick members.
  2. Avoid having too many people without insurance that end up needing care.

Insurance isn’t just for old people. It’s also for the random event. Young people lacking insurance raises the cost of the whole healthcare system one of them gets a sudden illness they can’t pay for.

The problem with the Republican alternatives so far is that they tend to only address the first purpose: making sure that the pool is mostly healthy. They tend to do this by creating high-risk pools. These pools are government-subsidized so that the regular market is free of the sickest folks.

The Republicans are calling for a form of socialized medicine whereby the worst costs are still borne by taxpayers, while the artificially-healthy market is free to line the pockets of insurers.

Now, such a scheme could work. It’s just that the Republicans will not be willing to take it to its logical conclusion: creating one risk pool (either nationally or per state) for all catastrophic coverage, and relegating health insurance to something more like an add-on that helps pay for the first 10-20% of coverage only. This is more like the risk equalization pools used in parts of Europe, and those still require young people to carry insurance.

Indeed, one expects that if the high-risk-pool system is put back in place, there will be a strong incentive for future governments to expand it into a full-on single-payer system. Historically high-risk pools have been underfunded, leading to higher premiums and deductibles. Their existence was one of the motivations for health insurance reform (i.e., Obamacare) in the first place.

Now that we’ve had a first round of insurance reform, one expects that the government will be compelled to repeatedly reform it until they get to a system that works. People will not be content to let this go, as tens of millions lose insurance, the systemic uncertainty grows, and all the while the corporations produce record profits. There will be pressure to keep fixing this system.

The Republicans don’t really try to tackle the enrollment problem, the fact that a lot of young people will tend not to buy insurance. They seem to believe, for some unclear reason, that if you make insurance cheaper it will entice young people to act responsibly (despite the fact that it’s already relatively cheap for them). It just doesn’t work that way. Coverage is not on their radar. Unless and until health insurance becomes a fashion statement, don’t expect the youth to seek it out.

Thus, it seems implausible that there exists an alternative to a health insurance mandate (taken-as-read that single-payer is a mandate too).

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.