Why wouldn't it work here?
Not claiming that it absolutely positively wouldn't work here. Mostly my complaint is about the notion that all the cool countries do it ERGO it's the obvious path for us. I find that mindless. The other iffy notion is that it's important to people ERGO they should be given it. That is also mindless. Softheartedness is a fine trait but it is not the be all and end all. Something that big deserves serious thought. I don't see that from advocates. I see utopian dreams and leaping before looking.
I have, indeed, given it a lot of thought, albeit not recently. I will mention a few points of concern regarding applying single payer that come easily to mind.
First of all, there are a lot of different systems out there. All those countries aren't single payer. The UK is the only one that is truly socialized and even they have a small private element. Canada is next closest. Beyond that is a mixed bag. The individual features need to be studied and compared. There are some good ideas beyond Medicare for All.
Any collectivist system works better the smaller and more closely related the group members because they share a culture, have trust, and a mechanism for policing deviance within the group like shame or shunning. Collectivism works best in a family, then a tribe. The further you get from that, the more differences you have. Even in families there are struggles over direction and resources. Imagine applying a common system across the US cultural bubbles and given our current state of animosity. We don't have shared values and we don't like each other much. We could probably not agree on the side of street to drive if we had to do that now from scratch.
Those countries have had universal care of some sort for a long time. I posted just the other day about the Canadian system starting in Saskatchewan in the early sixties when insurance was rare. The British NHS, when started, covered Brits, a distinct culture, not completely homogeneous but more cohesive than they are now and way more cohesive than we are now. We would have had a better shot at it in the fifties when there was a common culture.
Now we have invested interested and expectations. One of them is our relationship with doctors, which we have experienced as private practice providers charging fee for service. NHS employs doctors. Canadians doctors are used to Canadian payments, which are not nearly what US doctors earn. One reason other systems cost less is that they pay providers a lot less. Doctors there accept that because for them it's always been that way. Here, that would be a big and unhappy adjustment with myriad externalities. Remember when HMO's were the thing? Remember why they were abandoned? Because they were cheap and didn't give the service Americans expected. So somehow we're now willing to accept HMO type service? And providers are willing to accept HMO type payments? You mean I can't get a heart transplant? Maybe five years ago they came out with recommendations that women get mammograms every two years rather than every year and starting at an older age. The new recommendations were consistent with what was standard practice in Europe. The reaction was fierce as though they were murdering women. American women are geared to expect mammograms every year starting at age 40. It matters not that we have no better outcomes than European women. It's political, not evidence based. People expect a physical every year and telling them that it's been determined to be a waste doesn't go over well.
If we are not prepared to be denied any service or treatment by the system, then the system will cost a fortune. I went to bi-annual mammograms and haven't had an annual physical in maybe five years but I am told I'm a fool for not taking some service that's "free" and might help me live longer. I can't argue with that. We won't be able to get people to do that, not Americans. It's all but impossible to scale back, to take away something that has become expected. European women don't expect annual mammograms so they don't feel deprived. When we feel deprived we march and we vote.
Any system that is affordable will require people to back off on their expectations, both patients and providers. And any system that is affordable will require rationing of some sort. Right now we ration by wealth and employment. If we're going to have some other form of rationing, for example, "death panels," then we have to come to consensus on that or force it on those who resist and imposed standard. IMO, the US won't accept any form of rationing that provides them with less than they have now whether they need it or not. More likely, people will take all the "free" stuff they can get. That's the American way. The onus is on those who want that level of service for everyone to find a way to pay for it and persuade the rest of the country. Platitudes and moral signaling and sloppy analysis ain't that. Neither is voodoo economics.
The fifties are long gone. And not just with regard to shared values and culture. Now along with cultural bubbles we have prospects of fewer and fewer people paying in with more and more people in need.
If we want to move in that direction, I think we have to do it gradually and we have to accept a tiered system. We don't have the institutions and mechanisms to do something as drastic as Medicare for All, certainly not all at once.
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