"Why Not Single Payer?" A Response to Paul Krugman and the Leading Democratic Presidential Contenders. Part 1.

I find Krugman's notion that an Individual Mandate is somehow more politically pragmatic than Medicare For All unconvincing and I don't buy his argument that it's a backdoor way to eventually get there.
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Faster than you can say the word "Sicko" and turn around 3 times, the Democrats' promise of health care for all has gone from "Universal Medicare For All" to "Individual Insurance Mandate". In Monday's New York Times, Paul Krugman defends that reversal in an article entitled "Why Not Single Payer?"

The possibility, after the 2008 elections, of a Democratic-controlled Congress which could pass Medicare For All (a/k/a Universal Single Payer Health Insurance) and a Democratic President who would sign it, could bring about the best chance to enact Medicare For All since Harry Truman first proposed it in 1948.

Yet without firing a shot and with no debate, the leading Democratic Presidential Contenders--Hillary Clinton, John Edwards and Barack Obama--as well as a good part of the Washington progressive infrastructure of think tanks and lobbying groups--have given up the fight for Medicare For All. Instead they propose variations of an Individual Mandate plan developed over the past 15 years by the "moderate" corporate wing of the Republican Party, a version of which Mitt Romney enacted in Massachusetts and which Arnold Schwarzenegger is proposing in California as an alternative to the single payer plan which the Democratic California legislature passed last year that he vetoed.

The thing is, I can't quite figure out why the Democrats are in such rapid retreat from Medicare For All before the first battle has even been joined. Is it another example of the political cowardice by which the only Iraq resolutions that can pass the Democratic controlled Senate are a Republican-driven bill condemning MoveOn.Org. and praising Gen. Petraeus and another declaring the Iranian Revolutionary Guards a terrorist organization? Is it because the Democratic candidates are afraid of being accused by Republicans of supporting socialized medicine? (If so, it won't help because Giuliani, Thompson, and Romney--whose Massachusetts plan Hillary largely imitates--all quickly claimed that Hillarycare 2.0 is socialized medicine, anyway.) Is it because they've been bought off by insurance companies and drug companies or fear that too many other Congress and Senate members have?

Or is it because they think that the insurance companies and drug companies are just too politically powerful to take on: Therefore the only way to insure most Americans is to make a deal with the devil that requires profit-making insurance companies to waive pre-existing conditions and charge everyone similar premiums regardless of age or health, in exchange for Congress delivering them 50 million guaranteed new profit-making customers, partly subsidized by the government?

Paul Krugman's NY Times column is one of the first direct attempts by a liberal former supporter of single payer to try to make the case for adopting the Individual Mandate approach instead. According to Krugman, "basically it looks like something that could actually happen in the next administration, while enacting a single-payer plan...excellent as those plans are, might take a very long time."

First, Krugman argues than an Individual Mandate would not require a big tax increase, although he admits (thus defeating his own argument) that taxes which most people would pay for single payer would most likely be lower than premiums that an Individual Mandate would require them to pay out of their pockets to buy insurance. Second, he argues than an Individual Mandate won't make people feel that they're "being forced into a government plan". But the essence of an Individual Mandate plan is that the federal government forces the uninsured to buy health insurance. It involves even more government coercion than Medicare For All.

Finally, he argues that the Democrats' proposals generally include a Medicare-like public insurance alternative which individuals may buy into and which "would evolve into single-payer over time." Krugman never quite explains how this piece of alchemy will occur. Moreover, he admits that this is the part of the Democrats' plan that the insurance industry will fight "tooth and nail". If the Democrats have already surrendered on Medicare For All without firing a shot, isn't it likely that the public alternative (the "socialized medicine" part) will be the first part of the plan to be compromised away when the legislative battles start in Congress and the insurance lobby starts exercising its muscle with its hundreds of lobbyists and tens of millions of dollars in campaign contributions?

In short, I find Krugman's notion that an Individual Mandate is somehow more politically pragmatic than Medicare For All unconvincing and I don't buy his argument that it's a backdoor way to eventually get there. I even wonder how strongly he believes his own arguments. Only last January, in critiquing Schwarzeneggers's Individual Mandate plan for California as a complicated "Rube Goldberg" device, Krugman argued that "the plan requires a much more intrusive government role than a single-payer system. Instead of reducing paperwork, the plan adds three new bureaucracies: one to police individuals to make sure they buy insurance, one to determine if they're poor enough to receive aid, and one to police insurers to make sure they don't discriminate against the unwell." If you then add a public Medicare-like alternative that individuals can buy into, you need a fourth bureaucracy to administer that system.

Thus, when Hillary Clinton claims that her plan requires no new government bureaucracy, she's not being candid with the voters. That lack of candor will quickly be exploited by the Republicans and the insurance and drug lobbies. While Republicans are wrong that her plan amounts to "socialized medicine", such charges will still ring true since, in fact, her plan will require intrusive government regulation of the private insurance industry and coercive action to be sure that all citizens are obeying the individual mandate to buy health insurance. That's one of the big reasons why, once the debate really starts, an Individual Mandate will not necessarily be a popular plan with the voters--Using the political pragmatism test, it stands a better chance of being rejected by the public and meeting the same fate as Hillarycare 1.0 than does Medicare For All, for which the political arguments are simple and clean.

Whatever Clinton might claim, Hillarycare 2.0 in fact requires a highly intrusive government presence in the lives of both businesses and individuals. As with Hillarycare 1.0, this is likely to be the biggest club that Republicans and their insurance company allies will use to defeat her or another Democrat as they did in 1994, unless so many compromises are made to water down the plan that insurance and drug companies decide it's in their interest to accept the 50 million new mandatory government subsidized customers to pad their bottom lines. (Remember that with private insurance, approximately 30% of the healthcare dollar goes to administration, executive salaries and profits, compared to 2%-3% for Medicare; when all the political deals are finally cut, the private insurance and drug industries might find a new government subsidy for their bottom line an attractive deal.) If an Individual Mandate plan is more politically expedient than Medicare For All, it's not for any of the reasons which Krugman cites and not because it's likely to be more politically popular with the voters. The real reason is that with a few backroom political compromises, it could become a that plan the insurance and drug industries could learn to love.


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