Single payer healthcare is coming to America. It’s inevitable.

Summary: Conservatives’ bold propaganda have made Americans fear the health care systems of our peer nations, systems that produce equivalent care a half the cost (or less) or ours — but cover everybody. America’s march to universal coverage began with Medicare (1965) and Medicaid (1966). Obamacare expanded it, covering more people but at unsustainable cost. Here Ed Dolan looks at the facts and draws the obvious conclusion: single payer insurance will come to America. The longer we wait, the more difficult the transition.

Health Care Reform

Single Payer Healthcare is Coming.

Stop Fighting It.
Start Figuring Out How to Make It Work.

Guest post by Ed Dolan.

As everyone knows by now, the United States is alone among advanced economies in not having a single payer healthcare system with universal coverage. It is, however, already much closer to such a system than most people realize, and the current round of Republican healthcare reforms, if enacted according to plan, will bring it even closer. Yet there is no reason to fear the single payer future. Read on.

The true scope of government in our healthcare system.

The federal government already operates three large healthcare systems, Medicare, Medicaid, and the Veterans Administration. Each of the first two is comparable in size to the single payer systems of most European countries. If we categorize healthcare expenditures by the type of primary payer, the three big federal programs accounted for roughly a third of all spending in 2015, according to data from the Centers for Medicare and Medicaid Services:

Who pays for health care?

To get a true picture of the government role in healthcare, though, we need a different perspective. If we categorize expenditures by the source of the funds, instead of the type of payer, the government share of spending is much larger. Partly that is because state and local governments account for 17 percent of all healthcare spending, not fully reflected in the chart above. Also, that chart hides the extent to which federal tax expenditures finance much of our ostensibly private health insurance. According to data from the Tax Policy Center, deductions and exclusions of health insurance premiums and related tax breaks cost the federal government some $250 billion in revenue in 2015 — as big a burden on the federal budget as if Uncle Sam wrote a check for that amount.

Deductibility of employer healthcare expenditures account for about three-fifths of total tax expenditures. The remainder come in the form of exclusions of Medicaid benefits from declared income, deductibility of insurance for self-employed individuals, tax breaks for some kinds of out-of-pocket costs, and other items. If we categorize healthcare expenditures according to the ultimate source of funds rather than the primary payer, we find that government budgets account for over half of all spending, as the next chart shows.

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What to expect from the Trump years, and why.

Summary: The media overflow with hysterical predictions about the next four years, but few well-grounded visions. Here is a brief look at  some of what we can expect, and why, and what these events reveal about ourselves.

What makes America great? Great for whom?

Trump: Make America Great Again

Investors have pushed US stock to near-record valuations (record valuations on price to growth basis) on the belief that the Trump administration will enact a massive fiscal stimulus — tax cuts (mostly for the rich) plus infrastructure and military spending — resulting in another round of fantastic fiscal deficits. Just as hard-rock conservatives Reagan and Bush Jr. did.

Skeptics’ rebuttal points to the eight years of Republican criticism of Obama’s deficits — deficits which prevented the 2008 crash from starting a depression and supported the economy during its long, slow recovery. How could the GOP justify massive deficits now, during an expansion? Conservative’s beliefs and history help us better predict how the conservative majority in Congress will vote. Start with their beliefs about deficits, easily stated.

  • Vast military spending and tax cuts are good; the resulting deficits are bad.
  • Tax cuts are good in both booms and busts, no matter how large the resulting deficits.
  • Deficits don’t matter for Republican Administrations, only for Democratic Administrations.

To see how this works we turn to one of America’s most influential presidents, whose administration radically changed America and set the patterns we still live by: George Bush Jr. The pivotal moment when fiscal policy change is described in this excerpt from The Price of Loyalty: George W. Bush, the White House, and the Education of Paul O’Neill by Ron Suskind (2004, p291). Cheney is the key mover, as in most things during the Bush Jr. years.

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What does the health care debate reveal about us, and our future?

Summary:  Today we have a glance at the debate about one of the most important domestic public policy debates of our time, repeated in every generation since 1945, that illuminates the moral and intellectual nature of America at this point in time. The photo below captures it perfectly, the aggressive ignorance resulting from generations of skillful propaganda on a weak people. Renewal is an inherent capacity of individuals and societies; we desperately need it (more on how to do this in another post).  This is the second of two posts today.

“Of course we want to have universal health care! We aren’t barbarians!”

— attributed to Margaret Thatcher, said in 1993 at Washington, DC (hat tip to Delong)

Keep govt out of my Medicare
This is America today


I am applying for health insurance as a self-employed consultant, a painful experience which reminds me of three important facts about America today. Facts which reveal the basic outlines of our situation.

First, our health care system is a disgrace, a failure to adequately handle a public policy issue solved years (or generations) ago by other developed nations. It’s massive cost and low effectiveness (leaving so many poorly covered, or uncovered) reveals the degeneracy of our ethics and folly of our governance. Decent medical insurance (with caps that don’t cause bankruptcy) can easily cost 1/4 to 1/3 of a blue collar family’s after tax income (without Obamacare’s tax credits).

Also, it shows how large vital sectors (finance, defense, health care) have become parasites, consuming resources disproportionate to their role and size. It’s the grifter economy, however well-intentioned the people involved (i.e., in health care and military).

Second, Republicans are the political group most responsible for this, since 1945 having fiercely fought every step to provide health care to America’s poor and working poor from Medicare and Medicaid (1965) to Obamacare. Even today they fight to deprive Americans of affordable health care, with a policy of Repeal and Promise to do something someday.  Rand Paul’s budget proposals call for a slow strangulation of Medicare, while today some GOP governors reject expansion of Medicaid even at no cost to their State (as of September, only 27 States have expanded coverage) — and some fight even the basic terms (e.g., Kansas).  It’s difficult to imagine such callousness, especially as their arguments are largely bogus.

Third, it shows our weakness as citizens that alone among the developed nations Americans have not exerted ourselves to provide adequate health care to all — despite the obvious self-interest in doing so — or run this sector in a rational manner.

Here are links to the latest rounds in the “debate”. Like most public policy debates in America, they’re polarized between facts and delusions. With each groups taking different sides in different debates; sometimes we have bipartisan delusions (e.g, the WOT).

(a) The Anti-Obamacare FAQ“, Reihan Salam, Slate, 14 November 2014 — A fact-free “Everything you need to know about why conservatives want to repeal the president’s health care law.”

(b)  A gentle but thorough rebuttal: “Here’s Why Conservatives Will Never Give Up Their War on Obamacare“, Brian Beutler, The new Republic, 18 November 2014 — Excerpt:

But in any case, none of these basic differences between liberals and conservatives explain, as Salam puts it, why conservatives are “so pissed off about Obamacare.” He attributes their indignation to the belief “that Obamacare only became the law of the land because President Obama misled the public,” then goes on to explain that conservatives aren’t hypocrites for wanting to turn Medicare into an Obamacare-like program for seniors, or for having once supported the individual mandate; then acknowledges that conservatives are miles from consensus on how best to replace Obamacare; and finally concludes that the law should be repealed anyhow.

None of this makes the Obamacare opposition seem even a tiny bit reasonable, but it does present a few good opportunities to explain why liberals think most of this is all window-dressing for a simpler explanation: Conservatives don’t just oppose distributive programs that help the poor and working class — these programs drive them batty in and of themselves. That Obamacare patched up the single biggest hole in the federal safety net, and in so doing extended government-sponsored health benefits to people through every stage of life, intensifies this reaction.

(c)  A detailed and typically brilliant rebuttal by Brad DeLong (Prof Economics, Berkeley): “Continuing on the ‘What Are Conservative Policy Ideas for Replacing ObamaCare?’ Beat”, Washington Center for Equitable Growth, 18 November 2014 — Excerpt:

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Obamacare forces even true believers to assess Obama. Will we learn, & do better in 2016?

Summary:  We laughed at President Carter, and suffered under his serial mistakes. Now we elected yet another President with remarkably little experience (less than Carter), and watch with astonishment the results. Since we’re Americans, we point a finger at anyone but the man in the mirror.

Perception: Obama-Kennedy


“… I mean in a way Obama’s standing above the country, above above the world, he’s sort of God.”
— Evan Thomas (Editor-at-large of Newsweek), interview by Chris Matthews on MSNBC’s “Hardball” (source here)

As we close Obama’s 5th year, let’s review his accomplishments.

  • A surge in Afghanistan followed by humiliating withdrawal.
  • An ever-widening war, waged without Congressional authorization, probably against the laws of war, killing an ever-lengthening toll of innocents.
  • Destruction of civil liberties on an unprecedented scale.
  • Institutionalized the Bush tax cuts, wrecking the government’s solvency and increasing income inequality.
  • He wasted the opportunity offered by the crash to institute desperately needed reforms and rebuild America’s decaying infrastructure.
  • And now his signature accomplishment has been proven — as so many people said — a complex and poorly executed mess.

Now of this should surprise us. I wrote this in February 2008 at the beginning of the Obama-as-savior craze. What matters more than Obama’s deeds and misdeeds, but the degree to which we learn from this experience. Will we choose more competent Presidents in the future, or continue to choose based on expensively crafted media facades?

As these problems reach critical dimensions and our economy sinks into what is (at best) a severe recession, our national leadership will likely move into the hands of someone with astonishingly little capacity to govern.  Barack Obama has amazing rhetorical gifts and the potential for greatness, but becomes President with his skills immature, his vision on major questions of public policy unformed, and no executive experience.

His brief career and campaign of empty rhetoric — appealing to the best of America’s history and aspirations — tell us little about the course he will chart for America, or how he will respond to the terrible choices that lie in our future.  He provides a frame into which his followers project their dreams — a virtual reality candidate.  (Candidates’ white papers, like party platforms, have historically proved poor guides to their actions)

This is our failing, not his.  High office in America goes to those with both drive and hunger for fame and power.  That Obama goes along with our childlike dreams says much about us, but nothing bad about him.

This election might result in weak leadership for our national government during tough times, unless he grows in office (which would be wonderful, but not something we can rely upon). As these problems reach critical dimensions and our economy sinks into what is (at best) a severe recession, our national leadership will likely move into the hands of someone with astonishingly little capacity to govern. Barack Obama has amazing rhetorical gifts and the potential for greatness, but becomes President with his skills immature, his vision on major questions of public policy unformed, and no executive experience.

When I wrote this America was dazed by the wonderfulness of Obama, excitedly watching Obama Girl. We are now five years older. As you watch Obama Girl below, ask if we are wiser after this experience?

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Affordable Care Act down the mindshaft: asking what it reveals about us

Summary:  Why do Americans oppose the the Affordable Care Act (ACA, Obamacare) while supporting so many of its provisions? What does this tell us about America? Today Chet Richards “asks the mineshaft”  for answers. It’s a community exercise, from the German Gemeinschaft (see Wikipedia).  Please post your views in the comments!



  1. The oddity of Americans’ view of the ACA
  2. Polls of US public opinion on the ACA
  3. For more information: other posts about health care

(1)  The oddity of Americans’ view of the ACA

One of the more curious aspects of the current political season is opposition to the Patient Protection and Affordable Care Act (aka PPACA, ACA, Obamacare).  Polls (such as this recent one by Gallup) show that 31% of Americans say they want Congress to entirely repeal ACA — and another 21% want certain parts repealed (most the individual mandate, which finances much of the rest). On the other hand, when the provisions are listed individually, most Americans support them.

One way to explain this phenomenon is that most Americans are “fatally stupid,” to quote University of Michigan professor Juan Cole.  But this is intellectual laziness.

A better approach is to understand the orientations of the people who oppose ACA, although they may support the provisions outside of the act. Can we do this? That’s the question we’re posing to the mineshaft in this posting.

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More death throes of the Constitution. Nothing remains in the ruins but politics.

Summary:  As the Constitution nears the time for its Last Rites, its enemies become bolder.  Reports of blows to the Constitution, even de facto repeal of specific provisions, become unremarkable blips in the daily news.  But some blows are larger than others. June 2012 might be a historic month for the Second Republic, worth marking with a black border on your calendar.

“The single most important thing we want to achieve is for President Obama to be a one-term president”
— Mitch McConnell (Senate Minority Leader), interview with the National Journal, 23 October 2010

What price is the GOP willing to pay? What will they sacrifice?  In the fourth year of Obama’s term we see the answers.  America.  The Constitution.


  1. Diluting the Sixth Amendment, a warm-up to the main event
  2. The main event: repealing ObamaCare
  3. For More Information

(1)  A warm-up to the main event

Diluting the Sixth Amendment“, Scott Lemieux (Asst Prof of political science at the College of Saint Rose), The American Prospect, 18 June 2012 — Excerpt:

The case today concerns the right to confront experts who produce forensic evidence. The Court has recently held — correctly, in my view — that the Confrontation Clause means that if states introduce forensic evidence compiled by experts it must make these experts available in court if the defense requests it. Today’s case represented Illinois trying to make an end-run around these precedents by having a state employee who was not involved in producing the forensic evidence — in this case, a DNA test of semen from a vaginal swab in a sexual assault trial — testify about the results. The defendant was not given the opportunity to cross-examine the private analysts who actually produced the evidence, and hence could not inquire in Court about whether proper procedures were followed. But the Court held that this did not violate the Sixth Amendment.

… As Justice Kagan says in a quite brilliant dissent, “Justice Thomas’s approach, if accepted, would turn the Confrontation Clause into a constitutional geegaw — nice for show, but of little value. The prosecution could avoid its demands by using the right kind of forms with the right kind of language.”

… Today, the Court preserves this {sixth amendment} in theory but guts it in practice.

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About the political significance of the conservatives’ health care propaganda

The new legislation, when it emerges from the Congressional sausage machine, will be an incoherent mess.  Then come the administrative revisions, court challenges, and remedial legislation.  Nonetheless this bill is a step in the massive reforms needed to contain the unaffordable growth of medical costs as the boomers retire — and to close the large gap in cost-effectiveness between our system and those of the better run european systems (e.g., France, Germany, Switzerland).

What might be the political repercussions of this bill?   I suggest watching  for these two developments during the next few years:

  1. Many conservatives made bizarre claims about the effects of the bill.  The public might come to regard these as delusional or dishonest. 
  2. People might look back on their propaganda and wonder if these conservatives were fools — or if they were smart people assuming that we are fools.

For an example of conservative debate about these issues we go to Glenn Reynold’s website, The Instapundit:

ANNALS OF GOVT. HEALTH CARE, CONT’D:  Docs Removed Wrong Testicle. “Details of the error surfaced this week after the hospital was forced to confess all thanks to freedom of information laws. Care at the hospital had previously been rated ‘good’ by the Care Quality Commission.”

How many mistakes are made each day in US hospitals?  Is the rate of medical errors (plus ill effects from lack of treatment due to inadequate or no insurance) higher in the US or UK?   Don’t bother to ask Reynolds.  He is an intelligent man, a law professor, using his skills to influence the debate with coarse propaganda. 

How common is wrong-site surgery ?

Wrong-site surgery happens in the US.  Even in our private sector hospitals.  Even in operations untainted by government money.  How often?

(1)  “Incidence, patterns, and prevention of wrong-site surgery“, Mary R. Kwaan et al, Archives of  Surgery, April 2006 — Abstract (red emphasis added):

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