I think that single payer is the only way to get control of overall health costs, not just the federal programs. With more and more small businesses dropping their health plans, a HR 676 type system makes sense, tacking on a couple of cents to the payroll tax, and running it through the highly efficient existing Medicare system.

Health consumers can always go outside the system to pay for certain procedures, just as they do now with procedures like cosmetic surgery. There will still be a large market for pricey, innovative procedures, given the income disparity in America. But single payer will cover every American to at least a rationale amount of health care.

Agreed.

And I think single-payer is completely the wrong solution to health reform. But I'm happy to engage in the reasons why, and it should be part of the discussion.

Totally agree. Single payer may not be politically feasible, but there is not reason to not model it. Heck, we are modelling other unattractive options (ie, the status quo)

Single payer may be politically unfeasible among politicians. In the general public, it is quite popular. http://www.pollingreport.com/health3.htm

As a Canadian who watched and helped his sister go through 5 years of elite treatment medical treatment for a rare brain tumor, I consider myself experienced with the single-payer approach and I have generally great things to say about it.

First things first, and this is a hugely important factor, Canada's health care system is PROVINCIALLY RUN. That is to say, constitutionally, it's not the purview of the federal government, it's the explicit responsibility of the provinces. Over the years, various federal governments have issued transfers to the provinces explicitly for health care, but the responsibility for delivery remains with the provinces.

Additionally, as Ezra noted once upon a time in a review of international health care systems, the providers in a single payer system are private. This is an important distinction. Doctors in Canada are small business-people competing for customers. Canadians choose which doctor to visit and the doctor with the most visits gets better reimbursement from the province.

Get that? That's provinces competing to do the best job on health care management (keeping costs down) with doctors and hospitals competing to get the most visitors, to keep business booming and government reimbursements coming.

The upside of this is that it promotes competition for efficiency of delivery. In fact, Canada's entire system evolved that way, beginning as a Saskatewan program pioneered by Tommy Douglas.

Now, before you write off the single payer system (I'm looking at you wisewon), keep in mind that not only did Canadians recently vote Tommy Douglas the greatest Canadian in a recent CBC reality show (http://www.cbc.ca/greatest/), but he's also Keifer Sutherland's grandfather (no lie).

We should be honest about the downsides of a single-payer system. Despite the sundry downsides you may here from US commentators, criticisms in Canada come from mainly two areas.

First is equal access. In Canada it doesn't really matter how rich you are or how much money you have to throw at your medical problems, you get treated in the same line as the poor farmer, the homeless guy and the suburban middle-class family who need the same treatment. To you, maybe, this is a bug. To me, it's a feature. The idea that in Canada we treat our poor in the same order we treat the rich seems an impressive display of equality when it matters the most.

The second is for wait times. This is not a material concern to this discussion. If you want to know why read http://www.prospect.org/cs/articles?article=the_health_of_nations .

While there are some exceptions to these rules, such as Canada's rare and controversial private clinics, the system generally works as advertised.

As an example, in 1996, when she was 10 years old my sister was diagnosed (in Newfoundland) with a rare brain tumor. She was treated in Newfoundland, but when a better treatment became available in Toronto the provincial government sent her to Toronto for the care and covered its cost. Had a better program existed in an American children's hospital, she could've been treated there.

My family was middle class for our rural community, but would hardly qualify as rich. My parents had a combined income of under $100,000 yearly, but my sister received three rounds of neurosurgery, three rounds of chemotherapy and a three-weeks-in-isolation bone marrow transplant. All without my parents paying out of pocket for anything.

In the US people go bankrupt in situations like this. In Canada, they live through it. My parents are now happily in retirement and relatively well financed.

Meanwhile an exgirlfriend of mine from Wisconsin needed her wisdom teeth out. Her plan was to go get the treatment and stiff the hospital on the bill. She said future creditors would understand, since medical bills are often skipped out on.

I'm not an American, and I don't know how typical or a-typical that is, but it definitely happened.

Are you still telling me the Canadian approach is completely the wrong solution? I'm sorry, but I just can't take Americans with a straight face on that point.

It seems that the single-payer folks should be some of the strongest advocates for a public health insurance option, so it's really imperative for liberals to bring them on and strengthen their cause. If anything, it will only counterbalance the Republican's plans and make Obama's plan seem like the moderate compromise.

Rob, I love that just us regular americans get that, but the supposed brain trust that should be running the show can't wrap their heads around this. If we were getting shafted by McCain, we'd expect it, but getting shafted by Obama is disgusting. Somehow trying to be bipartisan means cutting the left out? WTF?

Thank you for the link Ezra.

Of course I have to quible (lol) that single payer would also promote more/better/cheaper preventive care, chronic disease care managment, health IT including EHR, and other innovation on delivery side. It is publicly financed, but privately delivered.

As for the modeling, it is important to note that pure single payer such as Conyers' bill would have a strike against it in total cost compared to the Stark bill, since Stark does not spend money to buy out the for-profit insurnace companies, while Conyers' does over 10 years or so (implements coverage right away, but buy out is over time).

SteveB - Do you know, what was said by Dr Oliver Fein of PNHP at today's summit? The C-SPAN coverage breakout session only covered the room that Rep Conyers was in and he did not say a single thing that I heard. Lots of other attendees made multiple comments (such as the nat'l BCBS Prez).

During the closing remarks I did call the White House and waited on hold for the WH call line for ages to lodge my dismay that Pres. Obama said he was open to omitting the public insurance option from national healthcare reform.

Wouldn't it be quicker just to say:

"let them eat cake"

Than:

"But it's important that single payer advocates at least feel their points were heard, and considered, and possibly even integrated."

flexibility?

with hr 676 all medically necessary expenses would be covered and you'd be allowed to buy private insurance, if you wanted it, to cover non-medically necessary stuff. and under hr 676 you could go to any doctor, hospital, clinic, lab, etc you want. try to get THAT with private insurance.

innovation?

i've got 3 friends who, over the years have had enough money that they could pay for their cancer treatments entirely out of pocket and have elected to travel to france for innovative treatment they couldn't get here. and the last time i was at the mayo clinic, the doctors recommended some minor elective surgery, but only if i were willing/able to go to germany for it, since the procedure done here in the u.s. is by comparison rather barbaric.

But it's important that single payer advocates at least feel their points were heard, and considered, and possibly even integrated.

um, no.

i want fantastic medical care [hell, i'd settle for decent care], and i want it without having to spend 40% of my healthcare $$$$$ propping up the lavish lifestyles of fatcat hospital chain and insurance company executives.