I have said it before and I will say it again.
I much prefer reading you coz you are too hot to look at and I don't listen a word you say when you talk.

Insurers most certainly are the enemy. We realize that demanding unconditional surrender from them is not realistic, however, and are content to pursue a strategy that allows them to negotiate peace terms that are favorable to us.

However, the cult-like devotion to "single payer" in lefty circles, as though it were some magic talisman that will solve everything, is really starting to annoy me.

In my experience, "progressives" are very, very good at getting angry about things. Taking action or takings reasonable steps toward rectifying problems is kind of an afterthought, as if getting angry was really all that mattered.

Also, that is a rambling, unfocused, generally atrociously loaded question.

"However, the cult-like devotion to "single payer" in lefty circles, as though it were some magic talisman that will solve everything, is really starting to annoy me."

Well, there was a pretty good plan adopted by two Democratic Presidential candidates in the 2008 primaries to achieve universal healthcare and make the system run more efficiently without resorting to single-payer.

But folks like Ezra Klein decided to support the candidate opposed that reform because Klein wanted to stay on the good side of the donor class.

Is it then any wonder that lefties might wander towards the seeming purity of single-payer when the non-single-payer alternatives get sold out by supposed healthcare bloggers like the Klein who only care about their short-term career interests?

As much as people like to think you can duplicate the conditions of Great Britain 1948 or Saskatchewan 1962 here in America 2008 I wouldn't say the differing sets of conditions are remotely similar. Single payer is a beautiful loser.

I don't want or need to imagine what health care is like in the perfect system. I KNOW what it's like not to have health care in the existing system. Any incremental improvement to our system I applaud. Health care is "a journey of a thousand miles begins with a single step" problem not an "Abracadabra!" problem.

Note - TAP should give you a 3 month sabbatical to bang out 'The Health of Nations' in book form and get you on the book circuit in December 2008 and into the 2009. If you want to shape policy, people need to know what their options are and I've never seen the options laid out better than in your THoN series.

I liked your arguments Ezra, but didn't watch long enough to hear the counters, so maybe they address this...

But I can't really fathom how it seems acceptable to leave 47 million(or whatever) uninsured while we go about remaking the United States in DailyKos's image. It's just strange that people think if we get something imperfect passed that gets those people something like Medicare, that means they can't still fight for single payer to happen in the future. Why do they have to give up their support for single payer to support passing something else? I don't get it.

A few comments:

Insurers are surely not the enemy, or at least not the important one. They represent $100-150B in overhead on a $2 trillion dollar system. We can get rid of them tomorrow, and the issues with cost and quality of health care would still exist in the same form. (Access is important, but as the Clinton proposal shows, insurance companies aren't really an impediment there either.)

Ezra's point is a good one, albeit more meta the enemy is American politics. He points to the Senate rules of 60 votes, I'd suggest that the money in politics is the larger culprit. 60 votes is a procedural hurdle, but politicians' positions being inappropriately influenced (put nicely) is a problem for all 100 votes in the Senate. Which is why Obama's past focus on process is directly relevant to health care reform.

And this actually directly relates to my continuing point on HCAN. By focusing on the "what can realistically get passed" in an environment where votes are inappropriately influenced by industry, you end up with "realistic" proposals for the Clinton/Obama camps that really aren't "fighting" insurers at all. Lobbyists have circumvented the fighting by restricting the rules of the game.

In other words, its dangerous being overly pragmatic in an environment where there is a good amount of corruption. So Ezra, while I wholeheartedly agree with your point generally and think its a relatively unique perspective, it requires a level of faith in today's politics to be content with restricting yourself to today's feasible legislation. If you don't believe in today's politics, its extremely logical to push for a system that can't be implemented today, and instead wait for the system to further move into crisis so that perhaps better reform could overcome those politics in the future.

There is one single goal for now: everyone must be protected forever against complete financial catastrophe from a health problem. "Single payer" Federal catastrophic insurance (that's "like Medicare") with a non-profit Federal optional insurance plan underneath the umbrella -- with subsidized purchase for low-income, mandatory purchase of Federal plan or competing private plans for children, will gather huge bipartisan support, public and corporate, and will neutralize insurance companies because they can still play a role if they compete effectively. Certainty of a payment process for healthcare providers will massively bring down costs, too.

"Getting" the insurance companies is an exercise in childishness.

Even though I am a single payer fan, I thought you did an extremely good job in a slightly uncomfortable setting. I think people were pretty impressed, even those who did not want to agree.

Wisewon: I agree generally, except for

"If you don't believe in today's politics, its extremely logical to push for a system that can't be implemented today, and instead wait for the system to further move into crisis so that perhaps better reform could overcome those politics in the future."

If you are opposed to the current system because it leads to illness and death, to wait until that system collapses (bringing even more illness and death as it collapses) is incredibly unethical. That would just be political opportunism by another name.

"policy dogmatists and political agnostics" is a great line, Ezra.

The essential difference, which I think Ezra gets at with "a position doesn't insure anybody," is this:

-a bill that does not pass leaves the uninsured uninsured.
-a bill that passes and has a public option gives the uninsured coverage.

I felt that a lot of people think, first and foremost, that you need to punish insurance companies when in reality what you ned to do is get people covered, and punishing insurance companies first and foremost doesn't do that.

The way things are trending for private insurers they may start to drop out of the market of their own accord.

Costs are up, employers are dropping plans, Medicare is cutting the premium it pays and the returns they can get on their investments are down.

Now would be a good time for a revival of non-profit health insurance plans/HMO's or some other innovative approach.

The Blue's did a good job for decades, a new version could be an approach. Unlike fighting congress, all it takes is some public-spirited people willing to set up the organization.

Just as property insurers have been dropping out of the market when their losses due to hurricanes and the like started to rise, the same thing can happen with health care. It just requires a bit of "encouragement".

It looked like there were the same number in the audience as on the panel

Nah, it's just an odd quirk of audiences that they sit in the back, not the front. This panel had a few hundred. The next panel I had that day had a dozen or so...

I thought what they did to you was a bit classless. You responded with humor and grace.

Good on ya.

I actually listened to the whole panel, and I was kinda disappointed in the focus. That audience didn't really need an hour or more of "wow does our current health care system suck" -- everyone there knew that already, and everyone there can find dozens or articles on the web detailing all the information the panelists repeated there. I was in meetings 10 years ago in California with essentially the same arguments about Single Payer and the status quo, and the strategic approach basically boiled down to, "We're right, and if we just tell enough Californians about this they'll agree with us and then we'll win."

The key question, as you brought up, Ezra, was, how do we win something? I think the question can be much, much broader than just nose-counting in the Senate. Someone could ask, "How do health care providers/unions/other organizations/ employers make decisions about what role to play in the reform effort?" Someone could look at past Single Payer campaigns in the US and review them critically. Someone else could review polling data in more detail about the public's views.

Your focus on the Senate would be very good as part of that larger picture. But the underlying question would need to start with an analysis of the conditions under which radical social policy change take place in the US, and an assessment of whether it's possible to create those conditions with respect to health care reform.

Ezra,
There are two questions here: is single payer the best option and is it the best option to pursue politically.

In your comments you suggest we should develop a France style system if possible but sometimes your writing leaves that unclear.

It seems clear that the left of center health care community is it self an obstacle to single payer. Part of making single payer possible is actually having advocates supporting it.

Less clear is how many votes in the Senate these compromises are actually getting. Maybe I missed the post but I've never seen you really get into brass tax about how many votes these various compromises we really get.

Just throwing Baucus's name out there doesn't really demonstrate how more centrist plans will actually get through.

P.S. I had really had wanted to get to this panel, but I couldn't make it.

In your comments you suggest we should develop a France style system if possible but sometimes your writing leaves that unclear.

This is a great point, albeit one that's been made previously. Your argument against single-payer is in some ways disingenuous-- you focus on the political feasibility of the proposal, but you've never really clearly laid out your own opinions on whether you'd support it if it was feasible. Here is your writing from just last week:

I'm not particularly sold on pure single payer, but my favored policies (think France) are a whole lot more radical than what currently seems feasible.

http://www.prospect.org/csnc/blogs/ezraklein_archive?month=07&year=2008&base_name=the_perfect_and_the_good#107568

You can argue that it doesn't matter if you do/don't support it, because its a hypothetical question. So is "Based on what we know now, what is right to vote for the Iraq War" Hillary kept saying yes, and it did matter. Principles matter. If you don't support single-payer as suggested above, then perhaps you should write out a post explaining why.

This is really about intellectual honesty. You know that I'm very against single-payer, think the political lens is a good one, etc.-- so its not that I'm making this point because I disagree with you more broadly. Its more that you're occasionally criticized on not supporting single payer and your responses back are less than forthcoming. You've never written a post on HR676, and for a liberal-minded health care blogger for several years, something doesn't sit right. If you want to resolve this, then take on the pros/cons of single-payer directly.

"How do health care providers/unions/other organizations/ employers make decisions about what role to play in the reform effort?"

They do this every day in the decisions they make. That is why when any of these organizations stand up and claim to want reform you only need look at their past decisions to see how disingenuous they are. Including politicians not a single one of the entities altruistically advocates reform for the sake of covering everyone, improving care, and making it affordable.

Health Care Providers don’t need reform to improve their error reporting, to develop best practices, or take action against fraud and abuse.

Unions oppose AHPs that would mimic Taft Hartley Plans, which have been unquestionably successful in providing affordable care to small groups by pooling them together, because they view them as competition. Union rules also contribute to some of the problems at the worst performing public facilities, i.e. Killer Drew.

Employers played soft for a decade promising benefits they couldn’t afford and now want someone else to bail them out and foot the bill.

Politicians are desperately seeking new money to spend. SS and Medicare trust funds are evaporating and they need their fix of funny money. If they don’t find new segments of the economy to nationalize their house of cards will be exposed and they might have to start making some grown up decisions. You can have a lot of fun with the roundings of a trillion dollar health care system.

Every single “advocate” is chasing personal benefit or salvation and masking it in phony compassion for the uninsured, under insured, and what other label will get them a pat on the back and some support.

There are 100s of things all of the advocates could have been doing for decades to improve the system but have chosen not to. Their goal has never been to fix the system it’s been to solve their problem or advance their power.

That crack about invading France and stealing their healthcare plan was lovely. In general, you showed grace under pressure -- good job. I do support single-payer but I thought your contribution was extremely useful.

I am not wedded to single payer. If private insurers have to be included in the mix, so be it. But what I am opposed to is forcing the public to pay for CRAPPY care from insurance companies. If insurance companies are going to be in the mix, then everyone should be entitled to the same care that a CEO or a member of Congress gets.

And the problem with the sorts of non-single payer plans that Ezra and Petey support is that they are about forcing us to buy crappy coverage from insurance companies, which will result in the declaration that we have "universal" coverage while poor and working people continue to receive terrible care that leads to bad outcomes. In fact, it will get worse, because employers will stop offering coverage to their lower wage workers once the mandate comes into place.

I've said many times that I prefer a system like France to full-on single payer, and even explained why. It's your job to use google, not mine to rewrite posts. But the bottom line is I don't have strong preferences between a lot of these bills. In a perfect world, I'd build something like France -- which I prefer to pure single payer systems for reasons of innovation, competition, and the ability to spend one's own money on health care. But if HR 676 were on the table, I'd be fine supporting that. If Wyden-Bennett is the best we can get, so be it. As I say in my presentation, I'm a political dogmatist and something of a policy agnostic. I'm more interested in getting something decent done than arguing between good options and perfect ones.

Ezra,

In a perfect world, I'd build something like France-- which I prefer to pure single payer systems for reasons of innovation, competition, and the ability to spend one's own money on health care.

Yeah, you've said this a couple of times, that is true. But as an earlier commenter also wrote-- you aren't as clear as you should be on this topic. Its just as easy to say what you said above, than say you're not "particularly sold" on single-payer, which doesn't really provide much clarity.

And while I haven't seen the video, if you never mentioned that you actually prefer the current Obama/Clinton proposals to single-payer, that's not fully truthful. Saying you're "policy agnostic" on a wide range of proposals that achieve UHC makes me wonder if you appreciate the consequences of these proposals. There are significant second-order effects that shouldn't make you so "agnostic." Wyden's plans has unanswered questions on the impact of total compensation for most Americans, single-payer has impact as you've suggested above, etc.

And as an aside, but an important one given that you've identified France as your preferred system: the hybrid system you've highlighted from France isn't really as you typically describe it. If you look at the benefits provided from the supplemental plans in France, they provide for co-pay reinsurance, dentistry and cosmetic medicine. There isn't a substantive medical benefit provided by those plans. I've made this point before and you've 1) never addressed it 2) keep plugging France as an ideal public-private hybrid.

I've said many times that I prefer a system like France to full-on single payer, and even explained why. It's your job to use google, not mine to rewrite posts.

Firstly that's just kinda hostile. A lot people say a lot things over the years it's not reasonable to expect people to have a perfect memory of your positions. For whatever it's worth I was aware of previous posts.

Also lots of people say they support a lot things and they don't always write in a manner consistent with those positions.

Further when the question was Barack Obama and required mandates you certainly came off as a policy dogmatist.

There's a real question how much progress can be made so long as insurance companies remain a central part of the system and also if half measures would undermine the possibility of real reform.

I'm sure we all appreciate your martyr complex, and your unstinting courage at surving an unpleasant morning.

We also appreciate the lecture that our focus should be on political organizing, umm, sorry to tell you this, a lot of healthcare activists have been doing that for a long time, one reason there are actually more sponsors today of HR 676, the single payer bill in Congress, than any other health reform proposal.

Obviously, we're not there yet. But that doesn't mean it will be any easier to enact a weak or substandard incremental reform than it is to win single payer, or Medicare for all, or the French system. Harry and Louise will campaign just as hard against the politically "viable" plan as they will against more effective reform.

And ultimately, that is the point. Enacting reform will not be easy, why not do it right?

Nobody thinks insurance companies are stupid or evil, though that is a handy straw man. But the insurance-based system is the primary reason for people being denied care even when it is recommended by their doctor, the primary factor driving skyrocketing costs and un-payable medical bills, and the primary cause of the ever growing number of uninsured and underinsured.

Any reform that fails to tackle the main source of the problem will simply not solve this crisis.

Charles Idelson, California Nurses Association

Very gracious of you and your answer was also spot on.

you focus on the political feasibility of the proposal, but you've never really clearly laid out your own opinions on whether you'd support it if it was feasible.

I don't know about Ezra, but I would certainly support ponies for everyone, if it was feasible.

But folks like Ezra Klein decided to support the candidate opposed that reform because Klein wanted to stay on the good side of the donor class.

Can't it be that Ezra just had a principled ideological objection to those particular policies? I'm entirely opposed to government subsidized healthcare--even what we've got is too much, and too unweildy. I don't have any donor class to worry about. I just don't think the government runs anything particularly well, and if they don't absolutely have to do it--space program, national defense, national parks--then they really shouldn't. Especially when it involves trying to micro-manage the marketplace, given the history of command economies is pretty abysmal.

Still, the main point is: can't most of us support or oppose something without there having to be some nefarious motivation on the part of the person who disagrees with you? Or is it not possible that someone has a legitimate disagreement with you?

A few insights about the panel, which I attended (and I asked the question toward the end, trying to reframe the conversation about what specific things we can do instead of spending time beating up Ezra - even though I think he deserves to take his lumps):

First, it was originally supposed to have John Conyers there to discuss HR 676 and what we can do to help it passed. He had to drop out at the last minute, and so we were left with a panel that wound up rehashing the case against insurers instead of figuring out how to move forward politically.

Second, it is instructive that in the comments here Ezra said HR 676 "isn't on the table" which is a flat out lie, and said on the panel that we who are angry at HCAN for excluding single-payer are making the perfect the enemy of the good. Ezra's comments preferring France to single-payer betrays, to me, a fundamental opposition to social democracy. I wonder if he would embrace single-payer even if we had a larger coalition and more money - his opposition seems intractable and not entirely based in the policy details.

Third, despite those errors, Ezra is undoubtedly right that single-payer advocates need to develop a more robust organizing strategy and better political tactics. The woman from CNA on the panel is an example - I love the CNA, no doubt about it, but she did not have a well developed sense of how to construct the necessary political movements.

Ezra was right in answering my question that we need to elect more single-payer supporters. And the "reverse Wofford" strategy is sensible. But surely Ezra understands the key to the 1991 Wofford campaign was its call for guaranteed health care - not for mandated insurance? HCAN has to spend $40 million on advocacy because it does not have a grassroots base. Only single payer can provide that here in the USA.

Finally, Ezra, if you feel you were sandbagged, it's only because you make it oh so easy to do so. You've been sandbagging single-payer for some time now.

Meant to add that HR 676 obviously has a big coalition behind it - over 100 cosponsors, momentum among the cities and mayors, and a significant number of grassroots organizations and members. To say it's not on the table is rather fundamentally dishonest. I'm sorry Ezra, it just is. Statements like that are why folks get so mad at you.

Also, I expressed my own criticisms to the panel organizer. I think that we needed a panel exclusively focused on achieving solutions instead of rehashing the case against insurers. It is a time for specific political tactics.