Responding to this morning's post on single payer, Kevin MD writes, "I'm not going to debate the pros and cons of single-payer, but for a variety of reasons, implementing a single-payer system in the United States is impossible. That's an indisputable reality." Wait, I dispute that reality! Politically, passing a single payer system and outlawing private insurance is incredibly unlikely. But there's nothing about America that makes implementation of a single payer system impossible. If we had the political will, we could figure out the policy. But we don't have the political will. Which leaves single payer supporters walking a difficult tightrope. On the one hand, there will never be the political will for single payer without effective and determined advocacy. So single payer supporters need to engage in that advocacy, and point out problems in competing proposals. On the other hand, barring a seismic political shift, single payer isn't passing the US Senate any time soon, and so dogmatically insisting that the only way forward is single payer is basically dogmatically insisting that there won't be health reform because you'll oppose achievable compromises. At times, this attitude has killed health care reform, as when Democrats refused Nixon's proposal in the 70s -- a proposal far more radical than anything being offered today. So it's tricky. The policy is possible, and simply requires political will. The will is absent and requires advocacy. But the advocacy, if conducted too dogmatically, can stand in the way of reforms that would help the 47 million uninsured and get us a step closer to single payer. I struggle with this a lot. 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. On the other hand, I have health insurance, and I try to be mindful that though I have the luxury of seeing this as an interesting policy problem, the human costs are enormous and reform is needed yesterday. So I try to make arguments for broader reform while simultaneously supporting the sort of initiatives and proposals that could pass in 2009. But it's an uneasy balance, and I see how other folks could arrive at a different equilibrium.
