This week there were two very different groups that evaluated two different single payer proposals.
The Mercatus Center, a liberterian group, evaluated Senator Sanders (I-VT) Medicare for all proposal.
The Rand Corporation evaluated the New York Health Act.
Both proposals made some strong assumptions on provider pricing and implementation challenges but I think both groups made reasonable estimates of a good case scenario for advocates. And both groups came in with roughly the same type of conclusions:
- Total health expenditures would go down slightly (~2%) at the end of the implementation period
- Government health expenditures would go up a lot
- Everyone would get covered
- Significant distribution of costs and benefits are not uniform in the population.
This last point is key. Single payer produces winners and losers.
The tweet above is the distribution of average winners and losers of moving to single payer in New York. This only looks at changes in taxes, premiums and cost sharing. On average, people who are in the bottom 90% of the income distribution are better off with single payer. People in the top 10% of the distribution are worse off. I think this graph understates the change as doctors are a disproprortionately likely to be members of the top 10% so they’ll get hit coming and going.
People who have something to lose will scream a whole lot more than people who are promised future yet to be delivered benefits/improvements.
Mechanically designing a single payer system is fairly straightforward in the American context. Levers can be twisted, knobs turned, incentives tweaked, budgets adjusted. Different people with different values will move those interacting variables in different manners, but a clear logic model to implement a version of single payer can emerge.
The challenge with single payer systems in the United States is the political problem. It is the problem of managing both change-aversion and juggling the trade-offs that produce happy but not motivated winners and extremely loud and angry losers who were well positioned in the status quo and are losing their advantages.
That is the challenge, not the mechanics per se.