Photo of the day

Okay, this is a pretty amazing hurricane photo in Atlantic photos of the week:

The eye of Hurricane Jose, imaged by the European Space Agency’s Sentinel-2A satellite, on September 9, 2017. 

CC BY ESA / Processed by Antti Lipponen

Single payer cognitive dissonance

So, Ezra Klein says Bernie pushing for single payer is actually a good thing, despite it being largely fantasy:

Jonathan Chait, at New York magazine, says Bernie Sanders’s Medicare-for-all bill “gets America zero percent closer to single payer.”

Chait’s argument, which I largely agree with, is that “single payer has always been, and remains, a political dilemma that nobody has been able to resolve, and there is no evidence the resolution has grown any easier.” But his conclusion — that Sanders “has accomplished approximately zero percent of the necessary work” — misses what I think Sanders is trying to do, and what a reasonable definition of success looks like.

Sanders’s bill stands very little chance of ever being enacted, or of getting America to single-payer. As I’ll explain, it solves precisely none of the problems that have foiled every other single-payer plan in American history. But it stands an excellent chance of getting the country quite a lot closer to single-payer.

What Sanders has achieved here is remarkable. A policy that used to be tentatively embraced by elected officials on the party’s left is now being enthusiastically embraced by key leaders from its mainstream, including the party’s most promising 2020 contenders. Even Joe Manchin, the Senate’s most conservative Democrat, is proclaiming himself open to the idea. Sanders has thrown a rock through the Overton window.

At the same time, it’s important to recognize what Sanders hasn’t achieved, and in fact hasn’t even tried to achieve: He has not solved or even admitted any of the very real challenges to implementing single-payer health care in the United States.

Sanders’s bill has 16 co-sponsors, including most of the Senate Democrats most often mentioned as possible 2020 presidential contenders. In one fell swoop, he has taken single-payer from an ideal on the margins of the Democratic Party to a goal endorsed by its likeliest standard-bearers.

The Democratic Party could’ve oriented itself around a number of health care goals in the coming years. It could’ve simply sought to improve Obamacare. It could’ve focused on cutting costs, or lowering premiums, or getting closer to universal coverage. But Sanders, I think, has preempted all that: He’s made the goal single-payer.

Most of Ezra’s post, though, is about how the goal of single-payer is virtually infeasible policy-wise and politics-wise.  Hmmm.  I love the goal of universal coverage.  To insist on the means of single-payer in the United States that has  a unique history and politics working against single payer, strikes me as unwise.  If the single-payer goal actually gets us closer to a good system of universal coverage, then, hey, I’m for it.  I’m just not sure that it does.  I worry that it sets up entirely unrealistic expectations.


The barrier to single payer is that the American health-care system has been built, by accident, around employer-based insurance. The rhetoric of single payer concentrates its moral emphasis on people who lack insurance at all. (“Do we, as a nation, join the rest of the industrialized world and guarantee comprehensive health care to every person as a human right?” writesSanders today.) But the barrier to single-payer health care is the people who already have coverage. Designing a single-payer system means not only covering the uninsured, but financing the cost of moving the 155 million Americans who have employer-based insurance onto Medicare…

That is not a detail to be worked out. It is the entire problem. The impossibility of this barrier is why Lyndon Johnson gave up on trying to pass a universal health-care bill and instead confined his legislation to the elderly (who mostly did not get insurance through employers), and why Barack Obama left the employer-based system intact and created alternate coverage for non-elderly people outside it…

There is nothing in Sanders’s rhetoric that indicates he even recognizes the shape of the political problem. Instead he employs the classic populist technique of imagining the people as a whole standing united around an obvious solution, and only the machinations of an invidious elite can thwart them…

Evil corporations are the only impediment he acknowledges. At no point does he grant that the most important source of opposition will come from actual American voters concerned about losing their current plan or paying higher taxes…

Obama himself said many times that, if he were starting a health-care system from scratch, he would prefer a single-payer system. Sanders’s single-payer bill is vague enough that the Democrats co-sponsoring it are really doing nothing more than saying the same thing Obama did: A single-payer plan would be nice, in a world that looks nothing like the one we inhabit. [emphases mine]

And Chait’s response to Ezra:

Among center-left health-care analysts, there is very little disagreement that Bernie Sanders says a lot of things on the subject that are misleading or wrong, and that his bill stands little chance of enactment even if Democrats win full control of government. His defenders instead make a different argument: By taking extreme positions, they say, Sanders creates more political room for rational reforms to take hold…

There is a virtual consensus among progressives that the United States would be much better off if it had implemented single-payer insurance, or some other national health-care plan used by industrialized democracies, many decades ago. Instead, the American health-care system grew up around the malformed incentives created by employer-sponsored insurance and fee-for-service medicine. The astronomical cost of medical care, the deep fear of change among the insured, and the entrenched interests of providers have all made the system nearly impervious to systemic reform.

Sanders has not cracked this problem. Nobody really claims he has, or even claims that he has grappled with it. His alleged contribution is to refuse to acknowledge the problem at all. He assumes implausibly large savings, and dismisses fiscal estimates of the cost of his plan as rigged by crooked drug companies. He tells a different, much simpler story than other Democratic politicians. In his words, the only important question is a conviction about the morality of universal insurance, and only obstacle to progress is the profits of the insurance and drug industry. (He omits doctors and hospitals, not to mention change-averse voters themselves.)…

The theory also dismisses the possibility that the candidates who endorse the Sanders plan open themselves up to the attack that they favor a large middle-class tax hike. The Sanders plan attempts to deflect this vulnerability by leavings its financing mechanism open-ended as a list of suggested revenue-raisers. It will work if candidates can get away with attaching themselves to the promised benefits of his plan without committing themselves to the pay-fors it requires. Republican politicians often get away with this kind of legerdemain — but only because they benefit from a partisan right-wing media ecosystem. Democrats need to run the gauntlet of an independent news media that is unlikely to let them run around promising trillions of dollars in new spending without trillions of dollars in new taxes.

Meanwhile, Catherine Rampell is having none of it:

Thanks to the Grand Old Party’s demagoguery, Democrats have for a little while enjoyed a virtual monopoly on facts, evidence and experts. Dems — or some of them, anyway — embraced serious, solutions-based, often technical policymaking and the hard choices that went along with it.

But the lesson the Democrats seem to have taken from the 2016 electoral trouncing is that they need to become more like Republicans. Meaning: Abandon thoughtful, detail-oriented bean-counting and attempts to come up with workable solutions grounded in (occasionally unpopular) reality, and instead chant virtue-signaling catchphrases.

Such as “single-payer.”…

But we’re not starting from scratch. We live in our patchwork world, which means if we want single-payer — an ill-defined catchall, by the way — we need to figure out how to get from here to there. This involves painful political choices, sharp tax hikes and some degree of buy-in from the many stakeholders who are going to get shafted in the transition.

The goal should be universal health care, however we get there. And we’re much likelier to get there if we start from a baseline of reality than if both parties hand-wave away inconvenient truths. There is no courage in saying everyone should have health care. The courage is in staking out a plan to pay for it.

Okay, maybe not so much dissonance.  I think this marks one of the times I just disagree with Ezra Klein.  I’m more persuaded by both Rampell and Chait.

And, to reiterate the key point– Democrats absolutely need to be for genuine universal coverage that reduces overall system costs.  If advocating for single payer gets us to that goal, well, alright, then.  But single payer is a pipe dream given where we are.  Yet, there are other approaches, e.g., gradual Medicaid buy-in, that are far more feasible as policy and politics that reach the same end.  Seems to me, that should be where we put our focus and not lose sight that the goal is the key, not the means.


Okay, you know what, I thought about this more after queuing it up to post and I’m even more frustrated by this.  It would be one thing if Sanders actually understood the realities and complexities of health care policy (the way in which he so readily elides the many complexities suggests he either doesn’t know or doesn’t care) and saw advocating for single payer as the most effective way to improve our health care system.  But, instead, it seems that Sanders really doesn’t understand or care about these complexities and has a doctrinaire commitment to single payer that ignores so much reality.  That’s frustrating and I don’t like seeing the Democratic party follow him down that path.

One chart (on teaching) to rule them all

This whole article in Quartz on what America does wrong on teaching is excellent.  Pretty sure this will make it into the Public Policy syllabus.  Now, of course, there’s so much more to school performance around the world than relative teacher pay, but this depressing chart really tells us a lot:

What this chart tells us in stark terms is that the United States simply doesn’t value teachers.  So many of our other problems flow from that.  If we valued teachers we’d invest more in them and get more of America’s best and brightest in in the profession and take more seriously what it takes for them to succeed.  Do all that, and America’s schools get noticeably better.  These two paragraphs capture a lot:

Money and prestige matter. The highest performing education systems always prioritize the quality of teachers says Andreas Schliecher, head of the education directorate at the OECD. “Wherever they have to make a choice between a smaller class and a better teacher, they go for the latter. Rather than putting money into small classes, they invest in competitive teacher salaries, ongoing professional development and a balance in working time.”

US teachers spend 38% more time in front of the classroom than their international peers: 981 hours compared to an OECD average of 712 per year. This is time that they are not collaborating with peers, honing their knowledge of their subject or the practice of teaching.

It’s somewhat of a chicken and egg problem in that we don’t pay teachers enough because we don’t value them enough.  And one reason we don’t value teaching is that we (accurately) see it as a low-paying profession.  I’d love it for some forward-thinking school system to find a way to blow this up and just start paying teachers a ton more and let all the benefits flow from that.

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