Lawrence I. Bonchek MD, FACC, FACS Editor in Chief, Journal of Lancaster General Hospital (JLGH)
Fixing U.S. Healthcare blog has been looking at the best counter-arguments against single-payer healthcare financing. A new editorial published by our local health system in its Journal of Lancaster General Hospital has put forth several more counter-arguments for us to consider.
We have claimed that all of these counter-arguments, both old and new, are well intended. Some are well taken. Some require hard choices. But some are based on faulty logic.
The new counter-arguments by Editor in Chief Lawrence Bonchek MD are:
- Single-payer has no realistic political chance of enactment in the foreseeable future.
- Government involvement in financing will increase Americans’ healthcare security but require them to relinquish something in return – trade-offs.
- Maybe the “healthcare cost crisis” is being over-hyped.
- Taking hospitals out of the free-market capital-driven economy will result in deterioration of existing equipment and will stifle innovation and re-investment.
- The looming threat of climate change may overwhelm and disrupt any orderly healthcare reform in “ways we cannot imagine.”
This recent editorial also restates counter-arguments previously discussed in Part 1 and Part 2. This post acknowledges them and refers the reader to our previous posts for discussion:
- There could be “massive unemployment” for health insurance industry employees.
- The fiscal impact of massively restructured single-payer finance system is unpredictable.
- There would undoubtedly be other unforeseeable negative consequences – “unknown unknowns.”
- Smaller hospitals and rural hospitals could fold.
- Planning and pronouncements “should be viewed with extreme skepticism.”
Political Reality Check
Dr. Lawrence Bonchek astutely identifies strong forces arrayed against enacting single-payer healthcare reform. First are the ideological opponents, which this blog has discussed at post and post. Second are the powerful vested interests with well funded lobbyists, also discussed previously.
As an aside, Dr. Bonchek debunks the claims of these opponents that the “free market will give more choice and bring down costs.” This blog agrees, with additional comments below under Capital Drain. Instead, he tilts toward an expanded public option under the Affordable Care Act (Obamacare) to introduce “real competition.”
This blog has agreed that any healthcare reform must proceed gradually, with great circumspection and even greater mid-course monitoring. But this blog has argued that Medicare has a good track record of rolling out complex programs. This blog disagrees with Dr. Bonchek’s conclusion that America should not try at all; instead, this blog concludes that we should just try harder, calling upon our spirit of can-do optimism.
Dr. Bonchek should also not be discounting recent polling that is increasingly shows that healthcare costs are now a top kitchen-table worry for Americans. It is true that Sen. Bernie Sanders is too far out ahead of Americans in forcing Medicare-for-All-now. Sen. Elizabeth Warren has pulled back to Medicare-for-All-soon. And more moderate candidates are selling Medicare-for-as-Many-as-We-Can, as soon as we realistically can. That sounds about right.
Trade-Offs with Single Payer
Dr. Bonchek cites the immutable law that security and freedom are zero-sum – the more you get of one, the less you have of the other. In particular, he repeats single-payer opponents’ tropes about less ability to choose your physician, longer waits, and (gasp) rationing. Dr. Bonchek is correct that trade-offs will be necessary. And he is also correct that “only the public knows what it values most.” However, he should bear in mind that insurance companies and HMOs impose more restrictions on physician choice than government-financed Medicare. He should then look at my post about distortions of wait time statistics. And he should reflect on the fact that the U.S. healthcare system currently “rations” (deprives) healthcare for 28 million uninsured and another 63 million underinsured Americans. He is undoubtedly aware that three quasi-experimental population studies since the early 2000’s showed a 6% reduction in mortality over 5 years after expanding Medicaid coverage. Thus, he well knows that having health insurance saves lives, and that being uninsured harms life expectancy and quality of life, not to mention risks bankruptcy. Dr. Bonchek has previously written that depriving uninsured Americans of life and health is not a defensible trade-off.
Over-Hyped “Healthcare Cost Crisis”
Fixing U.S. Healthcare blog has previously claimed that excessive healthcare spending will put a drag on economic growth and will eventually sap America’s national strength. This blog now agrees that these fears are indeed over-hyped. Instead, this blog is now claiming two things: Healthcare costs are hitting the average American hard in the wallet. See, for example, this blog’s review of current polls on the subject. In addition, healthcare spending imposes an “opportunity cost,” diverting spending from other important national priorities like infrastructure, education and the environment. Surely Dr. Bonchek will agree that, putting over-hyping aside, controlling healthcare costs and extending access to all Americans is not hype, but rather a reasonable national priority.
Capital Drain
“Capitalism rules the world,” writes London School economist Branko Milanovic in the current issue of Foreign Affairs. “Societies around the world have embraced the competitive and acquisitive spirit hardwired into capitalism, without which incomes decline, poverty increases, and technological progress slows.” There is no longer any tenable argument for “socialism” or communist central planning. However, as discussed in my post, invoking “socialism” to oppose healthcare reform is a thinly veiled political ploy that inflames the discussion and distracts from serious reform efforts. The real 21st century rivalry is between two capitalisms, the “political” (Chinese style) and “liberal” (Western style). Smart policy, in either form, will avoid disturbing the capitalism that invests in plants, equipment, and technology in the healthcare sector, and reaps a profit from efficiency, customer service, and outcomes. But reform is needed to root out “rigged” forces that only serves greedy interests, not health. Such reform will require the full faith and clout of the U.S. government to overcome entrenched, powerful interests defending the status quo. Only the transparency and rule of law, operating within the Constitutional framework of government, can ensure accountability, which is currently lacking from non-profit and for-profit board rooms. For more discussion see “Nobel Economist: What It Will Take to Fix U.S. Healthcare.”
Climate Change
This is perhaps the real crisis, which has been under-hyped because it moves so slowly as the elude our notice up to now. Dr. Bonchek’s comment puts us in mind of obvious direct threats to health, such as the smoke pollution from Australian bush fires. And brings to mind not so obvious threats like the spreading habitats for disease carrying mosquitoes. Others remind us that climate change will affect the most vulnerable populations first and most strikingly, and in many cases will manifest itself in the form of health problems. To my thinking, this is a reason not to duck healthcare reform, but rather to embrace reform as a crucial part of preparedness for the looming climate crisis!
Take Action
All in all, another good reason to take action!
Image Credit
Title: Lawrence I. Bonchek, MD, FACC, FACS, Editor in Chief, Journal of Lancaster General Hospital
Copyright: Journal of Lancaster General Hospital 2019. Used with permission.
Fixing U.S. Healthcare 
Another objection to single-payer healthcare is the problem of “free riders” — visit: https://fixushealthcare.blog/2019/02/19/healthcare-reform-what-about-free-riders
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