The horizon is not so far as we can see, but as far as we can imagine

A Quick Note About Single Payer

I’m seeing some Dem wonks–establishment ones–who think that the Democrats will wind up embracing single payer, possibly in the next election.

I want to state something simple about this: Do not try to be clever about this.

Offer Medicare for all, with a bill that is no longer than 20 pages. Do not try to “fix” things, because this generation of approved wonks is incapable of doing that, or of writing a bill that is shorter than War and Peace.

That’s unnecessary. The great bills under FDR were all short, the bill creating Canada’s single payer system was short, etc.

Writing too many finicky implementation details into bills is lunacy. You write principles and outcomes and let bureaucrats, regulators, and appointees figure out how to deliver.

And, in the case of Medicare, it basically works, and it works better than anything the current generation could possibly come up with. This is incontestable in practice, because the bills they have written over the last 30 years are all awful messes.

Medicare for all. Just extend who gets it.

That’s all.

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  1. My God, that would bankrupt the insurance companies!!!! It’s not like they make enough profit from car insurance, home insurance, insuring businesses, or the like, you know ….

    Furthermore: You’re asking modern-day bureaucrats to consider writing laws and regulations with a sense of logic, reason and scruples?
    How out-of-touch can one be?
    Corruption, duplicity, and double-standards are the rule of the day ….

  2. Hugh

    Democrats would only embrace single payer if they were certain they wouldn’t have the votes to enact it. In 2018, the House might, might be in play, but the Senate won’t be and Trump will still be President.

    Wasn’t it Nancy Pelosi who said she had always been in favor of single payer? Does anyone believe her? I can see Democrats using single payer in much the same way they used the amazing disappearing public option, as a way to rope in the rubes, and their votes, without ever intending to deliver anything.

  3. The Stephen Miller Band

    I agree, Ian, but it ain’t gonna happen for all the obvious reasons.

    Health Insurance, or access to healthcare at all, is more and more being used like anti-vagrancy laws (Jim Crow Laws) were used to keep Blacks slaves in the South long after Emancipation. In future, if you want access to even sub-standard but not terrible healthcare, you will have to find it through an employer. Many employees will be slaves to their employers, because if they have a preexisting condition, and many people do despite what conservative lawmakers say to the contrary, you will not be able to get insurance if you leave your current employer and thus will not have access to affordable healthcare and thus you will effectively have no healthcare at all.

    Krugman has a great article about it. I watched a documentary on Netflix last night entitled Blood On The Mountain. It’s excellent. A movie you should watch that complements it well is Matewan. America is ever-so-surely becoming the Company Town and the people Serfs. I truly believe this is Trump’s idea of Shangri-La — he and foriegn potentates enjoying the greatest chocolate cake they’ve ever eaten on gold furniture solemnly & hypnotically rubbing their grubby paws on glowing orbs as The Little People cheer him on with an emphatic cacophony of melodic Black Lung Death Rattles that rivals the Mormon Tabernacle Choir on its best day.

    The Unfreeing of American Workers

  4. Hugh

    I would note that Conyers’ HR 676 short title “The Expanded & Improved Medicare For All Act” is 13 1/2 pages as a Word document (and that’s with all the standard legislative language folderol). You can cut it to 7 if you clear the formatting and use a font like Arial 9. The PDF version is 30 pages.

  5. nihil obstet

    The encyclopedic massive bills detailing implementation rules are, I think, not from bureaucrats nor even from politicians nor even from wonks. They’re from corporate lobbyists. Most bureaucrats prefer laws that can actually be implemented; abandon simplicity and implementation slips away into the thickets of complexity. Politicians do want to be able to claim that this or that undeserving group will not be allowed to leach off the program that he set up, so he’ll add some pet rule like checking beneficiary citizenship that requires a whole set implementation rules. Despite their reputation for detail-oriented smarts, most wonks are pretty mediocre. They tend heavily towards cut-and-paste because they consider themselves too valuable to work through the details of what they’re proposing. The result is a mess of contradictions. On which they rest quite happily because they think focusing on the overall goal is something ignorant people do. So from politicians and wonks you get moderate screwing up.

    But the lobbyists! They’re there to subvert any efforts at the public good into corporate looting opportunities. For that you need very specific tax loopholes and specific financial incentives, and blocks to most cost-saving procedures and rules insuring that only certain licensed providers can be remunerated and that the remuneration must be high and protected for future years, and . . . .
    So they dance into the legislative rooms with hefty campaign contributions, which, remember, are not bribes, and pages of text already written up to their corporations’ financial advantage. The campaign contributions convince the politicians of the corporate concern for the common good and a 2000 page bill is passed.

  6. Willy

    Taiwan has been mentioned here, where some of NHI (which includes everybody) was modeled after Medicare.

    And if single is what the majority wants, fuck the lobbyists. They have to be negated.

  7. StewartM

    I fear Hugh is right. The Dems will be all for it when they are powerless, but find a zillion reasons not to do what they promise if they actually get power.

    Jon Walker notes that Trumpcare got through the House despite facing the opposition of virtually all the medical-industrial complex:

    Republicans were able to get some lobbying cover for voting against the health care industry because the AHCA is also a big windfall for top executives in every other industry. The same dynamic would exist for Medicare-for-all: American business leaders are starting to acknowledge our dramatically overpriced health care is crippling every other sector. As Warren Buffett recently told investors, “medical costs are the tapeworm of American economic competitiveness.”

    However, I am less optimistic. That is because American CEOs are far less interested in the long-term prosperity of the corporations they are supposedly working to protect than in protecting their own pockets. Even though it’s quite true that Medicare-for-All would provide huge competitive benefits to their companies, removing a trillion dollars from the cost of providing health care coverage to their employees, if it costs the CEOs more money in taxes personally, then they’ll be against it.

  8. wendy davis

    dunno how to tell how many pages it is by clicking into the link, but ‘Expanded & Improved Medicare For All Act, H.R. 676’; pretty long list of co-sponsors.

    and the bernistas swear the bern’s gonna offer a companion senate bill…any day (read: year) now. meanwhile, he’s just gotta defend obamaDontcare, see?

    hard to see it’ll go anywhere, but somebody keeps tellin’ me that miracles do happen. maybe if we all clap hard enuff? ‘look! tinkerbell’s light’s flickering! clap harder!’

  9. The stayed corporate Democrats do not want single payer health care. They are just slightly less assholey than the Republicans. This is not going to change.

  10. Chaz

    I wonder that if you leave to much to the bureaucrats, appointee figure and regulators to sort out, you will be left with a lot of the usual deadlock. Plus and the administration that doesn’t like the system will purposefully chip away and loosen and undermine it so it teeters on the breaking point giving them reason to say “look see it doesn’t work… we must privatize again”

  11. different clue

    Complexity is used to hide all kinds of legal fraud and opportunities for illegal fraud if gettable-away-with. That is the Clintonite Scum Shitocrat Party will ignore your advice.

    The only “single payer” bill the Clintonite Scum Shitocrat Party would ever support would be at least a thousand pages long.

  12. There is enough chance for greed – it just resides elsewhere. Simplicity is key – too much to do.

  13. bruce wilder

    A lot of centrist Dem politics revolves around “it’s complicated” and subjective and supremely ignorant assessments what’s “normal” (Hillary is normal and Trump is not normal, or so i have been told) and narcissistic conceptions of politics as “the art of the possible, the attainable” — these are the corollaries of prospective possibility that surround and support and precede the main event: “there is no alternative”.

    Altogether, the Dem brand of neoliberalism is one big con game conducted by reactionary conservatives trying to get good and decent people to give them political support for nothing in return. It is a politics of convenient narratives that economizes on knowledge, judgement, memory and reasonable foresight to the point where people might as well be voting at random.

    Single-payer is one of those no-brainer truisms of the left, like “don’t get bogged down in a land war in Asia” and prosecute fraudsters and banksters, which can be discarded as soon as the election is over, because no one was paying attention before and no one will pay attention afterward.

  14. John

    A sane approach would be Ian’s suggestion of Medicare for all. To take care of the insurance companies, require liability insurance on every gun, rifle, weapon in the country and let Mr. Insurance Free Market Freedom Fries determine who is a safe gun owner and who is not. Just like with cars.
    But we do not live in a sane country.

  15. marym

    Medicare is highly privatized (Medicare Advantage, Medicare supplements, the prescription drug program, and the transfer of dual-eligibles out of Medicare into privatized Medicaid managed care). It’s important to distinguish between expanding access to today’s Medicare-as-we-know it, and HR 676 – Expanded and Improved Medicare for All.

    Convenient summaries of HR 676 here(2 pages) and here (1 paragraph).

  16. Benedict@Large

    Very important point. In the early days for the writing of ObamaCare, I made the suggestion that Obama should look at Congress and say, “Give me a bill that eliminates medical bankruptcy, and I will sign it.” Instead he’s stuck with 800 pages of stew that’s under attack, and no one can think of a simple rallying slogan that can bring the people together behind it.

  17. Mallam

    Medicare has deductibles, it has co-payments, it has premiums, and there isn’t an out of pocket maximum. These many problems of course don’t deal with the sudden disruption moving millions of people over to Medicare would have for the economy etc. This is pretty bad advice, and would never pass legislative muster.

  18. Ian Welsh

    You think that Democratic wonks, trying to improve Medicare, would make it more public and less private?

  19. StewartM

    @Ian Welsh

    I doubt the “Vox Democrats” would (the Clintons/Obama/Booker/DWS etc). Belief the supposed superiority of the private sector is a tenet of faith for them too almost as much as it is for the Republicans (look at Clinton’s attacks on Medicare-for-All during the primaries).


    Yes, having *no* out-of-pocket expenses and recognizing that one’s eyes and mouth/teeth are part of one’s body too is extremely important. Though I’ve always said I’d favor expanding the VA too into a NHS-like system and having the NHS set the Medicare-for-all reimbursement rates for anyone choosing a private provider. No harm having a bit of public redundancy in the system to safeguard it.


    I’m not sure what you’re saying, are you suggesting Medicare-for-All would be difficult to set up? The setup of the original Medicare system took months; ACA implementation by contrast took years. And yes, you’d throw many out of work people doing economically unproductive work, but the very people who favor Medicare-for-All also favor free college (for retraining) and also favor a truly full-employment economy. To fix the US economy we have to massively downsize a whole host of sectors which are either unnecessary or bloated, jobs that are either economically unnecessary or even harmful.

  20. marym

    @Ian Welsh

    I always thought the Democrats planned to make Medicare more like Obamacare than the opposite.

    In 2011 and 2012 Obama admin floated the idea of raising the Medicare eligibility age. There was grumbling in the ranks and Durbin went to the press in 2012 to say it was now off the table. He said he wanted to wait till the ACA exchanges were up and running so people would be able to get affordable private insurance till Medicare kicked in.

    So I thought that would be the migration path, continually raising the eligibility age, and migrating Medicare Advantage and the prescription drug program to the exchanges, and maybe some further convoluted subsidy regime for policies for older people. Just my guess.

    That’s why proponents of single payer need to be clear on the need for a publicly financed, publicly administered, universal, not-for-profit system.


    HR 676 has provisions for salary continuation, training, and priority placement for insurance company workers. It also has a provision to leave the VA and Indian Health Service independent for 10 years, and then a review of integrating them with the national health plan envisioned in the bill.

  21. S Brennan


    While I agree with the strategic goal, I think the tactic should be to expand medicare downward in steps. I used to say to 50 yo, but insurance now treats a 45 yo as they used to a 50 yo, so in response, I’d say push medicare downward to 45.

    This covers the group most effected by illegal, but commonly practiced, age based lay-offs which converts savings into insurance premiums. It also protects those who pay $800-900 per month premiums for insurance…that will still leave you bankrupt should you have cancer. Thirdly, bankruptcy becomes more non-recoverable as you age, you lose more, have less time to recover and are often not-hirable in their profession after 40, STEM workers are particularly effected by H1-B substitution, which ensures only youthful employees.

    Full disclosure; none of the above would improve my life one iota, but it would help X’ers and those that follow.

  22. karenjj2

    This has a chart of where the medical insurance dollars are expended as well as an interview with a doctor trying a different approach under the current usurious system

    Medicare for all is an extremely practical answer to genuine health care and the bill to so has been entered over the past 15+ years at every session of the Congress of the corps, by the corps and for the corps.

  23. karenjj2

    PS: Only thing overlooked in discussion above is the recent discovery that Obombacare was looting Fannie Mae and Freddie Mac funds to pay insurance corps subsidies

  24. Steeleweed

    Agree. Current private systems are about medical insurance, not about healthcare.
    Medicare is accepted pretty much everywhere, mostly via assignment so patient don’t need to pay out-of-pocket and wait for reimbursement. It has all the machinery in place and would only require scaling up of personnel & computer systems. It would naturally require funding, but that would be less than paying for the profit-making insurance companies who contribute nothing to healthcare.

  25. realitychecker


    They may be able to get away with deeming driving a “privilege,”, but gun rights are in the Constitution.

    Nice try, though. Ought to appeal to the simple-minded.

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