From the NY Times blog: http://theconversation.blogs.nytimes.com/2009/07/29/whats-wrong-with-a-single-payer-system/

Gail Collins: David, your writing on health care has been incredibly thoughtful, so I’m going to take this opportunity to poke you a little. Then I’ll shut up so you can talk.

The other week I said I agreed with you about the critical importance of cost controls. Then I asked — O.K., I sort of demanded — that you denounce the Republican leaders in the Senate who were flinging around proposals to make it illegal to investigate cost controls at all. You basically said that was a stupid thing to do, but that the Republicans weren’t really the problem since they aren’t in charge.

A single-payer system would be far and away the most cost effective answer.

But actually, they are. And so are we. The reason the country can’t solve the health care mess is because the people with the biggest bullhorns don’t speak honestly and clearly about it. Nobody understands the Democratic plan, and that scares the public. The irresponsible Republicans are just waiting to make whatever comes out sound terrible. The responsible Republicans are working to come up with a compromise that’s going to be even more incoherent than the Democratic version.

My version of reality is that:

A.) Since something like a third of the cost of health care is in administration, and the problem with reorganizing health care has to do with all the multitudinous plans and policies, a single-payer system would be far and away the most cost effective answer. We don’t talk much about it because it isn’t politically possible. But it isn’t politically possible because we don’t talk about it. The opponents of a public plan are afraid that people would all gradually migrate toward it, causing the insurance industry as we know it to wither away. Wouldn’t that be a good thing?

B.) There have to be limits on what doctors can prescribe. The president pretends the only limit will be on useless tests and drugs that have an equally good, cheaper alternative. But useless and equally good are in the eye of the beholder.

There are already limits unless you have a really, really good insurance plan, but a lot of the country either has very good coverage or imagines their coverage is good because they haven’t really tested it. They’re afraid of change. Yelling “rationing” every three seconds totally poisons the discussion. And that is no little matter.

I’ve already gone on longer than I promised, so there’s no C.

David Brooks: Gail, as you know, I begin and end my days by reciting Congressional Budget Office reports. I even put on tefillin, just to make it seem holy. So let me begin my reply with the sentence from the latest report. It’s from a section in which the C.B.O. analyzes what the House plan, with the strong public program and all the rest, would do to health care inflation:

The net cost of the coverage provisions would be growing at a rate of more than 8 percent per year in nominal terms between 2017 and 2019; we would anticipate a similar trend in the subsequent decade.

This is devastating. The plan was sold as a way to bend the cost curve, to reduce the rate of health care cost growth. Instead, the cost of the plan to the federal budget would rise by 8 percent a year, and there wouldn’t be anything close to offsetting revenues to pay for it.

I’m not crazy about the public plan, but I’m not vociferously against it either.

This is a loud trumpet for all health care reformers. Start over. Get serious about costs. We can either pass this kind of reform and bankrupt the country or we can pass another kind of reform. End of story.

Now that I’ve got that out of my system, let me say I admire your get-serious list (though my sixth grade teacher once said that if you have an A and B, you should also have a C).

I’m not crazy about the public plan. I dislike the idea of the government competing in a marketplace it regulates. I think the temptation to subsidize the public entity will be overwhelming. But I’m not vociferously against it either. That’s because:

A.) I’m not that thrilled with the insurance companies.

B.) I think it will save money, but not that much (the C.B.O. agrees).

C.) (!) I think it will produce small administrative efficiencies.

Democratic politicians throw around statistics claiming that Medicare has much, much lower administrative costs than private insurers. I’ve been told by various economists that this claim is three-quarters trickery. It’s a lot cheaper to administer a targeted population that uses a lot of care than it is to administer a large population that uses little care per capita. Plus you can save a lot of administrative costs if you don’t actually regulate treatments that much.

As for your second point, that there should be limits on what doctors can prescribe, I say: “Amen to that.”

If I had to add a few other items to the list, I’d say putting a serious cap on the tax exemption is the way to measure the seriousness of a reform proposal. Without that, it’s not serious. And finally, I’d say that there have to be cost conscious consumers within a closely regulated market. Unless you get proper incentives for both providers and consumers, I doubt you’re going to get very far. In the current plans, all the emphasis is on the providers.

There’s a group called the Fresh Thinking Project, which has a sensible list of reform ideas.

I’d only add in closing that the health care system is as big as the entire British economy. There is no way something that big and complex and dynamic can be run out of Washington. We have to try to set up a dynamic system, not trying to establish a set of rules to be imposed by fiat. The smart reformers at the Office of Management and Budget are aware of this. I’m not sure the congressional staffs are.

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