Photo: Pablo_K/Getty Images/iStockphoto
Nobody likes health insurers, but the Democratic candidates’ fixation on them as an all-purpose bogeyman for any problem with health care, as demonstrated at this week’s debates, is a demonstration of why single payer in the U.S. wouldn’t work like its supporters see it working abroad and would like it to work here.
One of the key arguments for a single payer system is that it’s cheaper than a system with private payers. That has generally been true around the world, but it’s not a law of nature. Single payer is cheaper because governments use their leverage as the sole buyer of health care to push prices down. They pay doctors and hospitals less, because they can. The savings don’t come from the single-payer system itself; they come from the choice to pay less.
So, what will happen if the U.S. adopts a single payer system? Providers like doctors and hospitals will make the same arguments Senator Michael Bennet did at Thursday’s debate: That they depend on the higher rates from private insurers to offset the lower rates they get from Medicare and Medicaid. If every patient’s insurer paid like Medicare, they’d close.
In a lot of cases, the hospitals aren’t bluffing: Hospitals need to charge patients more than in other countries to make their finances work, because they pay their doctors more than in other countries. Achieving costs like in countries that have single payer would require cramming through unit cost savings so our costs align with those countries. And that path runs straight through doctors and hospitals, which are a lot more profitable than insurers.
Senator Kamala Harris noted – correctly – that American emergency room costs are outrageous, leading patients to hesitate before they seek care they might need. But while Harris framed this as a problem with health insurance, it’s hospital systems that set those high prices; insurers increasingly pass those costs through to patients, but if they didn’t, premiums would be even higher than they are now.
Former Vice President Biden, bizarrely, threatened to put health insurance executives in jail “for their misleading – their misleading advertising, what they’re doing on opioids – what they’re doing paying doctors to prescribe.” That’s not chiefly an insurance issue, either – it’s an issue with pharmaceutical companies.
And at Wednesday’s debate, Senator Elizabeth Warren objected that health insurers had made $23 billion in profits last year. $23 billion is a lot of money, but total U.S. health expenditure – public and private – was $3.5 trillion as of 2017, the most recent year with available data. Since we spend about twice what our peer countries in the OECD tend to spend for approximately the same outcomes, our excess health spending is about $1.8 trillion. Abolishing health insurer profits would take us roughly 1 percent of the way to getting in line with our peers on costs.
I understand the impulse not to name the key villain, the key element in our health care system that’s making it unaffordable, which is providers and the payments they require. People feel positively about doctors and hospitals; they do not feel positively about insurers. But when you try to implement a single payer system, you will have two options: Fight the providers, or pay them whatever they want, in which case the shift to single payer won’t save much money and will require enormous tax increases.
I would also note that, while cost saving through monopsony buying power is not an ironclad consequence of adopting single payer, it is also possible to achieve that end without adopting single payer at all. The government can control payment rates to providers without actually making all the payments if it regulates prices. That is, it is possible to take on the providers first, which would save money for the government, employers, and individuals – making money available for all sorts of things, including expansions of health coverage.
While this approach would also require fighting the powerful provider lobby, it would make available allies you would not have with you for a fight to expand government spending and implement single payer. You could tell employers their cost for employee health benefits would go down, without offsetting new taxes. You could tell individuals they’ll get to pay lower premiums. You could even tell insurers their costs will become more predictable.
This would still be a very difficult political fight – doctors and hospitals save lives, and so it’s understandable people feel good about them and trust them when they object to policies. But this approach wouldn’t involve fighting everyone at once.
Democrats Should Fight Doctors and Hospitals, Not Insurers
Trump said on Saturday that he’d soon present his own plan on busing. (He won’t.) Shorter version of his attention-seeking remarks:
HARRIS: Busing was necessary to secure the full integration of public schools across America.
BIDEN: While I backed integration, busing struck me as an overreach.
TRUMP: The wheels on the bus go round and round. Many people are saying that. Round and round, round and round.
Harris’s plan worked
Harris’ surprise cross-examination of frontrunner Joe Biden produced the third-biggest fundraising bonanza since her launch. The Democratic senator is working to capitalize ahead of a crucial second quarter fundraising deadline: She blanketed news shows with nearly a dozen TV appearances, and her digital team is pumping out clips and other reminders of her interrogating Biden, hoping that Democratic voters will envision her doing the same thing to Donald Trump. …
Inside Harris’ campaign, the first debate was viewed as the unofficial start of the contest, the first big opportunity when primary voters start paying attention to the presidential race. The debate coincided with a new level of comfort she’s described feeling in recent weeks with opening up about her upbringing and personal life, more than a half-dozen aides and allies told POLITICO, something they’ve been gently urging her to do as a way to forge a connection with many voters who don’t know her. …
Harris’ objective was not to fade into the background of an ideological slugfest between Biden and Bernie Sanders, the advisers said. Her campaign had spent months fixated on Biden, whose support from black voters has kept him atop all of the early polls. They gamed out several scenarios in which she could use her personal story as a point of contrast with his decades-long record, including over his opposition to busing.
While walking through her planned exchange with Biden over busing, Harris’ campaign planned for a variety of answers from him, from contrition to a more measured approach to the more forceful denial of the position that he ended up giving — a stance that was called out by fact-checkers as untrue given his past quotes rejecting the wisdom of busing.
Harris herself ended up settling on a line that within minutes would appear in social media memes and just a few hours later would be screen printed on t-shirts selling for $29 on her website: “That little girl was me,” she said, of her desegregated class.
the top line
Democrats Should Fight Doctors and Hospitals, Not Insurers
By Josh Barro
They’re ignoring the key element in our health care system that’s making it unaffordable: providers and the payments they require.
the national interest
the national interest
Trump Thinks Putin’s Attack on ‘Western-Style Liberalism’ Was About California
By Jonathan Chait
Our authoritarian president hates liberalism but does not understand what it means.
Samantha Bee Has an Offer the 2020 Democratic Candidates Can’t Refuse: Drop Out!
By Devon Ivie
Some bribery is on the table.
The president will just want to confirm that the check cleared
Libyan government fighters discovered a cache of powerful American missiles, usually sold only to close American allies, at a captured rebel base in the mountains south of Tripoli this week.
The four Javelin anti-tank missiles, which cost more than $170,000 each, had ended up bolstering the arsenal of Gen. Khalifa Hifter, whose forces are waging a military campaign to take over Libya and overthrow a government the United States supports. Markings on the missiles’ shipping containers indicate that they were originally sold to the United Arab Emirates, an important American partner, in 2008.
If the Emirates transferred the weapons to General Hifter, it would likely violate the sales agreement with the United States as well as a United Nations arms embargo. Officials at the State Department and Defense Department said Friday they had opened investigations into how the weapons ended up on the Libyan battlefield.
the top line
Planet Fitness Celebrates Members Who Pay for Its Product But Don’t Use It
By Josh Barro
There is an odd incentive if you own a gym: You need to find a way to attract customers who are not especially eager about your product.
Kamala Harris Ends the Era of Coddling Joe Biden on Race
By Zak Cheney-Rice
Over the years, Joe Biden has benefited from black candidates feeling compelled to take a conciliatory pose when confronted by racism. No more.
More evidence that people are intensely interested in the 2020 election
Last night’s debate on NBC/MSNBC/Telemundo got 18.1 million TV viewers, making it the most-watched Democratic debate ever.
The 2015 GOP debate on Fox News (with Trump) still holds the record with 24 million viewers.
Will the Debate Put Mayor Pete’s Campaign Back on Track?
By Ed Kilgore
Buttigieg had a good debate performance, and was properly contrite in addressing a recent police shooting in his city. But he has more work to do.
The punishment for an infamous moment in recent American history
BREAKING: White supremacist sentenced to life in prison for deadly car attack in Charlottesville, Virginia.
the national circus
the national circus
Frank Rich: Kamala Harris’s Debate Performance Should Scare Trump
By Frank Rich
Beyond her dismantling of Joe Biden on Thursday night, she showed off her formidable skill as a prosecutor. That’s likely to unnerve the president.
Elizabeth Warren Thinks We Need More Diplomats
By Sarah Jones
In her first post-debate plan, Warren describes how she would rebuild the State Department and promises not to give ambassadorships to donors.
Andrew Sullivan: Democratic Candidates Are in a Bubble on Immigration
By Andrew Sullivan
The debates proved that they are fundamentally out of touch with the difficult realities of the issue.
early and often
Live Polling of the Debates: Good News for Harris, Warren, Biden, and Substance
By Gabriel Debenedetti
These voters liked the senators from MA and CA, but they aren’t yet abandoning the former veep. And they don’t like food fights.
Supreme Court to Hear DACA Cases Next Term
By Ed Kilgore
But the Court chose not to review an Alabama ban on the procedure used in most second-term abortions, with Thomas calling for reversal of precedents.
Are These Quotes From Marianne Williamson or Metal Gear Solid?
By Brian Feldman
Marianne Willamson. Hideo Kojima. Two great minds, linked on the astral plane.
Europe is boiling
For a third straight day, a ferocious heat wave is baking large parts of Europe, and the exceptionally high temperatures are making history. On Friday, the town of Villevieille in southern France hit 113.2 degrees (45.1 Celsius), the hottest temperature ever recorded in the country.
The scorching temperature surpassed the previous record of 111.4 degrees (44.1 Celsius) set in the southern town of Conqueyrac in France’s historic 2003 heat wave, which was blamed for 15,000 deaths.
It appeared more than one location had surpassed the 2003 record, as Carpentras in southeastern France rose to 111.7 degrees (44.3 Celsius).
The heat was so intense that, for the first time since initiating its heat warning system (after the 2003 heat wave), Météo-France declared a red alert, the highest level, for the southeast part of the country Friday.
Dem candidates understand that impeachment is not top of mind for a lot of voters
Number of times these words were mentioned at the debate last night:
Special Counsel 0
Obstruction of Justice 0
Here’s Who Won (and Lost) the Second Democratic Primary Debate
By Eric Levitz
The ten candidates’ performances, ranked, from best to worst.
We might already know what next term’s biggest case will be
BREAKING: Supreme Court agrees to hear Trump’s bid to end Obama’s DACA program. Case likely to be decided next year in the heat of the presidential campaign.
Harris doing some cleanup from an otherwise bravura performance
Hi-larious from the president
Nearly one year after his infamous Helsinki moment, Trump makes light of Russian interference in US elections, smiling along with Putin as he says “Don’t meddle in the election…please. Don’t meddle in the election.”
Marianne Williamson’s Weirdest, Most Wonderful Debate Moments
By Matt Stieb
During Thursday’s Democratic debate, the self-help guru shifted the conversation in unexpected directions, from New Zealand to the moon.
How Much Did Thursday’s Debate Hurt Joe Biden?
You wrote about Wednesday night’s debate that though Joe Biden currently holds a commanding lead in many Democratic primary polls, Elizabeth Warren and co. barely mentioned him. But once Biden appeared onstage at tonight’s affair, that dynamic rapidly changed. Some candidates were not shy about going after him; the night’s most memorable exchange came when Kamala Harris, in what seemed to be a pre-planned attack, raked him over the coals for opposing busing, connecting his stance to her own childhood and putting him squarely on the defensive. Biden didn’t make any big mistakes, but tripped over his words occasionally and looked his age for a good portion of the evening. (No offense to 76-year-olds.) How much do you think tonight damaged him as a frontrunner?
Clearly Harris’ team saw an advantage in directly pursuing Biden’s voters that others — who were afraid of antagonizing his supporters — didn’t. But Biden’s team was roundly rejecting the idea that he was grievously hurt by these exchanges — “voters, not Twitter!’ was their informal post-debate rallying cry. The beauty here is we’ll see, and soon. One interesting thing: the conventional wisdom in the spin room did seem to shift from “Harris seriously hurt Biden’s chances tonight” to “but maybe she looked overly scripted, and real voters won’t care” fairly quickly. Until we get numbers, of course, this is all just pundit talk. But what the exchange clearly did was establish that his model is likely not the only electable one.
Interesting. It definitely was a script, and it did feel a little uncomfortably opportunistic to me. On the other hand, Harris has been underperforming expectations so far, and this is a moment people will remember. So even if it doesn’t hurt Biden, it will likely boost her, correct? She was excellent beyond that exchange, too.
I’m not sure I agree that she’s been underperforming, but she’s been holding steady at a fairly low number, all things considered. What she definitely did tonight was establish herself as a top-tier candidate. But what does that really mean, in practice? It means we mean something new by “top-tier.” That tier is Biden, Sanders, Harris, Warren, and Buttigieg, but not necessarily in that order, at all. The difference: before there was a tippy-top-tier of Biden alone. I’m not convinced that’ll still be the case — at least as far as pundits and analysts are concerned. Again, we’ll see how voters feel.
19 of these people may soon agree.
Haha. Beyond Biden and Harris, did you think anyone boosted or damaged their candidacy in any serious way?
Gillibrand successfully made herself a major character in the night’s drama for much of the night, and I think Bennet forced his way into more conversations than anyone expected. But if you’re Hickenlooper, you’re not going to be happy to be so far to the edges of the debate’s central moments, only to see your former chief of staff overtake you.
Gillibrand said basically what she’s been saying on the trail for something like 6 months now. The difference is she interrupted the field and edged her way into the night’s discourse on a few issues where she felt she’d been overlooked. It was an obvious strategy, but the night’s biggest takeaway has to still be about Harris and Biden.
One thing that’s fascinating: Bernie Sanders essentially being at the periphery of so much of this, despite being literally center-stage.
Not so different from how it’s felt in the campaign generally lately.
He stuck to his greatest hits, as he often does, but that meant that he didn’t do much confrontation until the end, on Iraq.
Going into this debate, Pete Buttigieg had hit a rough patch in his charmed rise, after his shaky handling of a police shooting in South Bend. In one of the more striking moments tonight, he fielded a question about it by admitting that he had failed to adequately reform his police department. What did you make of his response?
He obviously knew it was coming, and admitting fault was a deft way to get credit for what’s widely been seen as a rough response. One thing that stuck out to me was that many expected someone to attack him for the response. No one expected that to come from Hickenlooper, and then Swalwell. That limited discussion of the actual substance.
Yeah, Swalwell yelled at him to fire his police chief, drawing a glare from Buttigieg.
Finally: what did you think of tonight’s moderators? I thought they asked pretty good questions and for the most part imposed order, though there were some stretches of lawlessness.
Strategic lawlessness! It was slightly strange that these candidates got to respond to what happened on the previous night, but clearly the moderators wanted to put on a show and maximize meaningful conflict. I think it worked, and I don’t have a problem with candidates running over their time. Rules shmules.
One thing that will definitely change about the questions in future debates: Harris and Warren will both have to defend their records now.
Biden’s Bad Night Exposed Some Dangerous Weaknesses
By Ed Kilgore
Biden looked old, ill-prepared, and vulnerable to an African-American challenger in the first debate. He must bounce back quickly lest it get worse.
Snap Judgments of All 7,000 Democratic Candidates
By Madison Malone Kircher
A two-hour debate is not enough time to develop nuanced opinions. But it’s plenty of time to develop totally unfair assessments of each candidate.
More of the same
After last night’s truth parade, Biden brought back the bullshit
Biden’s claim tonight that he only opposed federally mandated busing and did not generally oppose “busing in America” was a flagrant misrepresentation of his position in the ‘70s and ‘80s. He’d made crystal clear he opposed busing as a concept, as a matter of principle.