Let me quote you a long and a short snippet from two excellent articles with historical perspective on the health reform debate. This one's from Jonathan Cohn at TNR:
Advocates of single-payer systems complain frequently that the mainstream political debate doesn't give their idea the attention it deserves. They are right. Public insurance programs enjoy huge economies of scale; they don't fritter away money on profits or efforts to skim healthier patients from the population. When it comes to billing, they tend to be a lot simpler than, say, a system with dozens of competing insurance plans. All insurance systems require providers to file a lot of paperwork; single-payer systems, though, require just one set. The centralized power of single-payer systems also gives them unparalleled sway over not just the amount of money they pay but how they dole it out; with that kind of leverage, they can push the medical system toward making key improvements in quality.
Conservative critics of single-payer raise the perfectly respectable question of whether a government program could really wield such power judiciously. But it's telling that, when Taiwan set out to create a universal coverage system for its newly prosperous society a few years ago, it carefully studied schemes from around the world--and settled on a single-payer system, because it seemed to deliver the best, most equitable medical care at the lowest price. Today, experts say Taiwan has one of the world's most efficient, convenient, and effective health care systems.
In an ideal world, then, single-payer would almost certainly be the best option. But is it politically feasible? Single-payer advocates like to point out that Representative John Conyers has a singlepayer bill in Congress with close to 100 co-sponsors. But many of those co-sponsors have signed on because, until now, it has been a cheap, meaningless way to win points with liberal interest groups. In the Senate, meanwhile, declared support for single-payer is virtually non-existent. Polling on the question is ambiguous, suggesting the public doesn't yet have a strong opinion about the single-payer option. But even now, as the country seems to be moving left, voters remain deeply skeptical of massive government programs.
That they are (and though it's improving year by year on the side of reform, the public still is unclear what reform looks like, and is just as concerned about cost as access), and Cohn makes an excellent political point about the many sponsors of HR 676 on a bill that can't pass the Senate. As for the shorter piece, this was from Atul Gawande in the New Yorker:
Many would-be reformers hold that "true" reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.
Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have.
Well, there's that, too. But the fact is that the reformers have the stage, and the country's attention for the first time since 1994. With an appointment at HHS near, the focus of Washington discussion will inevitably turn to health reform. That won't stop the gossip about what beltway people mean by bipartisanship but for the moment we'll accept the working definition that "bipartisan" in the Obama era means "enough votes to pass the Senate", that he gets points from the public for comity, and that he still has plenty of political capital to spend. Given that working definition, we can and should expect push-back against the New Deal-denying Republicans, and from the Democrats, historical and current perspective on the close relationship between health reform and the economy.
However, when you review polling on the topic, be sure to pay the most attention to the independents. They're the one that will decide whether the public is behind reform or not (just like they're the one's deciding that Obama is popular by siding with Democrats.) And for all practical purposes, expect the indies to act like the late, lamented New England Republicans - socially liberal and fiscally conservative, concerned about access AND cost. Health reform will have to address both (or at least explain it), or it won't be moving anywhere in the Senate. And, as always, given the irrelevance of the current batch of House Republicans (see stimulus bill) that's where the action will be on health reform.
Update [2009-2-19 10:54:18 by DemFromCT]:: Ezra comes at this from a different angle, using Jacob Hacker (and the necessity of a public plan matched against private plans) as a discussion point:
In other words, the private plan isn't a backdoor to single payer and it's not a progressive sweetener to be traded away. It's essential to a high-performing universal health care system and should be included because it's good policy in a sector that needs more of it.
Whatever the merits or demerits, people should be aware there's more on the table to discuss than just single payer (though single payer deservers to be at the table, the Senate remains a hard sell and so does the Dem House.) For a practical example, see today's note from the Commonwealth Fund:
The Commonwealth Fund, a leading private health policy research group, unveiled a comprehensive plan for changing a U.S. health care system that is the world's most expensive yet lags many other nations in important measures of quality.
They hope the Obama administration and lawmakers consider the ideas as they move forward this year with plans for major changes in the health care system. This plan is one of many being advanced as U.S. policymakers move toward action.
The proposal favors a mix of public and private insurance options over the idea of a fully government-run health system.