Debating Health Care Reform

To the Editor: I'm very grateful to the Report for publishing my article ("Single Payer Meets Managed Competition: The Case for Public Finance and Private Delivery," January-February 2008), for commissioning commentaries, and for highlighting the vitally important issue of health care reform. Many thanks also to the commentators for their time, energy, and wisdom on this issue.

In "Another Voice," Mary Crowley applauds my effort to justify fundamental health care reform on the basis of moral values, but laments my emphasis on cost-effectiveness and my silence about justice. Crowley asserts that the status quo of American health care is highly unjust. I concur. But in view of our society's widespread disagreement about the demands of distributive justice, I thought we should begin where there is broader agreement.

I appealed to four goals enjoying very broad support: universal access, cost controls, patient freedom, and quality of care. There is more agreement on the goal of universal access than on the claim that justice requires it—some hold that it is required by beneficence or decency, not justice, while others believe it is not required at all, but is nevertheless an appropriate goal. As for cost-effectiveness, I argued that the single payer approach was the most affordable means to achieving the leading goals. Advancing this argument permitted me to counter, with substantial empirical evidence, some common American mythology: that the single-payer approach is unaffordable and gravely threatens freedom and quality.

Paul Menzel believes I make "a strong case that single-payer national health insurance with managed competition in delivery is morally the preferred structure for universal access" and best achieves the four goals. In view of American political culture, however, he doubts that this is the model champions of reform ought to push. Menzel recommends a Dutch/Swiss/Federal Employees Health Benefits model: a multiplicity not only of delivery plans, as in my approach, but of insurers as well, competing both with each other under regulations guaranteeing certain basic benefits and with a public insurance option. As long as enrollment in any plan were truly open to all, then the public plan could compete without unfair disadvantage. Americans could then "vote with their feet" over time, demonstrating their preferences and presumably rewarding the best approach.

Menzel is likely correct that this vision has better political prospects than mine. But I resist any approach that retains employment-based insurance, which is highly inefficient and regressive. Moreover, to cut back on wasteful administration and to avoid the twin evils of adverse selection and risk avoidance, I would hold out for substantial regulations that not only require open enrollment for all and a uniform, adequate benefits package, but also prohibit premiums, deductibles, and large copayments.

Len Nichols grants that "a single-payer system with managed competition is the best form of single-payer system around." But he doubts I have shown the approach to be superior to "the best reform plans being proposed on the campaign trail or in Congress already." I confess to some confidence in this comparison. McCain has no serious reform proposal. Obama, at least for the foreseeable future, intends to retain employment based insurance and preserve too many other features of the status quo. No reform this timid can achieve universal coverage affordably. By contrast, Senator Wyden's Healthy Americans Act proposes major reform, including the demise of employment-based insurance. I believe my approach better protects against adverse selection and (by eliminating premiums and deductibles) financial barriers to enrollment in particular health plans while doing more to reduce wasteful spending. Nevertheless, this bill deserves serious consideration—and Nichols served us well in mentioning it.

Ezekiel Emanuel's commentary is exactly what he promised to the Report: not a reply to my article in particular, but a critique of the single-payer approach in general. This is noteworthy because my proposal's merger of public finance and managed competition in delivery steps away from Emanuel's principal target: a traditional single-payer approach in which fee-for-service delivery predominates. (It also brings my approach closer to his.) At the same time...