That slope just ain’t very slippery

Slapping the Camel’s Nose – Megan McArdle . Megan responds to those of us who’ve been asking “Why do you keep denouncing single-payer health insurance systems, National Health Care systems, and the elimination of private health insurance when nobody in the US is proposing eliminating private health insurance?”:

Now, I felt this was relevant, because in fact, no one I know who is interested in national health care views these bills as the final iteration of American Healthcare 3.0.  Everyone agrees that these bills are very bad, fix few-to-none of the underlying problems with the American healthcare system (cost inflation, the tax break for employer-provided insurance, etc.) 

This last isn’t true. Many people, including Ezra Klein and Matthew Yglesias and Kevin Drum, think these bills do some of the most important things of all in fixing the American health insurance system. Namely, they ensure that every insurance plan has to accept everyone at the same premiums regardless of prior health, that you can’t be kicked out of a plan for getting sick (or old, or anything), and that you can’t have a lifetime cap on payments.  Universal community rating is probably the single most important reform of all, as it removes private insurers’ perverse incentives to make money by denying coverage to sick people. But Megan is right that everybody agrees this is only the beginning of health care reform. Anyway, continuing:

But we have to do this because we can’t just do nothing, now.  So we’ll do this now, add a whacking great new line-item to the budget, and then fix it later.  The implied fix is things like cost controls on pharmaceuticals, comparative effectiveness treatment to decide which treatments “work” (and by extension, which ones shouldn’t be provided), and an ever-expanding role for government treatment mandates.  The goal of everyone, to a first approximation, on the “pro” side of these health care reforms is a European-style system where the government basically runs the whole show. 

This is not true, because in “European-style systems”, governments do not “run the whole show”. They just don’t. In Europe, just as in the US, you have public hospitals and private clinics and individual private-practice physicians. Most surgery and cancer therapy in France takes place in private clinics. Most hospitals in the Netherlands are private. And almost every country in continental Europe has private health insurance companies; in France, the overwhelming majority of citizens have private health insurance, while in the Netherlands literally everyone does.

Maybe they contract out the billing services to insurance companies, which you may choose between (though you can’t choose covered services, etc).  Maybe there’s a safety valve in the form of a private system that the very affluent can buy into.  But for 95% of the population, the government dictates what treatments are covered, and usually, how much should be paid for them.

Megan must think France is a very affluent country indeed, because those “very affluent” who buy private supplementary health insurance in France comprise 92% of the population. In the Netherlands, since 2006, the percentage of people with private insurance shifted from “most” to “100%”.

What Megan is saying is basically: sure, you’re saying you’re preserving the private health insurance sector now. But really, you want to eliminate it in the next round of reform, and if we let you have your way we’re on a slippery slope to single-payer sooner or later, because we know you all really love Euro-style single-payer systems. But this is just wrong. I’m a liberal who loves Euro-style health insurance systems, but I’ve never been in a single-payer system; they’re in the UK and Canada, and maybe Sweden, I’m not sure. The ones I know are in the Netherlands and France, and they’re not single-payer. And if those systems are supposed to be on a slippery slope to single-payer, well, that’s a strange slippery slope. France instituted universal coverage through private insurers in 1946 I think, and sixty-odd years later over 90% of French people are still buying private health insurance. The Netherlands has had universal care through a mix of public-private plans since the ’40s too, and in 2006 it actually scrapped the public basic insurance plan in favor of putting everyone into the private market, regulated and subsidized to achieve universal coverage. If the health insurance reform bill in the House is a stalking horse for importing the Dutch system wholesale, that’s fine with me. But a Dutch-style system means universal private health insurance, and it’s still just flat-out wrong for Megan to characterize that as a “government-run health system” or “single-payer” or “eliminating the private health insurance market” or whatever.