The Heart of the Problem

The editors of the Washington Post cast their steely-eyed gaze on the heart of the problem with a single-payer system for the United States:

The public piece of the American health-care system has not proven itself to be particularly cost-efficient. On a per capita basis, U.S. government health programs alone spend more than Canada, Australia, France and Britain each do on their entire health systems. That means the U.S. government spends more per American to cover a slice of the population than other governments spend per citizen to cover all of theirs. Simply expanding Medicare to all would not automatically result in a radically more efficient health-care system. Something else would have to change.

With monopoly buying power, the government could tighten up on health-care spending by dictating prices for services and drugs. But the government already has a lot of leverage. A big reason it does not clamp down now on health-care spending is that it is hard to do so politically.


To realize the single-payer dream of coverage for all and big savings, medical industry players, including doctors, would likely have to get paid less and patients would have to accept different standards of access and comfort. There is little evidence most Americans are willing to accept such tradeoffs.

None of this should come as a surprise. Just as we spend much, much more per capita on health care than any other country in the world, mile-for-mile building and maintaining roads costs significantly more in the United States than in Germany, France, or Japan. There may be a reason that people in the United States trust their governments less than people do elsewhere. Our government is less worthy of our trust.

There are any number of explanations for health care’s high costs. Our political system. Our legal system. Our laws. Our people. Their behavior. Expectations both on the part of providers and patients. Our circumstances. If reforming health care were easy and painless we’d’ve done it already.

My view, since the failure of Bill Clinton’s attempt at health care reform has been that cost control must come first. That will require basic structural changes in our health care system well beyond changing who pays for health care. It will be fought tooth and nail by everyone with a stake in how health care is provided today. Which is everyone.

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