Why Is Centralization Good?

The editors of the Washington Post go off on “Medicare For All”:

SINGLE-PAYER HEALTH care can work. Government-run systems operate in other industrialized countries and often achieve comparable or better overall results, for less money, than the health-care patchwork in the United States. So why aren’t Sen. Bernie Sanders (I-Vt.) and Sen. Elizabeth Warren (D-Mass.) proposing something that resembles those systems?

The two presidential candidates promise far more generous benefits than other countries offer. They pretend that the United States wouldn’t have to make any of the trade-offs other nations have had to make. They promise fantastically generous benefits, no premiums, co-payments or other cost-sharing, and a miraculously low price tag. It’s fiction.


All Americans should have decent health-care coverage. They should also have good schools, good roads and world-class universities. Nations with single-payer plans have had to make real-world compromises among these various needs. If the Warren and Sanders plans sound too good to be true, it’s for a reason.

Let me make some scattered observations. We can’t reduce the cost of our health care system without reducing somebody’s income. Some of those somebodies will be in the insurance sector but most of them will be in the health care sector.

What’s the fixation with centralization? Here are the populations of some of the countries with which people routinely compare the United States:

Country Population (millions)
France 66.99
Germany 82.79
UK 66.44
Canada 37.59

and here are the populations of some U. S. states:

State Population
New York 19.54
California 39.56
Florida 21.30
Texas 28.57
Illinois 12.74

The total U. S. population is something like 330 million. Get the point? Those countries are more like states than they are like the U. S. as a whole. We are also much larger physically and enormously more diverse than any European country. We are very nearly as large and diverse as all European countries put together.

If we’re seriously considering a single payer system, why not a system more like that of Canada, a country which we resemble culturally much more than we do France or Germany. Canada’s system is run by the provinces.

Administration of Canada’s system costs about half as much as ours. We simply are not going to realize savings in administrative costs beyond Canada’s. I would be astonished if the savings in administration from going to a single-payer system here would even match that and the financing assumptions of practically every body’s plan makes that assumption. Everything our government does costs more than anywhere else. Why should health care be an exception?

There are actually good reasons why a single payer system is not a good fit for the United States and I usually summarize them by saying that we don’t have enough social cohesion. That covers a lot of territory including a greater emphasis on individualism, diversity, and a long-standing culture of political incompetence. We don’t trust our government for good reason.

I’m actually more concerned that every American should have access to decent health care than I am that they should have access to decent health care coverage. Framing it that way conditions the discussion.

6 comments… add one
  • bob sykes Link

    Why doesn’t someone propose the German system. Germany has a mixed system. There is a mandatory government-run policy that provides basic coverage, and people can buy additional coverages if they want to. My daughter, who has lived and worked in Germany for 15 years, says the service is excellent. There are no horror stories like the ones that routinely come out of the UK and Canadian systems.

    While the quality is good, the German system is expensive, and I’m not sure it’s cheaper than ours. My daughter pays 30% of her gross income for health insurance and the state pension plan.

  • I’ve lived and worked under the German system. Their system is about half as expensive as ours.

    However, I do not believe their system would work in the U. S. The Germans are very process-oriented. I can’t imagine us doing the same.

  • steve Link

    “We don’t trust our government for good reason.”

    I think that we are actually kind of schizophrenic when it comes to trusting government. Conservatives dont trust government to run health care, but they like Medicare. They have absolute faith in the police (any unarmed person who gets shot must have deserved it) and, for the most part, government monitoring us. Remember how they support torture? Complete trust in our government to figure out who to torture and how to do it. Remember yesterday when the conservative writer just assumed that our all powerful, omniscient government would have no problem finding killers in Mexico when we cant even find them here in the US?

    Liberals have some counterpart issues too. So I would say that we selectively distrust government based upon our ideology. This even goes for the anarcho-capitalists. Someone has to protect those precious property rights, the government (even if it is just through the courts).

    “every American should have access to decent health care than I am that they should have access to decent health care coverage.”

    Have to pay for it somehow. Even if you cut costs so that they were on par with the cheapest first world quality care, it would still be very expensive.


  • Grey Shambler Link

    Things have changed considerably since 1965 when Medicare was signed into law. Americans both live longer, and are less healthy. We pretty much all agree we want to be a civil, compassionate society, so it’s agreed Medicare will cost more. How the money is collected and dispersed is one thing, what is covered is another. Steve’s of course right about not torturing the elderly whose time has come, to squeeze a few miserable months of life at great cost. But at my age, I have another angle, we pay for knee replacement and pacemakers, but at the moment, what’s keeping me from working and being productive is hearing loss. That’s not covered, nor corrective vision surgery or even eyeglasses. Would it make sense to cover these things so older workers could work?

  • CuriousOnlooker Link

    I wholly agree with the post. I argued many of the same points.

    To go further – is there savings from scale from each state managing health care to the Federal government doing it? I believe there is actual dissavings.

    Here is an interesting question – has anyone ever polled on Americans trust in the Federal Government vs their State government vs their local government? My guess is trust in state government is higher.

  • Jimbino Link

    I, too, suffered under the German healthcare system. I was forced to pay for what I found to be inferior medical and dental care. I was very happy to get a raise to DM3500 at Siemens, which allowed me the option to leave the Krankenkasse system and make myself “freiwillig versichert,” which in my case ended up being “freiwillig unversichert.” Hell, beyond their forcing you into undesired health care, in Germany you’re forced to pay church taxes, even if you’re Baptist, for Chrissake!

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