By Sarah Thomson, Jonathan Cylus, Tamás Evetovits
World Health Organization

The Role of Voluntary Health Insurance (VHI)

In most countries, VHI exacerbates inequalities in access to health care rather than reducing them, because VHI is consistently more likely to be taken up by richer households.

Private insurance is only shown to be protective at health system level where it explicitly covers user charges and also covers most of the population, including most poor people.

Only three countries in Europe (and indeed globally) meet these conditions: Croatia, France and Slovenia. Table 8 (in the report at the link below) shows how VHI covering co-payments in these countries achieves very high rates of take up, covering over 80% of those who have to pay co-payments in Croatia, around 90% of the population in France and around 95% of those with compulsory health insurance in Slovenia.

The experience of these three countries suggests that VHI covering co-payments is not an equitable or efficient way of improving financial protection. Equity in financing is undermined by the high financial burden imposed on poor households compared to rich households, even where VHI is free for very poor people. Efficiency is undermined not only by the high administrative costs incurred by private insurers in all three countries compared to entities providing compulsory health insurance, but also by the high – and sometimes hidden – transaction costs involved in regulating a complex market.

Key messages on the role of VHI

• VHI generally exacerbates inequalities in access to health services.
• It is only shown to enhance financial protection at health system level where it covers co-payments, is accessible to and affordable for all those who need it and is heavily subsidized by the state for poor households.
• Across countries it is not effective in reducing out-of-pocket payments, in contrast to public spending on health.
• VHI is also a more regressive means of financing the health system than public spending on health.

https://apps.who.int…

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Comment:

By Don McCanne, M.D.

Yesterday’s Quote of the Day used this same WHO report to make the point that “even in Europe’s richest countries people are pushed into poverty” by the deficiencies in their health care financing systems. Today’s message is that European voluntary health insurance “exacerbates inequalities in access to health services;” “is not effective in reducing out-of-pocket payments, in contrast to public spending on health,” and it is also “a more regressive means of financing the health system than public spending on health.”

What is the lesson for the United States? A single payer Medicare for All program would provide all essential health care services for everyone while removing financial barriers to care. Instead we have a fragmented system that is dominated by voluntary plans including those in the individual market, the ACA marketplace plans, employer-sponsored plans, and the private Medicare Advantage plans. These perpetuate those deficiencies found in the European voluntary health insurance plans.

Right now there is an intensive effort to perpetuate our fragmented system of individual voluntary plans, and even expand it through private Medicare Advantage plans and ACA marketplace plans. That’s ridiculous when we could have an efficient, effective, equitable system that’s affordable for everyone by enacting and implementing Single Payer Medicare for All.

Yes, the Europeans have lessons for us, but we need to understand what they actually are and then apply them.

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By Sarah Thomson, Jonathan Cylus, Tamás Evetovits
World Health Organization

From the Forward

“One of the report’s key findings is that even in Europe’s richest countries people are pushed into poverty – and many already poor households experience financial hardship – as a result of having to pay out of pocket for health services. This indicates that all Member States can take steps to improve financial protection.” – Hans Kluge, Director of the Division of Health Systems and Public Health WHO Regional Office for Europe

From the Executive Summary

New numbers for Europe

Drawing on publicly available national household budget survey data, the report provides up-to-date numbers on financial protection for 24 high- and middle-income countries in Europe.

• The incidence of impoverishing health spending in the study countries ranges from 0.3% to 9.0% of households. There is wide variation among European Union (EU) countries (from 0.3% to 5.9%) and among non-EU countries also (from 3.6% to 9.0%).
• The incidence of catastrophic health spending ranges from 1% to 17% of households in the study countries. It varies widely among the 18 EU countries in the study, including wide variation among countries that joined the EU after 30 April 2004.
• Catastrophic health spending is consistently heavily concentrated among the poorest fifth of the population.
• Out-of-pocket payments incurred by households with catastrophic health spending are mainly due to outpatient medicines, followed by inpatient care and dental care.

Gaps in coverage

People are exposed to out-of-pocket payments and unmet need when there are gaps in coverage. Gaps in coverage arise from weaknesses in the design of three policy areas: the basis for population entitlement leaves some people without access to publicly financed health services; the range of services that is publicly financed – the benefits package – is narrow, or there are issues relating to the availability, quality and timeliness of these services; and there are user charges (co-payments) in place for services in the benefits package.

Weaknesses in coverage policy undermine equity and efficiency by creating financial barriers to access; shifting the financial burden of paying for health care on to those who can least afford it – poor people and regular users of health services; and encouraging inefficient patterns of use.

Acting on the evidence

To be effective, changes to coverage policy should be supported by an adequate level of public spending on health. Countries in which the out-of-pocket payment share of current spending on health is relatively high will need to invest more publicly in the health system to reduce out-of-pocket payments. Simply increasing public spending might not be enough to improve outcomes for those most in need, however. The sequencing of policy is therefore important. Some countries will need to redesign coverage policy at the same time as seeking additional public investment in the health system.

There is a wealth of good practice in Europe. Lessons can be learned from countries with strong financial protection and countries where financial protection is weak overall but steps have been taken to protect poor people.

https://apps.who.int…

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Comment:

By Don McCanne, M.D.

It is often said that we can learn much from Europe on how to more effectively and equitably finance health care in the United States. What is often not said is that we can learn a lot on how not to do it. As WHO’s Hans Kluge states, “One of the report’s key findings is that even in Europe’s richest countries people are pushed into poverty.”

It is not as if we don’t already know how to do it. PNHP’s Physicians’ Proposal for Single-Payer Health Care Reform would address the deficiencies that result in the failure of European systems to provide adequate financial protection for absolutely everyone.

Rather than advocating for a European-style health care financing system, we can do better. By enacting and implementing a well designed Single Payer Medicare for All, we would have a better than European or Canadian-style system – we would have the best health care system in the world.

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By Jonathan Oberlander
The Milbank Quarterly, September 15, 2019

Excerpts

“Medicare for All” has emerged as a major flashpoint in American politics. Its unexpected rise is, in part, a reaction to a decade of the Affordable Care Act (ACA, also known as Obamacare) — an ironic development given that the ACA embodies a reform model that builds on private coverage and Medicaid.

Yet, just as Medicare for All is moving to center‐stage in US health care debates, supporters of the idea are fighting over where to define its boundaries.

This essay traces the evolving language of health reform in the United States, clarifies the various meanings of Medicare for All, and explores what the debate over the label and other Medicare‐related expansion plans, including the pubic option, reveals about health care politics.

The Shifting Language of Health Care Reform in the United States

As Canada managed to insure all its citizens while spending much less on medical care than the United States, reformers in this country increasingly began to call for adopting Canadian‐style national health insurance. By the 1990s, “single payer” had become the term of choice for American reformers, including Physicians for a National Health Program, who advocated replacing our mix of public and private coverage with one government insurance program.

Single payer accurately described how medical services would be financed in a Canadian‐like system—hospitals and doctors would be paid for covered services by one insurer. Still, single payer was ultimately a technical term that generated little public appeal, public understanding, or political momentum.

Reformers’ recent invocation of Medicare for All reflects a significant change, and undoubtedly an improvement, in political strategy. Medicare for All immediately connects proposals for government insurance to a popular, familiar, and entrenched program that already exists in the United States rather than to a confusing financing label or a mostly unfamiliar and often vilified foreign insurance plan.

Polling data support the labelling change: Americans are much more likely to register support for Medicare for All (or universal health coverage) than single‐payer health insurance. The turn to Medicare for All also reflects the improved performance of Medicare, whose relative success (compared to private insurers) in moderating spending growth since the 1980s and maintaining low administrative costs has bolstered the program’s reputation among reformers and policy analysts. Medicare is often portrayed not merely as an equitable platform through which to provide all Americans with insurance, but as a symbol of administrative efficiency and cost control. Medicare for All is thus seen as the key to making health care a universal right, eliminating the problems of the uninsured and underinsured, reining in spending and regulating prices in the world’s most expensive health care system, and reducing the prolific waste and administrative costs generated by convoluted billing and insurance arrangements.

The Pure and Hybrid Models of Medicare for All

The pure model of Medicare for All seeks to establish a national insurance program operated by the federal government, prohibiting private insurance for services covered by the publicly funded government plan. In contrast, the hybrid model would allow private insurance plans that abide by federal regulations, including those sponsored by employers, to operate alongside and within a government‐run Medicare program.

The pure and hybrid models advance varying goals, embody different philosophies, and reflect different political calculations. The pure model, which is how the health reform community has until now generally understood Medicare for All, presumes that America’s various health care pathologies can only be remedied by eliminating private insurance as a major source of coverage. The goal is not simply to achieve universal health insurance but to do it through a government program and without relying to any meaningful degree on private insurers. Health security will never be achieved, from this perspective, unless private insurance is jettisoned because the corrosive effects of market forces are seen as the central problem in American health policy.

In contrast, the hybrid model is willing to leverage both public and private insurance to cover all Americans. It makes a concession to perceived political realities and attempts to lessen disruption by preserving a significant role for private insurers and employers. It also embraces the altered nature of Medicare, building on the preexisting Medicare Advantage component.

Advocates of the hybrid model believe that the goal of enacting universal coverage justifies the retention of private insurance. However, by preserving Medicare Advantage, such models also inherit its problems, including a record of federal overpayments to such plans.

A Medicare‐like Public Option

Adding to the confusion is a third health reform plan… Americans could join a new “Medicare‐like” or “Medicare‐type” public option or otherwise remain in their current health plan.

Such plans are not Medicare for All, nor are they even Medicare for More since they generally seek to establish a new Medicare‐like program rather than directly expand the current Medicare program.

Ultimately, public option plans aim to advance the rhetoric of choice while harnessing the benefits of association with Medicare without triggering the political liabilities of Medicare for All.

From the Conclusion

Medicare for All is now receiving more serious consideration from presidential candidates and lawmakers than at any time since the program’s enactment over five decades ago. The debate over what Medicare for All means and which model of Medicare (or Medicare‐like) expansion to pursue reflects persistent tensions in health policy between pragmatism and principle, incremental and systemic reform, and building on or tearing down the status quo.

The question is whether Medicare will endure beyond 2020 as a prominent reform model that defines the health care debate or whether we are witnessing an ephemeral development that presages US health policy moving in yet another direction.

https://www.milbank.org…

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Comment:

By Don McCanne, M.D.

Jonathan Oberlander has provided an excellent description of how the “Medicare for All” label has been transformed from one representing the altruistic model of single payer reform that would ensure affordable, equitable health care for absolutely everyone into a confusing term that has different meanings for different advocates, but particularly has been used to ensure that the private health insurance industry continues to have a major role in marketing their insurance products and their administrative services for self-insured employers.

The concept is being sold that we can have Medicare for All while still allowing individuals to obtain private plans through their employers, or through the individual market, or through Medicare as private Medicare Advantage plans – that it really wouldn’t make much difference if choice of private plans remained an option. The nation really hasn’t grasped the concept that not only are private plans responsible for creating barriers to care (high deductibles and limited provider networks), but, most of all, they are also responsible for creating profoundly expensive administrative waste (hundreds of billions of dollars), and are responsible for the failure to control excessive prices in health care. The “pure” Medicare for All model recovers this waste and redirects it to filling in the voids in care for the currently uninsured and underinsured.

We can’t expect those in bed with the insurance industry to be responsible in their rhetoric, but those who really do care about the health care of all of us should have a better understanding of what is happening by reading Oberlander’s treatise on the subject.

Where are we going to get the money? In a pure single payer model, we’ll recover close to half a trillion dollars in administrative waste; we’ll use economic tools (global budgets, negotiation) to ensure that prices reflect value; and we’ll use separate budgeting to ensure appropriate capacity in the system.

Although Oberlander shows us how we moved away from the poorly understood, wonkish term “single payer” when we adopted the “Medicare for All” label, unfortunately we are going to have to distinguish the pure model from the others. Perhaps the easiest way is to salvage the single payer term by referring to “Single Payer Medicare for All.” Otherwise opponents will assign unfavorable attributes to “Medicare for All” and then use that to condemn the model.

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By Rachel Madley
The New York Times, September 17, 2019

Twenty minutes after I learned I had Type 1 diabetes — after narrowly avoiding a diabetic coma — a nurse pulled my parents away from my bedside and urged them to call our insurance company immediately. If they didn’t call right away, she warned, insurance would not cover the stay. At that moment — now 10 years ago — my parents had to choose whether to comfort their sick and frightened 14-year-old daughter, or spend hours on the phone with our insurer. Of course, they left me to make those calls, and my nightmarish relationship with the insurance industry began.

Type 1 diabetes is an autoimmune disease that destroys the body’s ability to produce insulin or maintain normal blood-sugar levels. There are no days off from this illness. Without careful monitoring and daily insulin injections, Type 1 diabetics risk blindness, kidney failure and death.

On top of the full-time job of monitoring blood sugar, American diabetics and their families have to work a second shift fighting insurance companies to cover their care. Even though my parents had insurance and both worked multiple jobs, the hospital bills, insulin and supplies drove them into debt, forcing them to forgo insurance, and medical care, for themselves.

When I turned 19, I was kicked off my parents’ plan. I took out thousands of dollars in extra student loans to buy insulin and diabetes supplies. After the Affordable Care Act passed, I was able to regain insurance, a high-deductible plan that cost me hundreds of dollars for each doctor’s visit and insulin refill.

So when I hear politicians talk about how much Americans love their private health insurance, I think: Really?

I am alive today not because of insurance companies but despite them. My insulin refills have been delayed countless times, not because of medical reasons, but because of what seem to be arbitrary insurance limits and requirements to continuously document my condition, which is permanent. Once, my insulin refill was delayed so long that I ran out, just when the insurance office closed for a three-day weekend. I was a student, away from home, with no other way to pay for my prescription. Terrified, I rushed to the pharmacy in tears. The pharmacist took pity on me and slipped me a vial of insulin without charge, saving my life.

The worst part about my story is that it isn’t unique, at least not in this country. Young adults with Type 1 diabetes suffer life-threatening diabetic ketoacidosis — a complication caused by insufficient insulin — at much higher rates in the United States than in Canada. Canada’s single-payer system provides seamless, lifelong coverage. But in the United States, diabetics must wage war with insurance companies to get the care we need, if we have insurance at all.

I’m glad that politicians are finally talking about health care reform. But those who only want to “protect” the Affordable Care Act or add a public option to our already byzantine mix of private and public plans are missing the point. Americans don’t “love” their private insurance, as many of them claim. They’re grateful for any coverage at all. Americans love their doctors, nurses and pharmacists, because those are the people who save our lives.

What diabetics — and all Americans — need is care that is lifelong and portable, covers all medically necessary services and drugs, and is accepted by all doctors and hospitals. Only a single-payer version of “Medicare for all,” in which care is publicly funded by one entity and privately delivered, would guarantee coverage to everyone in the United States, and eliminate the greed and administrative waste of private insurance.

It has been 10 years since my diabetes was diagnosed. I can’t help but think about the doctors and nurses who cared for me with such skill, my parents who sacrificed their needs for mine and the pharmacist who kindly slipped me that vial of insulin. I’m alive today because of them.

Will I have to live the next 10 years holding my breath through every doctor’s visit, praying that insurance will approve my medication, and in time? Will I ever be able to stop my endless fights with insurance middlemen? I know I’ll never live a day without worrying about my health. But maybe one day I, and millions of other diabetics in America, can live without worrying about how to pay for it.

Rachel Madley, a Ph.D. student at Columbia University Medical Center, is a student board member of the New York chapter of Physicians for a National Health Program.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Love your private health insurance?

People do not love facing a high deductible that may make health care unaffordable.

People do not love not being able to go to the physician or hospital of their choice because the insurer limits care to restrictive provider networks.

People do not love the instability of coverage due to factors such as loss of employment, change of residence, or change in qualification for subsidized plans.

People do not love paying high COBRA premiums to maintain insurance after termination of employment at a time that income has ceased.

People do not love paying outrageous drug prices set by pharmaceutical firms and pharmacy benefit managers.

People do not love the uncertainties of delays or denials due to prior authorization requirements of the private insurers.

People do not love tolerating their flat incomes because potential wage increases are diverted to increases in employer-sponsored insurance premiums instead.

People would not love contributing to half a trillion dollars in recoverable administrative waste if they realized they were doing that.

All of these and much more would be resolved by enacting and implementing a single payer model of Medicare for All. Now that would be a program that people really can love.

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We are very grateful for the efforts of the author of this op-ed, Rachel Madley, and the many other student members of Physicians for a National Health Program (PNHP) and the student arm – Students for a National health Program (SNaHP) – for advancing the cause of health care justice for all. The future of health care is in their hands.

The 2019 PNHP Annual Meeting and Leadership Training sessions will be held in Philadelphia November 1st and 2nd. It is particularly important for the future of health care to see that we have a great turnout of students and residents. Donating to the Nicholas Skala Student Activist Fund can be particularly gratifying because of the knowledge that the funds will be directed to helping students master the policies and politics of effective, equitable health care reform for all:

Nicholas Skala Student Activist Fund
https://pnhp.salsalabs.org…

2019 Annual Meeting and Leadership Training
https://pnhp.org…

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Matt Bruenig
People’s Policy Project, September 12, 2019

The Census released its annual income, poverty, and health insurance statistics earlier this week. The summary report shows that 8 million of the nation’s 42.5 million poor people would not be poor if they did not have to pay medical out-of-pocket (MOOP) expenses like deductibles, copays, coinsurance, and self-payments. Medicare for All (M4A) virtually eliminates these kinds of payments, meaning that these 8 million people (18.8 percent of all poor people) would find themselves lifted over the poverty threshold if M4A were enacted.

This headcount poverty measure actually understates how significant MOOP expenses are to poverty in this country. According to this same data, in 2018, the total poverty gap stood at $175.8 billion. This figure is derived by calculating how far each poor family’s income is below the poverty line and then adding those calculations together to get an aggregate amount. MOOP expenses make up $38.2 billion of that total gap, meaning that Medicare for All would cut poverty by about 22 percent.

Coincidentally, MOOP expenses also chew up about 22 percent of the income of poor people. That’s right: more than 1 in 5 dollars received by the nation’s poor goes towards out-of-pocket medical expenses. For families with incomes above 400 percent of the poverty line, the same figure is only 4.6 percent.

What this means is that, by eliminating medical out-of-pocket expenses, Medicare for All would reduce headcount poverty by 19 percent, reduce the overall poverty gap by 22 percent, and increase poor people’s incomes by 29 percent. Indeed, M4A’s elimination of MOOP expenses would contribute more to the incomes of the poor than the Earned Income Tax Credit currently does. This makes M4A one of the most potent anti-poverty programs proposed thus far in the current presidential race.

https://www.peoplespolicyproject.org…

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Comment:

By Don McCanne, M.D.

Besides the obvious advantage of single payer Medicare for All in making health care affordable for everyone, Matt Bruenig shows us that it would also “reduce headcount poverty by 19 percent, reduce the overall poverty gap by 22 percent, and increase poor people’s incomes by 29 percent.” It “would contribute more to the incomes of the poor than the Earned Income Tax Credit currently does,” making it “one of the most potent anti-poverty programs proposed thus far in the current presidential race.”

Who could be opposed to that? (Don’t answer.)

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By Ezekiel J. Emanuel and Victor R. Fuchs
The New York Times, September 12, 2019

Fallacy No. 2: Medicare for All is unaffordable.

The key to evaluating the cost of Medicare for All is to distinguish between increasing spending on health care and shifting expenditures from private insurance to the federal government.

True, Medicare for All would increase federal health care spending. But that is not the same as increasing total health care spending, which was over $3.5 trillion last year. Instead, Medicare for All would move money from one column (private health insurance spending) to another (federal health spending); it does not automatically increase total costs.

A recent study by the Mercatus Center at George Mason University — a free-market center generally hostile to government programs — estimates that for the 10 years between 2022 and 2031 the total national health costs for Senator Bernie Sanders’s Medicare for All plan would actually be $50.1 trillion. That would be $2 trillion less than if we let the system operate as it currently does. However, Mercatus researchers doubt that the Sanders’s plan would ultimately save trillions because they believe Congress would have to increase Medicare rates paid to hospitals and physicians to get the legislation enacted. They may be right — or wrong. But that is a different argument — a prediction about the politics of enacting laws — than that Medicare for All would inherently increase total health care spending.

We have our doubts about Medicare for All. But unaffordability is not a reason to oppose it. Whether it’s our current arrangement or a future Medicare for All, the per capita cost of our health care system already far exceeds that of any other industrialized country — including those with single-payer systems. When you hear a health care price tag in the trillions, know that the existing system has already brought us there.

Ezekiel J. Emanuel is an oncologist and a vice provost at the University of Pennsylvania. Victor R. Fuchs is an emeritus professor of economics at Stanford University and former president of the American Economics Association.

https://www.nytimes.com…

The New England Journal of Medicine, March 24, 2005, “Health Care Vouchers — A Proposal for Universal Coverage” by Ezekiel J. Emanuel, M.D., Ph.D., and Victor R. Fuchs, Ph.D.

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The best health care reform is already in place

By Laurence Kotlikoff
The Hill, September 8, 2019

As with the previous Democratic debates, this week’s debate in Houston will likely start with our country’s forever question: How can we provide health insurance to all without bankrupting the country?

The Republican Party’s answer is to define basic health insurance as no health insurance. The party yearns for, and is suing in the courts, to restore the halcyon pre-ObamaCare days when 50 million Americans were uninsured and insurance companies could deny coverage at will.

This stance isn’t going to fly with the Party’s rank and file, whose own future health care and that of friends and relatives is at stake. But, hey, political self-immolation seems all the rage.

Vision two is Senator Sanders’ traditional Medicare (Parts A, B, and D) for All. Actually, it’s a far more generous version than traditional Medicare, which features co-pays, co-insurance, limits on catastrophic coverage and significant monthly premiums. As a result, millions of participants are forced to purchase Medigap coverage. Under BernieCare, there are no co-pays (except for prescription drugs) and no limits on coverage. Bernie care includes lab work, maternity, vision and dental care, and long-term care for the disabled.

Employers would, to their joy, be banned from the health care business. But their workers will be able to keep their doctors and use the same hospitals, who will simply send their bills to Medicare. Indeed, setting aside requisite tax hikes, BernieCare is far more generous than most employer-provided plans.

BernieCare, which Senator Elizabeth Warren (D-Mass.) and several other Democratic presidential candidates endorse, works great in theory. And it may in practice. The biggest bottom line is the share of GDP spent on health care. Other developed countries are delivering excellent universal health care at well south of 14 percent of GDP. We’re at 18 percent of GDP and growing. And they are all doing it with a healthy dose of central government control.

If it’s a choice between our current system and BernieCare, I’d go with BernieCare in a heartbeat. Yes, there are lots of concerns — people overusing the system, costs that far exceed the senator’s estimates, government price control over what is a fifth of the economy, doctors opting out of medicine because of limits on their reimbursements and long waiting lines.

But 14 percent of U.S. GDP can surely buy a truly first-class health care system for all. Also bear in mind that medicine in our country is already largely government run but done so with maximum inefficiency, leaving 30 million uninsured and far more underinsured.

BernieCare surely beats “Don’tCare” — the Trump-McConnell answer. But is there another reform that makes more sense?

Yes. “Medicare Part C for All.” This is the brain child of John Goodman, the father of Health Saving Accounts. I pushed for this solution in The Healthcare Fix. Goodman recently discussed the plan in the Wall Street Journal.

Medicare Part C is also called the Advantage Plan. Some 22 million Medicare participants – one in three – have opted for Medicare Advantage over traditional Medicare.

Laurence Kotlikoff is a professor of economics at Boston University (BU), a fellow of the American Academy of Arts and Sciences, a research associate of the National Bureau of Economic Research, and a fellow of the Econometric Society. He served on President Ronald Reagan’s Council of Economic Advisers.

https://thehill.com…

The MIT Press, September 2007, “The Healthcare Fix” by Laurence J. Kotlikoff (proposes vouchers for health insurance)

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Comment:

By Don McCanne, M.D.

It has been fascinating to observe the insights on single payer Medicare for all of some of the nation’s more prominent economists who have not already been in the single payer camp. They seem to understand the clear benefits of the model, and yet they regress to supporting their own preferred but lesser models of reform, very often a model using variations of subsidized vouchers for purchase of private plans, as the authors of today’s excerpts support.

Even the Affordable Care Act was based partly on the voucher concept with the establishment of the ACA insurance exchanges. There is currently a push to use vouchers (“premium support”) to expand coverage through private Medicare Advantage plans. If we ever do approach having truly universal coverage, it will likely be the results of the contest between Medicare Advantage vouchers and a single payer model of an improved Medicare for all. A recent Quote of the Day discussed why this Medicare Advantage for All model is such a terrible idea.

Yes, it has been fascinating to see the insights of so many economists on the single payer model, yet it has been terribly frustrating to see that many if them continue to reject this obviously superior model.

Some years ago at Stanford University I was on a panel with Victor Fuchs in which he presented his voucher proposal and I presented the single payer approach. After the session was over, he approached me and asked me if I would like to work with him and Ezekiel Emanuel on their voucher model. I asked him if he would like to work with us on the single payer model. We both laughed, but, sadly, the impasse is not at all funny.

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