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Alexandre and others voicing similar views:
I think you are misreading my position. I am not arguing that the market-for-the-rich, public-system-for-the-poor solution is superior to a single system. In the ideal world, I would like to see a public single payer system because such a system provides both, transaction cost savings (economic efficiency) and universal coverage.
We do not live in the ideal world, however, and as many on this list correctly pointed out, the attainment of a univresal single payer system in the US borders with impossibility in the current political climate. In this situation, the Left has two choices, either (a) kiss the public care system's sweet ass goodbye or (b) make a strategic decision to strive for the most politically desirable, under the circumstances, elements of that system.
In my posting I argued that universal coverage is more politically important for the Left than economic efficiency, so this is the aspect where the Left should concentrate its effors and resources. I also argued that universal coverage can be achieved through alternative institutional designs that do not necessarity involve a single payer. One such possibility is the means-tested public subsidies of health insurance premiums (social keynesianism of a sort). I did not argue that this is the most cost-efficient solution (it is NOT) - but that it is probably the most realistic one, given the current political climate - especially that insurance companies are likely to support it (they would gain new business).
To summarize, the choices are:
1. the status quo - inefficient, no universal coverage 2. single payer system - efficient, universal coverage, extremely difficult to implement 3. mixed system (i.e. means-tested subsidies) - inefficient, universal coverage, relatively easy to implement.
The interest of the Left include (a) serving its 'natural constituency' (low and moderate income, working class) who will benefit more from universal coverage than from economic efficiency, and (b) establishing its political salience by scoring some political victories. It thus follows that in the short run, the Left should pursue option (3) rather than (2). Once universal covergage is estabslied, that does not preclude future efforts to make the system more efficient by reducing transaction costs (single payer option).
wojtek
>1st-It will probably not achieve universal coverage, since there are
>people who are neither poor enough to be included in the public system
>not rich enough to get a good private insurance plan.
>2nd-By submitting the majority of people to market logic, you will let
>many persons undercovered, since coverage of private insurance is not
>adjusted to the individuals necessity, but to the amount of money a
>person can pay for a private insurance.
>3rd-(and maybe the worst)-A public system designed to cover only the
>poor will have a poor quality, since the middle class have more efficient
>means to make political pressure to improve the healthcare quality. By
>getting those people out from the public system, you will worse the
>healthcare quality.
>
>I'm medical oncologist and work in Brazil (whose reality is different
>from the US). Here we have a one payer health system, althought it
>is under heavy pressure from our right wing government, and so isn't
>working well. I assure you that if this system didn't exist or if it
>was restricted to the poor (who, in my country, are very poor), something
>like 50% of the population wouldn't have access to cancer treatment.
>
>
> Alexandre
>
>