A conservative Republican (me) supports single-payer (very reluctantly), because there is no real alternative

(promoted from the diaries by streiff)

William Teach of The Pirate’s Cove concluded, in an article entitled CNN Poll: Fewer Want GOP To Repeal And Replace Obamacare:


The time to kill Obamacare was the 2012 election. With a President Romney, he could have slowed or even stopped the implementation of Obamacare, even without control of the Senate. All the rules and regulations could have been spiked. Once it was implemented, though, getting rid of it would be damned difficult. How many Big Big Big Government programs have been killed off? A handful at best? Instead, most become institutionalized, and, even when they are failing, even with miserable performance, they still stick around.

Of course they do: even the worst government program has some beneficiaries, people for whom maintaining the program is far more important to their economic well-being than the waste of money is to taxpayers in general.

Patterico is incensed:

This Means WAR: The ObamaCare Betrayal by Senators Capito and Murkowski Can Never Be Forgotten or Forgiven

Filed under: General — Patterico @ 5:00 am PDT

As I mentioned yesterday, I am astounded that so many people want to blame the GOP’s failure to repeal ObamaCare on those who are least to blame: folks like Rand Paul and Mike Lee. As I said, the real villains are the people who voted for the ObamaCare (partial) repeal bill in 2015 — but oppose it today.

Well, Mitch McConnell will soon call for a vote on a reanimated version of that same bill. And now we’re starting to learn who the scoundrels really are.

At the top of the list of giant hypocrites, you’ll find Senators Shelly Moore Capito of West Virginia and Lisa Murkowski of Alaska — who have both declared their intention to vote against the ObamaCare repeal bill that they both voted for in 2015.

This means war.

Capito and Murkowski are the most worthless type of hypocrites imaginable. They have postured as being against Obamacare, but they never really were. They voted in favor of the (partial) repeal in 2015 — and yet they claim they cannot vote for the same bill today, in 2017.

What is the difference between 2015 and 2017? Yesterday afternoon I sent emails to the press offices of Senators Capito and Murkowski, asking them why they would choose not to vote for the exact same bill they voted for in 2015. I received no response from Senator Capito, and a canned statement from Senator Murkowski that does not remotely begin to address the questions I had asked.

So what is the difference between 2015 and 2017? I’ll tell you what the difference is. The difference is that today, in 2017, we have a president who would sign that repeal bill into law. In 2015, we did not.

Senators Capito and Murkowski knew this. They lied to their voters, straight up.


More at the original. As I said yesterday, none of the Republican plans have been anything more than Obaminablecare Lite, because there are only so many ways you can utilize the private, for-profit insurance system to force coverage for everybody.

The plain fact is that about half of Republicans — including me — objects to Obysmalcare not due to the way in which it attempts to provide insurance coverage for everyone, but that the government is trying to provide health care coverage for those who cannot or will not pay for it themselves in the first place. The problem is that the other half of Republicans might hate Obumblecare¹ but agree with the cockamamie notion that the government should be responsible for providing health care coverage, and the GOP’s electoral advantage depends in part on a significant number of people who would lose health insurance or Medicaid if the current law is repealed.

There are only two significant ways to change the laughably-named Affordable Care Act: either total repeal, with no replacement, or single-payer. Every Republican congressman and Senator knows that voting for repeal only will take away health care coverage from some of the voters who put them in office.

Conservatism lost when Mitt Romney was defeated in 2012. The ACA had been passed, but still wasn’t in force at that point, so it could have been repealed without actually taking anything away from anybody. The option to return to the government not guaranteeing health care died in that election, and the realistic person needs to admit that.


I’ve said it many times before: he ACA was never meant to actually work, but was simply meant to pass, in order to establish the principle that the federal government was ultimately responsible for seeing to it everyone had access to health care. That principle has been established, and it won’t be repealed.

I have previously supported some form of single-payer plan, not because I like the idea that the government would guarantee access to health care — I hate that idea, I despise that idea, I abominate that idea — but because, if the government is going to do that, single-payer is the most rational way to do it.²

Oh, I still think it will be a disaster: Sachi ab Hugh’s 2010 article about her father’s treatment under Japan’s single-payer system is the most telling one I have ever seen, and the Veterans Administration hospitals scandal was hardly surprising, given the need to cut costs; it’s qualitatively indistinguishable from the cost-cutting method of delaying care used by the United Kingdom and Canada. But with the principle established that the federal government will be ultimately responsible for providing health care coverage, there’s little else that can be done.

Mitch McConnell is the Republican’s point man on the repeal-and-replace program. But the Distinguished Gentleman from Kentucky represents a poor state, one in which former Governor Steve Beshear’s (D-KY) Medicaid expansion reduced the uninsured rate from 19% to 7%. Current Governor Matt Bevin (R-KY), the TEA party challenger to Senator McConnell in 2014, who said he would reverse his predecessor’s order, backed off of that, and while he now has a plan to require some work for the able-bodied to retain Medicaid, it’s a tough sell.


The simple fact is that the Majority Leader’s home state is one of the greatest recipients of the ACA provisions expanding Medicaid! Does anyone really expect him to be the 51st vote to repeal the ACA?

He has to do what he has to do to remain Majority Leader, but, in the end, he will not let the Bluegrass State lose the Medicaid expansion. If we don’t get to single-payer in time, and the ACA isn’t replaced, count on Mr McConnell to try to retain the federal portion of Medicaid spending in the expansion, rather than let it fall back on the Commonwealth.

Serious question: how many Republicans could support the current Affordable Care Act if they hadn’t laden it with the name Obamacare? How much of the opposition is due to not wanting our loathsome 44th President to get the credit for it?

The very sad fact is that we will either have some form of health care coverage similar to the Affordable Care Act, or we will go to some form of single-payer, most probably an expansion of Medicare to cover everybody. We will not revert to the 2008 status quo ante, as much as I wish it were so, and I am not naïve enough, or stupid enough, to think otherwise. At least with a Medicare expansion, everyone will have to pay something, as the Medicare tax hits all paychecks, and a Medicare expansion will require a great expansion of the Medicare tax, currently pegged at 2.9%³ Health care in this country being roughly 17.8% of gross domestic product, and the current Medicare tax rate of 2.9% paying almost exclusively for people no longer in the workforce, I come up with a 20.7% Medicare tax rate, which would (hopefully) be offset by no longer having to pay for health insurance.4


There are some quick improvements which could be made to a single-payer bill. A smart Republican could co-sponsor it with Senator Bernie Sanders (S-VT), a Medicare expansion which Mr Sanders already planned for in his 2016 primary campaign, one which limited coverage to American citizens and legal residents,5 and limited coverage to necessary procedures, excluding elective ‘treatments’ including abortion, ‘sex reassignment surgery’ and non-reconstructive plastic surgery. Such limitations would be attractive enough to conservatives to (perhaps) gain their (reluctant) support.

Again, I expect any single-payer plan to be ugly and messy; I simply don’t see it as any uglier or messier than the current ACA system.
Cross-posted on The First Street Journal.
¹ – Sammy Finkelman asked me, “I like those terms Obysmalcare and Obumblecare. How come nobody ever came up with that before, or did you get them from somewhere?” Including Obaminablecare, while I came up with those myself, I can’t imagine that I’m the only one who did; it’s possible I heard one or more of them elsewhere, and it registered only subconsciously.
² – Full disclosure: I will turn 65 in April of 2018, and thus become eligible for Medicare. I have previously said that, even if I had a billion dollars in the bank, which I do not, I would still take every last ruble of the Social Security and Medicare benefits to which I am entitled, because I have already paid for them.
³ – 1.45% for the individual taxpayer, and 1.45% for the employer; self-employed individuals must pay the full 2.9%. Even those on Medicare normally pay some premiums for additional coverage.
4The previously referenced article by Sachi ab Hugh noted that her family in Japan maintained three private health insurance policies, to insure good health care. I anticipate that any shift to single-payer in this country will lead to something similar for people of means in the United States.
5Excluding even those illegal immigrants who are working and paying Medicare taxes.



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