What is there really left to say about single payer? It works well, almost everywhere except the United States, where it is deemed too expensive and politically impossible.

On the quality of our system, here are some stats from the Commonwealth Fund:

Adults in the U.S. are more likely than those in the 10 other countries to go without needed health care because of costs. One-third (33%) of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill a prescription because of costs. This percentage is down from the 2013 survey (37%). As few as 7 percent of respondents in the U.K. and Germany and 8 percent in the Netherlands and Sweden experienced these affordability problems.

Fourteen percent of chronically ill U.S. adults said they did not get the support they needed from health care providers to manage their conditions. This was twice the rate in Australia, Germany, the Netherlands, New Zealand, and Switzerland.

Although the U.S. has made significant progress in expanding insurance coverage under the Affordable Care Act, it remains an outlier among high-income countries in ensuring access to health care. The authors point out that all of the other countries surveyed provide universal insurance coverage, and many provide better cost protection and a more extensive safety net.

So the self-proclaimed “greatest country in the world” appears to be somewhat sick and poor compared to its peers at similar levels of wealth and development.

Our health care system is expensive because the finance and health care industries pay politicians to write the rules in ways that stifle competition, use cynical propaganda campaigns  and scare tactics to convince the public they are engaged in competition, keep information away from consumers that would allow them to make reasonable cost-effectiveness choices, and generally maximize their short term profits at the long term expense of public health and the economy. Hillary Clinton had a very succinct way of summarizing this:

In the past, the health insurance industry has deployed sophisticated propaganda efforts to divide single payer proponents and weaken any political support for the idea. Former Democratic presidential nominee Hillary Clinton once considered such a system, but wondered, “Is there any force on the face of the earth that would counter the money the insurance industry would spend to defeat it?”

Like I said, our health care system, including all the public and private elements, is off the global charts insanely expensive both in terms of total spending relative to our economy, and in terms of the value we get in return for that spending. Shifting any portion of this expensive system from private to public funding would mean that the government would be paying more of the price tag, and government revenues would have to go up to pay for that. In other words, yes, we would be paying higher taxes in place of the high insurance premiums, co-pays and out-of-pocket payments we are making directly to the finance and health care industries now. Cynical politicians, who remember are bought and paid for by these industries, purposely confuse voters by equating the portion of the bill paid by the government with the total cost of health care, as in this Washington Post article:

But the government’s price tag would be astonishing. When Sen. Bernie Sanders (I-Vt.) proposed a “Medicare for all” health plan in his presidential campaign, the nonpartisan Urban Institute figured that it would raise government spending by $32 trillion over 10 years, requiring a tax increase so huge that even the democratic socialist Mr. Sanders did not propose anything close to it.

Single-payer advocates counter that government-run health systems in other developed countries spend much less than the United States does on its complex public-private arrangement. They say that if the United States adopted a European model, it could expand coverage to everyone by realizing a mountain of savings with no measureable decline in health outcomes, in part because excessive administrative costs and profit would be wrung from the system.

In fact, the savings would be less dramatic; the Urban Institute’s projections are closer to reality. 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.

But they go on to point out that the reason these costs are so high is that “A big reason [the government] does not clamp down now on health-care spending is that it is hard to do so politically.”

It’s almost impossible to even try to tackle these problems unless and until we have constitutional reform making it clear that big business ownership of politicians is not the same thing as free speech by individual members of the public. And our elected officials who are owned by big business are not going to give us this constitutional reform. It’s a conundrum that seems almost impossible to solve – if the 2007 financial crisis did not whip up enough public anger to counteract and overcome industry propaganda, it is hard to imagine a crisis that would.

So we would have to get that constitutional amendment (somewhat blandly called “campaign finance reform”, which understandably does not spark the public imagination) done. If we did that, we could look at some incremental reforms to move us toward either single payer or a more efficient public-private system. One idea seems particularly attractive to me. The state exchanges under the Affordable Care Act are an attractive idea because they encourage insurance companies to compete against one another for consumer health care dollars. The ACA also established a pretty uniform set of minimum coverage requirements that make it clear what we are paying for. Understanding what you are buying, and then having some choice of providers of that service, is the basic foundation of a functioning market system. The market should be able to set reasonable prices under these conditions, in theory. The insurance companies have the bargaining power and incentive to take on the health care industry over price and drive prices down.

So this all sounds pretty good. Where it is clearly failing, it is because some insurers are choosing to pull out of the exchanges, leaving buyers without any choice and destroying that link between supply and demand. What would make sense to me is to figure out what the premium would be for people to buy into Medicare and/or Medicaid directly, and then require these Medicare and Medicaid options to be available on the exchanges in a given state if at any time the number of private insurers competing on the exchange drops to less than 3 (or maybe 2, but 3 seems better). That way the insurance industry has complete control over whether they choose to shoot themselves in the foot or not. This won’t happen without the constitutional amendment first.

A shorter-term incremental measure that could help without the constitutional amendment would be to create some kind of common platform for all insurance companies to share price and outcome with consumers. Some insurers already have their own systems for doing this, and we have the system of common procedure codes, but it is all way too confusing. The government could force the insurance and health care industries to get together, come up with a crystal clear communications strategy, and put it all on a common platform. They would be required to provide you with this crystal clear information at the beginning of every doctor, hospital, and pharmacy visit. All without the government paying a dime more of people’s health care cost or providing any more price controls than they do now.