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What Americans Really Want from Health Care Reform Is Impossible

Michael D. Tanner

It is an old joke among health policy wonks that what the
American people really want from health care reform is unlimited
care, from the doctor of their choice, with no wait, free of

For Republicans, trying to square this circle has led to panic,
paralysis, and half-baked policy proposals such as the ObamaCare
replacement bill. For Democrats, it has led from simple disasters
such as ObamaCare itself to a position somewhere between fantasy
and delusion.

The latest effort to fix health care with fairy dust comes from
California, whose Senate voted to establish a statewide
single-payer system. As ambitious as the California legislation is,
encompassing everything from routine checkups to dental and nursing
home care, its authors haven’t yet figured out how it will be
paid for. The plan includes no co-pays, premiums or deductibles.
Perhaps that’s because the legislature’s own estimates
suggest it would cost at least $400 billion, more than the
state’s entire present-day budget.

Adopting a single-payer
system would crush the American economy, lowering wages, destroying
jobs and throwing millions into poverty.

In fairness, legislators hope to recoup about half that amount
from the federal government and the elimination of existing state
and local health programs. But even so, the plan would necessitate
a $200 billion tax hike. One suggestion being bandied about is a 15
percent state payroll tax. Ouch.

The cost of California’s plan is right in line with that
of other recent single-payer proposals. For example, last fall,
Colorado voters rejected a proposal to establish a single-payer
system in that state that was projected to cost more than $64
billion per year by 2028. Voters apparently took note of the fact
that, even after figuring in savings from existing programs,
possible federal funding, and a new 10 percent payroll tax, the
plan would have still run a $12 billion deficit within 10

Similarly, last year Vermont was forced to abandon its efforts
to set up a single-payer system after it couldn’t find a way
to pay for the plan’s nearly $4 trillion price tag. The state
had considered a number of financing mechanisms, including an 11.5
percent payroll tax and an income tax hike (disguised as a premium)
to 9.5 percent.

On the national level, who could forget Bernie Sanders’
proposed “Medicare for All” system, which would have
cost $13.8 trillion over its first decade of operation? Bernie
would have paid for his plan by increasing the top US income-tax
rate to an astounding 52 percent, raising everyone else’s
income taxes by 2.2 percentage points, and raising payroll taxes by
6.2 points.

Of course, it is no surprise that Medicare for All would be so
expensive, since our current Medicare program is running $58
trillion in the red going forward. It turns out that
“free” health care isn’t really free at all.

How, though, could a single-payer system possibly cost so much?
Aren’t we constantly told that other countries spend far less
than we do on health care?

It is true that the US spends nearly a third more on health care
than the second-highest-spending developed country (Sweden), both
in per-capita dollars and as a percentage of GDP. But that
reduction in spending can come with a price of its own: The most
effective way to hold down health care costs is to limit the
availability of care. Some other developed countries ration care
directly. Some spend less on facilities, technology or physician
incomes, leading to long waits for care.

Such trade-offs are not inherently bad, and not all health care
is of equal value, though that would seem to be a determination
most appropriately made by patients rather than the government. But
the fact remains that no health care system anywhere in the world
provides everyone with unlimited care.

Moreover, foreign health care systems rely heavily on the US
system to drive medical innovation and technology. There’s a
reason why more than half of all new drugs are patented in the
United States, and why 80 percent of non-pharmaceutical medical
breakthroughs, from transplants to MRIs, were introduced first
here. If the US were to reduce its investment in such innovation in
order to bring costs into line with international norms, would
other countries pick up the slack, or would the next revolutionary
cancer drug simply never be developed? In the end, there is still
no free lunch.

American single-payer advocates simply ignore these trade-offs.
They know that their fellow citizens instinctively resist rationing
imposed from outside, so they promise “unlimited” care
for all, which is about as realistic as promising personal unicorns
for all.

In the process, they also ignore the fact that many of the
systems they admire are neither single-payer nor free to patients.
Above and beyond the exorbitant taxes that must almost always be
levied to fund their single-payer schemes, many of these countries
impose other costs on patients. There are frequently co-payments,
deductibles and other cost-sharing requirements. In fact, in
countries such as Australia, Germany, Japan, the Netherlands and
Switzerland, consumers cover a greater portion of health care
spending out-of-pocket than do Americans. But American single-payer
proposals eliminate most or all such cost-sharing.

Adopting a single-payer system would crush the American economy,
lowering wages, destroying jobs and throwing millions into poverty.
The Tax Foundation, for instance, estimated that Sanders’
plan would have reduced the US GDP by 9.5 percent and after-tax
income for all Americans by an average of 12.8 percent in the long
run. That is, simply put, not going to happen. So Americans are
likely to end up with a lot less health care than they have been

Santa Claus will always be more popular than the Grinch. But the
health care debate needs a bit more Grinch and a lot less Santa
Claus. Americans cannot have unlimited care, from the doctor of
their choice, with no wait, for free. The politician who tells them
as much will not be popular. But he or she may save them from
something that will much more likely resemble a nightmare than a
utopian dream.

is a senior fellow at the Cato Institute and the author
of “Going for Broke: Deficits, Debt, and the Entitlement Crisis.”