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Jonathan—professor and chair of Social Medicine and professor of Health Policy & Management at the University of North Carolina-Chapel Hill, "The Virtues and Vices of Single-Payer Health Care," The New England Journal of Medicine, Vol. 374, p. 1401-1403

The substantive virtues of single-payer programs are compelling. But so are their political liabilities. Medicare for All, which aims to constrain health care spending, faces intense opposition from insurers, the medical care industry, and much of organized medicine. It would trigger fierce resistance from conservatives and the business community and anxiety in many insured Americans fearful about changing coverage and the specter of rationing. The ACA's comparatively conservative reform approach inspired false charges of "socialized medicine," "pulling the plug on grandma," and "death panels." It takes only a little imagination -- or a look back at the history books -- to predict the reactions that an actual single-payer plan would evoke.

Jim Jordan and other key conservative firebrands have caused a fair share of House Speaker Kevin McCarthy‘s biggest headaches. But instead of leading the rebellion this time, they helped him quash it.

As the House Freedom Caucus was preparing to discuss whether to officially oppose the speaker’s bipartisan debt deal — a move that would potentially galvanize conservative opposition — Jordan (R-Ohio) phoned several fellow members with a request, according to a person familiar with the calls. The former chair of the group urged them to hold back, effectively giving conservatives who wanted to vote with McCarthy license to do so.

Reich 16 (Robert Reich, Chancellor's Professor of Public Policy, University of California at Berkeley, Senior Fellow at the Blum Center for Developing Economies (“Why A Single-Payer Healthcare System Is Inevitable,” Huffington Post, August 28th, http://www.huffingtonpost.com/entry/why-a-single-payer-healthcare-system-is-inevitable_us_57bb38d0e4b0b51733a4e665)

The best argument for a single-payer health plan is the recent decision by giant health insurer Aetna to bail out next year from 11 of the 15 states where it sells Obamacare plans. Aetna’s decision follows similar moves by UnitedHealth Group, the nation’s largest health insurer, and by Humana, another one of the giants.

Koslov and Jex 15 (Tara Isa Koslov, Acting Director of the Federal Trade Commission’s Office of Policy Planning, Elizabeth Jex, attorney advisor specializing in biopharmaceutical health policy in the Federal Trade Commission’s Office of Policy Planning, J.D. from Georgetown University, Federal Trade Commission, July 2, 2015. “Price transparency or TMI?” https://www.ftc.gov/news-events/blogs/competition-matters/2015/07/price-transparency-or-tmi)

But transparency is not universally good. When it goes too far, it can actually harm competition and consumers. Some types of information are not particularly useful to consumers, but are of great interest to competitors. We are especially concerned when information disclosures allow competitors to figure out what their rivals are charging, which dampens each competitor’s incentive to offer a low price, or increases the likelihood that they can coordinate on higher prices. Too much transparency can harm competition in any industry, including health care. Typically, health care providers (hospitals, outpatient facilities, physician groups, or solo practitioners) compete against each other to be included on a health plan’s list of preferred providers. When networks are selective, providers are more likely to bid aggressively, offering lower prices to ensure their inclusion in the network. But when providers know who the other bidders are and what they have bid in the past, they may bid less aggressively, leading to higher overall prices.

1. don’t address administrative complexity or force providers to compete based on costs because the only prices compared are internal to the insurer---preserves the majority of industry inefficiencies

2. price don’t determine decisions, consumers care about quality

Helaine Olen 17, former columnist for Slate and co-author of The Index Card, 1-9-2017, "Health Comparison Tools Were Supposed to Shrink Medical Bills. They’ve Failed.," Slate Magazine, http://www.slate.com/articles/business/the_bills/2017/01/why_those_price_comparison_tools_to_reduce_medical_costs_don_t_work.html

It’s a new year, and you know what that means: Your health insurance deductible just reset. Which for many of us means looking forward to paying a significant amount out of pocket for health care until we’ve spent enough for our insurance payments to kick in. According to the Henry J. Kaiser Family Foundation, in 2016, the average deductible for an American with employer-based insurance was $1,221. People covered through the Affordable Care Act exchange will likely pay more than that. Close to 90 percent of those enrolled will select a plan with an individual deductible of at least $1,300, or $2,600 for a family. Can’t afford it? Feel squeezed? No worries. Your employer or insurer probably offers an online price-comparison information tool for you to find the best deal on everything from blood work to birth control. “Be a smart health care consumer,” reads the landing page for my insurance company’s price-comparison site. “Use our tools and information to help you save money.” But will it? Less than five years ago, online price-transparency tools, with which patients can compare the costs of nonemergency procedures in advance of booking them, were heralded as miracle cures that would finally get health care costs under control. No longer would the cost of medical procedures be a mystery. It made sense. Online, we can compare prices for books and hotel rooms and TV sets. Why not doctors? “Life inside the fortress will increasingly be disrupted,” noted health care economist Uwe Reinhardt said of the concept in a 2013 Journal of the American Medical Association article. The rush was on. A 2015 survey by human resources consultancy Mercer found that more than three-quarters of U.S. employers said they offer employees access to such tools. Numerous states jumped into the fray, passing legislation that mandated some form of transparent pricing.* Yet this past spring, JAMA re-emerged with a less rosy diagnosis. In a study of how employees at two corporations actually made use of the health care cost-measurement tools made available to them, researchers at Harvard Medical School discovered that not only did few use them, their spending actually increased after the tools designed to encourage comparison-shopping were introduced. “There was no evidence that health spending declined in the settings where transparency tools were offered,” a JAMA editorial noted. What went wrong? Comparison tools work by allowing people seeking nonemergency health care like hip and knee replacements, MRIs, physicals, and lab work—and even more mundane services like earwax removal—to compare the cost of the care at different practitioners and determine what their co-payment will likely total based on their insurance and whether they’ve met their deductible. That should be easy enough. But do you really pick your doctors the way you bargain shop for electronics on the web? Of course not. A 2008 survey by the (now-defunct) Center for Studying Health System Change found that about half of us turned to friends and relatives for recommendations when seeking a new primary care doctor. And when it comes to specialists, almost everyone relied on the advice of other medical professionals, with less than 10 percent turning to online information to make a choice. Things haven’t changed much since then. A 2014 poll from the Associated Press and the NORC Center for Public Affairs Research found barely 1 in 4 identifying excellent ratings on sites like Yelp or Healthgrades.com as a decisive factor in deciding on a particular doctor. Moreover, one man’s frivolity is another woman’s necessity. With health care, many of us are willing to pay extra for everything from convenience to communication skills. When the AP–NORC poll asked people what traits made for a high-quality doctor, “affordable” and “accepts my insurance” were the two least important qualities, outranked by more than a dozen other traits including attentiveness, office environment, and bedside manner. Yet another survey, this one by Healthgrades, found many patients prioritizing location over co-pay and quality ratings when they needed a hospital. And when consumers do make cost-conscious decisions, their ability to make good ones is limited. A recent study released by the National Bureau of Economic Research makes the point. The researchers looked at a company that moved all its employees into a high-deductible health insurance plan. Yes, the workers spent about 15 percent less on health care. Unfortunately, they appeared to cut their medical consumption willy-nilly, making little distinction between needed treatments and ones they could forgo. They didn’t actually spend less on the services they sought out. “We show that consumers did not price-shop after the switch—that is, they did not move toward cheaper providers, for example, when they were going to undergo a specific procedure,” wrote Benjamin Handel, one of the authors of the study. As for the JAMA paper on health care comparison tools, the researchers speculated that if consumers did attempt to price services, it’s quite possible they ended up paying more money. That’s actually not that surprising. Behavioral finance studies repeatedly find we use cost as a measure of quality. The more expensive an item, the better we think it is. Yet even if consumers did use comparison tools as they were supposed to, it’s questionable how much they could actually impact prices. The medical system in the United States is a complex beast. The recipients of the services, even if they are the best shoppers around, have little actual control on the overall costs. For example, the Health Care Cost Institute determined the average knee replacements cost more almost $17,000 more in Palm Bay, Florida, than in Miami, which is 180 miles away. But few consumers, even if they do the research, are likely to sign up for a surgery that far from their home. How will they get there? Who will pay transport and house their families? What happens if there’s a complication after they return home? That’s not even the big picture, because these tools aren’t actually taking on the American medical health care system itself. They’re simply offering customers some room to maneuver within their insurer’s fortress, to borrow Reinhardt’s phrase. When many of us use an insurer’s price-comparison tool, we’re receiving the prices the medical providers have agreed to charge people using that company. “A hospital can charge one person $500 for a cholesterol test and $10 for another,” says Steven Weissman, a former health care executive turned industry critic. “The problem with health care transparency tools is they do nothing to make health care providers compete the way other businesses compete.” And how much does it really matter? It’s not, after all, the nonemergency MRIs and lab bills that are breaking the bank. Less than half of all medical services can even be priced in advance, according to the Health Care Cost Institute. Hip and knee replacements, which are an example frequently cited by price-transparency promoters, are a mere fraction of our annual tab. And getting an advance estimate for everything from emergency-room visits to strep tests at the doctor’s office is all but impossible—if an ill patient is even capable of that. In many situations, the power remains with the providers. Pharmaceutical giants set the prices of their drugs. As long as the law permits a hospital that chooses to be in network with a particular insurer to service patients with out-of-network providers, consumers will remain at risk of receiving a surprise medical bill if they need to visit an emergency room. Advertisement Yet cheerleaders remain undeterred. Dr. Adam Bernstein, the chief medical officer of Rally Health, speculated that the problem the 2016 JAMA study revealed is that consumers need a “financial reward” in return for using the online price-comparison site, such as making the insured pay a greater share of the bill if they choose a provider charging more than a pre-determined amount for a particular medical service. Others say that as tools are able to include more information about pricing from providers, more people will use them. “Transparency hasn’t even started,” Dr. Giovanni Collela, a founder of Castlight Health, a publicly traded company that markets yet another online price guide, told the New York Times last year. Supporters say they hope that over time patients can be coached into using the tools more often. Maybe. Maybe not. I’m all for transparent pricing of medical services, but I suspect that even at their most successful, price tools will only make a marginal difference in what we pay the doctor. Once again, we’re seeking an individual solution to an economic and political problem that our politicians not only don’t have the will to solve themselves, but which they might actively make worse by repealing the Affordable Care Act.

Katherine Baicker & Helen Levy 13. From the Department of Health Policy and Management, Harvard School of Public Health, Boston (K.B.); and the Institute for Social Research, University of Michigan, Ann Arbor (H.L). 08/29/2013. “Coordination versus Competition in Health Care Reform.” New England Journal of Medicine, vol. 369, no. 9, pp. 789–791.

Many current proposals to increase the value of care delivered in the U.S. health care system focus on improved coordination — and with good reason. Badly coordinated care, duplicated efforts, bungled handoffs, and failures to follow up result in too much care for some patients, too little care for others, and the wrong care for many. A host of current reform efforts aim to reduce these inefficiencies in both public and private markets. These efforts range from penalizing hospitals with higher-than-expected readmission rates, to rewarding primary care providers when patients receive higher-value care, to providing incentives for the adoption of electronic health records. Accountable care organizations (ACOs) and bundled payments are designed to create monetary incentives for coordinated care. The hope is that coordination will improve value by ensuring that the right care is provided in the right place at the right time. These laudable efforts, however, may unintentionally be at odds with another strategy for improving value: promoting competition in health care markets. In general, less competition means higher prices; one well-publicized symptom of the lack of competition in U.S. health care is providers' ability to charge different prices for the same service.1 Competition may drive higher quality, particularly when prices are constrained.2 The benefits of competition in private markets may even spill over to higher quality in Medicare, for which the Centers for Medicare and Medicaid Services (CMS) sets prices.2 A number of policy interventions, such as quality-reporting and price-transparency initiatives, are based on the idea that better information can promote competition and lead to greater value, and these initiatives have the potential to be very effective when patients have a choice of providers. Efforts to promote integrated, coordinated care, however, can generate incentives for provider consolidation that may reduce competition — witness, for instance, the antitrust concerns surrounding the implementation of the ACO initiative.3 Consolidation may take the form of vertical integration, such as a hospital's acquisition of physician groups, which has ambiguous consequences for competition, or of horizontal integration, such as the merging of two hospitals, which nearly always reduces competition.2 Consolidation is most likely to raise prices when providers of similar, rather than complementary, services merge — which is why hospital mergers are closely monitored by the Federal Trade Commission (FTC). There are subtler forms of anticompetitive behavior as well. Bundled payments, a darling of procoordination delivery-system reformers, can spark antitrust concerns, as they have done most famously in the case of computer software. The problem arises because bundling offers providers who have market power in one product domain (such as tertiary hospital care) an opportunity to dampen competition in other product domains (such as primary care) by requiring insurers to contract with them for both products in order to receive discounts.4 There is thus often — though not always — a trade-off between coordination and competition. Well-integrated provider networks may promote coordinated care that improves the allocation of health care resources, but they are likely to undermine competitive pressures to keep prices down while maintaining high quality. Coordinated systems may thus deliver the right care to the right patient at the right time, but at the wrong price. Competitive markets may do a better job of keeping prices low, but with the well-documented drawbacks of fragmentation. Some policies, such as the use of electronic health records, can in theory promote both competition and coordination, but only if they are implemented well — an interoperable health information technology (IT) environment, for example, should promote both, but health IT without interoperability may simply lock patients in to their current providers or provider networks by making it difficult or costly to move their records, reducing competition. The opportunities for a win–win are limited. The current suite of policies for addressing the ills of the health care system does not embody a unified approach to the roles of coordination and competition (see table Key Current Policies and Their Potential Effects on Health Care Coordination and the Competitive Environment.). In part, this lack of coherence reflects the fact that our insurance “system” is really several different systems, including moderately competitive private insurance markets for the nonelderly, nondisabled population and a single government payer, Medicare, for the elderly and disabled that largely pays providers set prices on a fee-for-service basis. These two payers currently pursue different approaches to reform. The most recent round of Medicare reform initiatives focuses on coordination, with ACOs as the prime example. In fact, the FTC has signaled that it will weigh the benefits of integration in improving quality against the potential harms of reduced competition.5 For the privately insured sector, the current focus is on enhancing competition through price transparency and “skin in the game” for consumers.

Markets are good at allocating resources within healthcare but not at increasing the total resource pool to ensure total coverage.

Thomas W. O’Rourke 17. University of Illinois. 05/04/2017. “Lost in the Health Care Reform Discussion: Health Care as a Right or Privilege.” American Journal of Health Education, vol. 48, no. 3, pp. 138–141.

Lawrence Singer 17, Associate Dean, Online Learning; Director, Beazley Institute for Health Law and Policy; Associate Professor of Law., Spring 2017, “Health Care Is Not a Typical Consumer Good and We Should Not Rely on Incentivized Consumers to Allocate It,” 48 Loy. U. Chi. L.J. 703, Lexis

Introduction Many believe that health care is, or should be treated as, a "typical" economic good. 1 As such, its delivery and distribution should be governed by "standard economic theory," 2 in the context of a "free" 3 or [*704] "competitive" 4 market. While each of these terms means something different, all of the terms share one characteristic: the primacy of consumers having "complete" or "perfect" knowledge of the good being sold. 5 This knowledge is related to the "value" of the good - its price and quality - so that consumers can make informed choices. 6 Even a cursory review of the attributes of the health care market, however, raises serious questions as to whether consumers have, or can ever have, the knowledge necessary for a competitive market to work in health care. 7 Medical care is complicated, and insurance policies are dense documents. And because we habitually minimize risks that we cannot, or would rather not, contemplate, 8 in a moment of need and [*705] vulnerability, the last thing one wants to do is negotiate prices pursuant to those dense and complicated documents. Of course, this is not to imply that the current health care market is working - at best, the market is characterized as a strange mixture of competition and "command and control" that is lacking in transparency. 9 Prices continue to rise; 10 consumers still find the individual insurance market challenging to navigate; 11 many individuals still lack high-quality, accessible health care services; 12 and many common measures of public health in the United States rival those of third world countries. 13 Still, there is a worry that the current movement toward more fully embracing competition as the means to allocate health care services is fraught with peril. Wrong choices made by patients acting as consumers [*706] lead to delays in accessing services. Even further, some companies may capitalize on the fact that these patients-consumers make wrong choices and might not thoroughly consider all options by incentivizing avenues of care that may be suboptimal with enormous consequences. This Essay advocates that health care should not be treated like any other good and that the vagaries of a competitive free market should not be the approach to achieve health care's so-called "Triple Aim": high-quality, low-cost, accessible health care. 14 This Essay's concerns about the role of competition are further heightened given the current movement toward "consumer directed" 15 or "defined contribution" 16 health care - the idea being that consumers should be empowered to make cost/benefit choices on their desired (if any) type of insurance coverage and then fully bear the implications of those choices. This is very much a competitive market approach, as it assumes that the industry must empower consumers to make self-interested choices to improve quality and reduce the cost of health care. In this defined contribution world, employers will no longer provide health care insurance to workers, 17 but rather will provide a fixed amount [*707] of money that an employee can deposit into a health savings account - along with the employee's own money - to pay health care expenses. 18 Coupled with a high-deductible health plan, whereby the employee is required to pay a minimum deductible of $ 1,300 (individual) and $ 2,600 (family) for catastrophic health care coverage, 19 this "skin in the game" is designed to interject a degree of value consciousness into health care purchasing to parallel any other consumer good. 20 In considering the impact of this expansion of consumer-directed health care and its increased cost-sharing obligations, one must realize that insurance is not just a payment mechanism, but rather the key to entering the health care marketplace. Health care services are expensive, and few can afford a long course of treatment without insurance coverage. 21 While private hospitals have a legal obligation to provide care, this only arises in the context of an emergency or a possible urgent [*708] condition. 22 Private physicians, pharmaceutical companies, and many other health care providers have no legal obligation to provide services or products for free or reduced costs. Therefore, one must present an insurance card within five minutes of visiting a physician. By design, pulling back the scope and level of coverage will cause patients-consumers to consider their need for care. While to some extent, benefit levels and cost sharing have always impacted health care access, the higher level of cost sharing brings affordability of health care to a point where patients-consumers cannot access essential services because patients-consumers are considering the costs of their health care before the service is rendered. Not only has defined contribution thinking taken sway amongst private employers, 23 but it appears to be gaining headway in possible Medicare and Medicaid program reforms. While the views of President Trump's administration continue to be unclear, 24 House Speaker Paul Ryan calls for the implementation of Medicare vouchers, which would enable beneficiaries to shop the private insurance market for the type of coverage they would prefer. 25 And some state Medicaid programs, such as [*709] Arkansas, 26 implemented a version of Medicaid vouchers in addition to the Centers for Medicare and Medicaid Services ("CMS") approving similar programs in Iowa, Indiana, Michigan, and Pennsylvania. 27 Given the significant cost savings associated with a defined contribution approach, the idea is likely to gain even further sway. 28 This Essay argues that overall reliance on competition and free market thinking (particularly value-incentivized consumers) to achieve an appropriate, fair allocation of health care services will cause significant harm to many people. In arguing this proposition, this Essay focuses specifically on the lack of transparency in health care; this lack of transparency means that the sine qua non of a free market - educated, self-interested consumers - is lacking. This Essay also contends that the free market approach will not work because it ignores the reality that invariably society will intercede to "rescue" individuals who made poor choices regarding their scope of insurance coverage, ultimately increasing the cost of every other patient-consumer's health care services. 29 Finally, reliance on this approach [*710] serves to further erode the social compact where everyone should be entitled to the basic building blocks of life to make their way in the world. 30 I. Health Care Lacks Transparency The health care industry is not transparent with respect to price or quality, 31 and its primary beneficiary - the patient - often lacks the capability and capacity to make informed choices. 32 Because an informed consumer able to make value judgments is lacking, the very foundation necessary for a competitive market to work is absent, causing the market to fail. The lack of transparency regarding the quality and price of health care [*711] services has been long known and lamented. 33 And there is a legitimate concern that this lack of transparency will create severely detrimental consequences in the new world of limited health insurance. 34 The nature of health insurance is changing: health plans are minimizing coverage and consumers can expect to bear more of the cost of care and to comparison shop cost and quality to a degree never expected. Invariably, these burdens will result in choices to delay care or seek less competitive, lower-quality options, causing harm. 35 The lack of transparency in large part results from health insurance historically shielding beneficiaries from the full cost of care. 36 Thus, unlike other types of common insurance where coverage is purchased for catastrophic events and rarely used, health insurance has traditionally been designed for the patient-consumer to pay for low-risk, often-encountered occurrences. While society may not agree that everyone has a right to health care, 37 insured individuals seem to agree that this right [*712] exists, because once coverage is secured, they often immediately seek health care services. 38 Indeed, while an important part of the difficulty in pricing insurance products on the exchanges is the lack of younger, healthier individuals opting into the market, 39 another significant factor is the higher-than-expected utilization of services as newly covered individuals seek (presumably delayed) medical care. 40 Government and private insurers have largely focused their efforts on cost containment, giving much shorter shrift to quality. 41 The Institute [*713] of Medicine's 2000 report, To Err Is Human, 42 sounded a clarion call on the poor quality of health care services - likening the number of deaths caused by provider error to a daily crashing of a Boeing 747. 43 Sixteen years later, however, it is fair to say that quality initiatives are still at a fairly basic level of development and implementation. 44 Consumers are traditionally shielded from cost and have focused little on quality. Because of this shielding, there is little consumer demand for tools to assist consumers' assessment of quality providers. 45 [*714] Widespread disparities relating to price and quality, seemingly unhinged from outcomes, are rampant. 46 For many years, the Dartmouth Atlas highlighted significant treatment differences in a wide variety of health care procedures, including tonsillectomies, coronary, stents, and hip fractures - all with no discernable link to quality. 47 Researchers long ago concluded that physician training and practice patterns were responsible for care variation, and that if the nation adopted best practices, then savings associated with standardized approaches would be [*715] immense. 48 Serious efforts at the federal, state, and private levels are underway to provide consumers with quality and price information to enable intelligent choices. For example, on a federal level, CMS' Quality Initiative provides consumers with quality-of-care information and provides the Hospital Compare 49 online platform for consumers to research hospital quality, patient satisfaction, and pricing. 50 In addition, the Patient Protection and Affordable Care Act ("ACA") allotted $ 250 million in state funds for the improvement of price transparency and requires CMS to make standardized extracts of Medicare claims available for provider evaluation. 51 States (e.g., Massachusetts and New Hampshire) 52 have also led the charge to provide information to consumers. 53 Massachusetts pioneered with its October 2013 legislation, which required insurers, physicians, and hospitals to provide health care consumers with the costs of health care procedures ranging from office visits at a primary care provider's office to surgical procedures. 54 In [*716] 2005, New Hampshire passed legislation that created the New Hampshire Comprehensive Health Care Information System, and mandated the creation of an all-payor claims data base ("APCD") and a consumer-friendly public website. 55 This information system collects provider data from a broad array of providers and services, and the New Hampshire APCD lists total and out-of-pocket costs for consumers. 56 Private insurers have also moved to empower consumers. For example, Blue Cross Blue Shield of Illinois provides detailed information on comparisons of in-network versus out-of-network provider services, ranging from CT scans to preferred brand drugs for certain medical conditions. 57 All of these initiatives are supported by incentivizing consumers to focus more deeply on the quality and cost of their care through increases in their out-of-pocket health care expenditures. Even if a consumer wishes to secure price and quality information, however, their ability to appropriately interpret this data may be rudimentary at best. 58 And, in many cases involving elderly, vulnerable, or frail individuals, the expectation of seeking and interpreting data may be completely unreasonable. [*717] To date, for example, leading quality indicators used by the federal government to determine value-based Medicare payments include percutaneous coronary intervention ("PCI") received within 120 minutes of hospital arrival, thrombolytic agent received within thirty minutes of hospital arrival, and ACE Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction and Beta Blocker prescribed at discharge for a heart attack. 59 These particular measurements, however, have very little resonance with consumers desiring to learn the quality reputation of potential providers whose care they may solicit. 60 "Star" ratings, on a one-to-five scale, are more meaningful as they distill a multiplicity of factors in a consumer-friendly manner. 61 But even these ratings may capture areas of little or no concern to a particular consumer, or oversimplify issues causing the rating to be misleading. And, ratings may fail to equalize across patient characteristics, thus incorrectly identifying providers as substandard, for example, because [*718] their patient population is sicker and consequently more prone to poorer outcomes. In sum, meaningful measures of value are lacking in the health care arena. Serious questions also arise regarding consumers' abilities to correctly interpret the available data so as to make reasonable choices impacting their access to quality care. II. There is no Available Proxy having an Interest Unified with Consumers to Evaluate Quality and Cost Data If we grant the notion that consumers may not be able to possess the knowledge necessary for a free market in health care to function, we might next look to see if there is an available agent, or proxy, able to fill this role on consumers' behalves. Logical agents include the government (in the case of Medicare and Medicaid beneficiaries), private insurers, or employers. And yet, the same tangle of relationships responsible for the regulatory burden and confusing incentives rife within health care come to the fore here. 62 The government certainly has mixed incentives that may not give patient interest its deserved primacy. While there are many regulations focused on care quality, at their root, Medicare and Medicaid are insurance programs that have a goal of cost containment. 63 While higher [*719] expenses, of course, do not necessarily equate with higher quality, neither are the two concepts divorced. Thus, the potential competing motivators of cost control and quality enhancement may cause these programs to not always align with patient interests. 64 Private insurers have the exact same issue. The tension between cost and quality in insurer goals is readily apparent in numerous lawsuits over many years. These lawsuits challenged the propriety of payment incentives on physician behavior, where insurers were accused of corrupting physician judgment by compensation formulas incentivizing less, and lower-quality, medical care. 65 The ACA further highlighted this tension by limiting the "medical loss ratio" - the portion of the insurance premium spent on insurer administrative expenses - to 20 percent. 66 In addition, given the high degree of turnover within an insured population, [*720] insurance companies take a decidedly short-term perspective on patient outcomes, often in conflict with a patient's long-term perspective on their health. 67 And, of course, insurance companies function by carefully defining, and thereby limiting, the financial risk they assume, so transferring risk to consumers by definition benefits the insurer. Finally, for many of the reasons articulated above regarding the government and insurers, employers too seem conflicted in their allegiance to access and health care quality. 68 Thus, the industry lacks a proxy with a unified interest with consumers. There is no unbiased, credible party able to make value judgments on behalf of patients-consumers. III. Relying on the Market to Allocate Health Care Is Wrong As the industry continues to move toward a defined contribution era where each patient-consumer is expected to conduct one's own research, balance cost and quality, and shop around, one must remember that not all consumers are equipped to manage these new responsibilities. The ability to access this type of information, process, and make an intelligent decision requires a level of sophistication that many people simply do not possess. 69 Further, unique aspects of an individual's medical condition may render it difficult for patients to properly evaluate competing criteria in a manner that facilitates free market choice. 70 [*721] Because of the highly personalized nature of health care services, the influence of procompetitive forces may actually cause harm to a patient. A patient may gravitate toward an option based on inappropriately weighing the cost of the service, without sufficiently considering the likely outcomes from a quality of life perspective. 71 Finally, even if one wants to assume that an educated consumer can make informed choices in a competitive market, the attendant costs associated with this assumption may be hard to swallow. Externalities abound in health care, as one's health status can have a significant impact on others. Individuals unable to pay for their care may be able to hold off on certain types of medical care for some time, but this often leads to very serious, more expensive consequences. 72 From both an ethical and legal perspective, the industry is not going to deny care to individuals presenting in an emergent situation, even if there is no payor and the cost is high. 73 In the end, however, the nation does not want individuals inflicting the social cost of their care - public health issues, accidents, and the like - on society merely because they were unable to make informed health care choices. 74 Even if we adopt a view of "buyer beware" - leading to high incidences of medical debt - this, too, has significant costs on society. In the end, delayed care is likely to be provided, but at a cost to society higher than might have been borne if it had been provided when first [*722] needed. It is simply unimaginable that there will be an ethos amongst our caregivers, health care institutions, and the public that will accept otherwise. There certainly is a place in health care for a consumer focus on cost and quality. An educated consumer is a good thing. We need to be mindful, however, that we do not attribute to the market a sophistication that it lacks when it comes to allocating as essential a service as health care.

Thomas L. Greaney 17. Thomas L. Greaney is a professor at the University of California Hastings College of Law, in San Francisco. At the time of this work, he was the Chester A. Myers Professor of Law at Saint Louis University School of Law, in Missouri.. 09/01/2017. “Coping With Concentration.” Health Affairs, vol. 36, no. 9, pp. 1564–1571.

The Hodgepodge Of Market-Improving Regulation Health care markets are subject to market imperfections and regulations that facilitate the exercise of market power. Accordingly, several studies have proposed a menu of regulatory interventions that can enhance competition and improve consumer welfare. In its comprehensive survey of regulatory tools, the National Academy of Social Insurance analyzed eleven nonexclusive categories of interventions that promote market competition.45 Martin Gaynor, Farzad Mostashari, and Paul Ginsburg offered a thoughtful analysis of similar “actionable proposals” at the federal and state levels designed to enhance the competitiveness of health markets.1 Awareness of the need to invigorate market competition has also garnered some attention at the state level. Recently, a Massachusetts commission has closely analyzed—without recommending—various interventions to controlling price variation among providers.46 While certainly warranted, these changes— individually or collectively—seem unlikely to have a major impact on the problem of provider monopoly. Some measures act on the demand side by improving the conditions necessary for informed consumer choice, such as laws requiring transparency on price and quality; encouraging consumers’ adoption of health savings accounts; imposing enhanced consumer protections; and facilitating the placement of providers in tiers by health plans. Others seek to enhance buyer bargaining power—for example, by authorizing health insurance exchanges to engage in active purchasing (which empowers state exchanges to selectively contract with carriers, set tougher participation criteria than the federal standards, or negotiate price discounts in order to effectively serve consumers)47 or banning contractual provisions such as anti-tiering (clauses that prevent plans from offering lowercost products or require the plans to include all entities within a health delivery system in the top tier so providers get maximum reimbursement) and anti-steering and “most favored nation” clauses (whereby health plans require hospitals to give the insurer the best price and, in some cases, to charge plan competitors much higher prices), all of which have the effect of disabling health plan bargaining.1,20,48 However, there are reasons to question consumers’ capacity and willingness to use enhanced tools enabled by changes on the demand side to make health care choices in the face of behavioral factors, uncertainty, and fear.49 Moreover, the effectiveness of such measures is questionable, given that a large proportion of health care costs is borne by people who exceed annual out-of-pocket maximums. 17 Even more problematic is the stark logic of the “dominant provider” problem: Empowering consumer choice is of little benefit where choice is lacking.1

Gaffney et al 16. From the Division of Pulmonary and Critical Care Medicine (Dr Gaffney), Massachusetts General Hospital; and the Section of Pulmonary and Critical Care Medicine (Drs Verhoef and Hall), University of Chicago. 07/2016. “Rebuttal From Drs Gaffney, Verhoef, and Hall.” Chest, vol. 150, no. 1, pp. 14–15.

We welcome this important debate, which is unfolding at a critical political juncture. Dr Berdine’s 1 counterpoint has usefully broadened our discussion beyond the issue of single payer to the larger question of the role of the free market in health care. Dr Berdine 1 argues that in an unhindered competitive health-care marketplace, the market will clear at a price and quantity of goods/services that, as if by definition, leaves all parties maximally satisfied. This argument is little more than a tautology that would, if possible, result in a health-care dystopia that society would not accept. Low income individuals might “choose” to spend their money on food instead of asthma inhalers. By Dr Berdine’s logic, this scenario is as it should be, and any intervention by government would only make things worse. Those dying of status asthmaticus might beg to differ, if they were able, as might patients with hypertension who suffer strokes because they elected to cover their rent instead of paying for physician visits. He argues that government involvement in the health care realm has “priced health care beyond the reach of the average person.” 1 It is a rather curious point, because the United States already has a relatively privatized and unregulated health-care system (compared with other high-income nations) while also having the highest costs.2 Furthermore, $375 billion of our expenditures can be attributed to wasteful administrative costs associated with our multipayer insurance market.3 Dr Berdine1 does make a good point when he notes that government-granted patent monopolies can result in high drug prices. To address this issue, a single-payer national health program would directly negotiate with pharmaceutical companies over drug prices. Indeed, the Veterans Health Administration pays 40% less for prescription drugs compared with Medicare, indicating that substantial cost-savings could be achieved by facilitating such negotiations.4

Ryan Gamlin 16, former health care management consultant and current medical student at the University of Cincinnati, 5-21-2016, "Administrative costs are killing U.S. healthcare," Medical Economics, http://medicaleconomics.modernmedicine.com/medical-economics/news/administrative-costs-are-killing-us-healthcare?page=0,0

The United States faces an unenviable paradox: the healthcare sector is an important source of job growth and economic output, but healthcare costs—now comprising nearly one fifth of economic output—are dramatically higher than those in other developed nations, and continue to rise. Warren Buffet summed up this dilemma vividly, saying that healthcare is the “… tapeworm of the American economy… I think the healthcare problem is the No. 1 problem of America and of American business.” Adding proverbial insult to injury, the United States—for all it spends on healthcare—gets far less for its money. The Commonwealth Fund’s report on international health system efficiency ranks the United States last of 11 developed nations on measures such as quality of care, access to care, efficiency of care, and equity of care. The work of the Commonwealth Fund contributes to a body of evidence suggesting that what we’re doing to provide, administer, and finance healthcare is just not working. The Lown Institute is one of a number of organizations working to understand the drivers of inefficiency, waste, and harm in U.S. healthcare, and I recently had the opportunity to attend their annual conference. While there, I presented my research exploring the relationship between a country’s administrative expenditures and health system efficiency. I’ll spare you the details [you can read the abstract here, and see one graph here], but the bottom line is that as countries spend a larger percentage of their healthcare dollars on administration (as opposed to public health, or providing patient care, for example), things get worse for patients and healthcare providers. High administrative expenditures seem to be associated with negative experiences of providing and receiving healthcare. While other countries devote a large share of their resources towards the prevention and treatment of disease, the United States spends a huge portion of our healthcare dollars on feeding the system itself. These huge administrative expenditures “crowd out” other important areas of health investment like public health (US public health expenditures are the lowest among all OECD nations). Not long after presenting my research on administrative costs, I had a curious experience. Listening to a medical school lecture on healthcare payment reform, I heard a number of second-year medical students arguing vigorously that the only way to reduce healthcare expenditures was to pay doctors less. I was amazed. As a percentage of total national healthcare costs, U.S. physician wages are small – approximately 9% – a number among the lowest in the developed world. Not only were these students arguing in opposition to their own self-interest, they were arguing against the facts. As a 2014 New York Times headline put it: Medicine’s Top Earners Are Not the M.D.s. The U.S. devotes a larger percentage of it healthcare economy to administration (doing things like moving a claim through the system, answering patient phone calls, and yes, paying the innumerable and sometimes incomprehensibly large salaries of administrators at insurers, hospitals, and healthcare systems) than any other country. I know few physicians at any level of training or practice who believe that administrators are the primary determinant in their ability to deliver safe, effective, and humane care. How then, have we ended up with a top-heavy system, one in which decisions about how care will (or often won’t) be provided are made by those far removed from the experience of caring for patients?

Enrique Diaz-Alvarez 13, Enrique Diaz-Alvarez works in finance in New York City., 12-9-2013, "The Backroom Deal That Could’ve Given Us Single-Payer," Jacobin, https://www.jacobinmag.com/2013/12/the-backroom-deal-that-couldve-led-to-single-payer

How much compensation? Well, in mid–2009, the total market capitalization of four out of the five top health insurers (the fifth is a nonprofit) amounted to about $60 billion. By then, the stock market had already rebounded nicely from the lows of the crisis, and the uncertainty over Obamacare had largely dissipated, so these were not particularly depressed valuations. Extrapolating this valuation to the rest of the health insurers would have a put a price tag of about $120 billion on the whole racket. This means that buying out the entire health insurance industry at an enormously generous premium of, say, 100 percent, would have cost the Treasury $240 billion — about 2 percent of 2009 gross domestic product. And this figure is highly inflated — premiums for buying out well-established companies rarely exceed 50 percent and are usually closer to 20 percent. Also, I am valuing the dubious claims of non-profit policyholders on par with the more vigorously-enforced property rights of for-profit shareholders. Other than the big smiles on the faces of health insurer shareholders across the country, what would have been the US Treasury’s payoff for writing a $240 billion check? Once again, the numbers are simple, and startling. US private insurance, whether for-profit or otherwise, may well be the most wasteful bureaucracy in human history, making the old Gosplan office look like a scrappy startup by comparison. Estimates of pure administrative waste range anywhere from 0.75 percent to 2.6 percent of total US economic output. Extrapolating again from the biggest four for-profit insurers, in 2008, the industry as a whole claimed to spend 18.5 percent of the premiums it collected on things other than payments to providers. (The other 81.5 percent that is spent paying for actual care is known as “medical loss ratio”. Keeping this ratio down is a health insurer CEO’s top priority.) Medicare, by contrast, spends just 2 percent. The difference amounts to $130 billion, to which we must add the compliance costs the private insurers impose on health care providers — $28 billion, according to Health Affairs. The costs incurred by consumers are difficult to measure, although very real to anyone who’s spent an afternoon on the phone with a health insurance rep. So, to recap, nationalization of the health insurance industry in 2009 would have cost no more (and almost certainly a lot less) than $240 billion. The savings in waste resulting from replacing the health insurance racket with an extension of Medicare would have resulted in no less than $158 billion a year. That’s an annualized return on investment of 66 percent. The entire operation would have paid for itself in less than eighteen months, and after that, an eternity of administrative efficiency for free. And, of course, happy shareholders.

Kenneth Shuster 13, The author, a rabbi and attorney, received his rabbinical ordination from the Rabbi Isaac Elchanan Theological Seminary, an M.S. in Jewish Philosophy from Yeshiva University, a J.D. from New York Law School, and an LL.M. from NYU School of Law. He is an expert in comparative Talmudic and American law and Jewish medical ethics, and has published numerous articles on Talmudic and American law, and comparative Talmudic and American law. 2013. Article: Because of History, Philosophy, the Constitution, Fairness & Need: Why Americans Have a Right to National Health Care. 10 Ind. Health L. Rev. 75, Lexis

Fourth, it is argued that a competitive, private, free market approach to health care would streamline health care costs to make them more cost effective. 102 However, it is precisely the competition between insurance companies in the private sector that has caused the costs of health insurance to spiral out of control and become unaffordable for so many. 103 A single-payer plan, by providing health care to all Americans regardless of their ability to pay, would keep health care costs down particularly because such a program will not need to spend small fortunes on advertising, consumer influence, and the administrative costs associated with these realities. 104 The lack of competition as a cost-controlling mechanism would apply to hospitals as well as private insurance companies. 105

Mueller et al. 17. Dutch Ministry of Health, Welfare, and Sport. 01/10/2017. “Administrative Spending in OECD Health Care Systems: Where Is the Fat and Can It Be Trimmed?” Tackling Wasteful Spending on Health, OECD Publishing, pp. 229–264. CrossRef, doi:10.1787/9789264266414-en.

1. At the macro level: Wide variation in spending on governance and administration 1.1. Administrative costs are influenced by the type of financing system The resources that countries allocate to administrative activities at the system level vary substantially. While the OECD average was around 3% of health spending in 2014, it was double that level in France and higher still in the United States (Figure 6.2). On the other hand, a number of countries report administrative expenditures of less than half that level.

Gerald Friedman 17, Professor of Economics, University of Massachusetts Amherst, 6-29-2017, "Why market competition has not brought down health care costs," Conversation, https://theconversation.com/why-market-competition-has-not-brought-down-health-care-costs-78971

Lemons and cherries So if the rising cost of administration is a primary force driving health care inflation, why don’t we do something about it? That’s because administrative complexity and waste are no accident but rather are baked into our private health insurance system and made worse by continuing attempts to use competitive market processes to achieve social ends other than maximizing profit. Paying a doctor was relatively simple in the 1960s. Most people had the same insurance policy, issued by Blue Cross and Blue Shield, which back then was a private company but operated like a non-profit under strict regulation. But in hopes of controlling steadily rising costs, policymakers encouraged insurers besides Blue Cross to enter health insurance markets, beginning with the HMO Act of 1973. The proliferation of for-profit companies with competing plans raised billing costs for health care providers, which now had to submit claims to a multitude of different insurers, each with its own codes, forms and regulations. Not only that, but insurers quickly discovered the dirty secret of health care finance: Sick people are expensive and make up most costs, while healthy people are profitable. In other words, the vital lesson for an insurer looking to make money is to identify the few sick people and get them to go away (“lemon dropping”) and find the healthy majority and do things that attract them to your plan (“cherry picking”). Insurers are happy to offer discounts on fitness club memberships to attract healthy people, for example. But they punish the sick with higher copays and deductibles, as well as increasingly restrictive and intrusive regulations on preauthorization. Economists call it adverse selection. Regular people call it paperwork hell. Whatever the name, it’s the purpose of increasingly complicated insurance plans and reimbursement forms.

David DeGrazia 08. American moral philosopher specializing in bioethics and animal ethics. He is Professor of Philosophy at George Washington University. 02/2008. “Single Payer Meets Managed Competition: The Case for Public Funding and Private Delivery.” The Hastings Center Report, vol. 83, no. 1, pp. 23–33.

Perhaps the most serious disadvantage of leaving the private insurance industry largely in place is that it pre serves adverse selection, which leads insurers to avoid insurance risks and limit their coverage. Adverse selection in health care occurs when a dispro portionate number of people in poor health select a particularly generous insurance plan.22 Where insurance companies compete as payers, they typically differ in the services they cover and in reimbursement rates. Suppose plan A covers outpatient psychiatric servicesw hile plan B does not, orA reimbursesm ore generously for such services. Patients with psy chiatric problems may gravitate to A, which results in A enrolling many people who need extensive services. This is very costly for the company that administers A. Given variations in different plans' terms, and given that patients may choose from among these plans, the threat of adverse se lection encourages health plans to offer less generous benefits and to ad vertise to wealthier, healthier groups, or to find other ways of avoiding those who most need health care. Now, a system could address the threat of adverse selection by requir ing that each plan cover the same ser vices and charge the same premiums, deductibles, and so on, and by guar anteeing that anyone can enroll in any plan. Standardization of the basic terms of each plan in a system of truly open enrollment tends to level the playing field. But if the terms of each . plan are to be uniform, why have dif ferent plans at all? A champion of competing plans might reply that each is to deliver health care, never merely provide in surance (as Blue Cross and Blue Shield do). Competition in delivery, the argument goes, will promote quality, thereby justifying higher ad ministrative costs. This may be cor rect. Note, though, that each move identified for avoiding adverse selec tion?standardizing prices and cov ered services, maintaining open en rollment, and requiring competing plans to deliver services?steps in the direction of a single-payer system. Later we will return to the prospect of merging single-payer financing with competition.

Don McCanne 16, McCanne is MD from the University of California at San Francisco, Senior Fellow and President at Physicians for a National Health Program, 1-14-16, “Disentangling moral hazard and adverse selection,” http://www.pnhp.org/news/2016/january/disentangling-moral-hazard-and-adverse-selection

In health insurance, moral hazard occurs when individuals obtain more health care than they would have if it were not paid for by the insurer. Adverse selection occurs when individuals with greater health care needs select plans that provide greater coverage. Both have an impact on health care spending. This paper estimates the relative impact of each of these in spending under private health insurance. Each is responsible for roughly half of the differences of expenditures between the most and least generous health plans. So enrollees in the more generous plans pay higher premiums because of both moral hazard and adverse selection. Today’s standard in insurance coverage is shifting towards lower actuarial value plans - plans that pay a lower percentage of the total health care costs. What does this study tell us about premiums for these less generous health plans? As more people enroll in them, which they are, the premiums increase to cover the additional expenditures for those who otherwise would have enrolled in the more comprehensive plans. The lower actuarial value plans are subject to favorable selection (the healthy buying less expensive plans in anticipation of not needing care), but that diminishes as higher cost patients move from the more comprehensive plans into these cheaper plans.

Julian Jacobs, “Should reducing inequality be a central bank mandate?” Official Monetary and Financial Institutions Forum, 1-27-23, https://www.omfif.org/2023/01/should-reducing-inequality-be-a-central-bank-mandate/

Moreover, a central bank’s political independence is particularly important to its functioning, especially in a moment of heightened polarisation and partisanship. A more holistic model that identifies inequality as a specific mandate could threaten to erode that independence and encourage more partisan behaviour. Such an outcome would be both economically hazardous and politically toxic – central bankers are unelected officials with no mandate to weigh into partisan policy debates beyond their monetary responsibilities.

Mehdi El Herradi and Aurélien Leroy, “Monetary policy and the top one percent: Evidence from a century of modern economic history,” Working Paper No. 632, De Nederlandsche Bank, April 2019, https://www.dnb.nl/media/jbybr2et/working-paper-no-632_tcm47-383633.pdf

5 Conclusion