Most of the liberal advocacy community seems pleased--in many cases, very pleased--with the Obama budget proposal on heath care. But there are exceptions, particularly among the best-known champions of single-payer reforms. One of them is Don McCanne, the president of Physicians for a National Health Plan (PNHP). He expressed particular concern about the savings Obama expects to extract from reform:

Although everyone agrees that slowing the increase in health care spending is essential, the budget proposals do not adequately address this. As examples, an information technology system will have very little impact on total health care spending, and competitive bidding amongst Medicare Advantage plans leaves in place our inefficient, fragmented, costly system of health care financing. Just yesterday, Nobel Laureate Joseph Stiglitz, who served in the Clinton administration, said that he has come to the view that single payer is "the only alternative." Only fundamental structural reform of our health care financing system is capable of achieving our goal of affordable, high quality care for everyone. Budget tweaks won't do it. 

I also approached Steve Auerbach, who is better known to the online community as "Dr. SteveB," the name he uses at DailyKos. He's a pediatrician and epidemiologist, as well as a PNHP member. He offered a broader rejoinder, although cautioning that he speaks only for himself and not necessarily for any affailiated group:

If we are serious about achieving health care coverage that is universal (all people), comprehensive (all care) and controls both total costs (percent of GDP) and individual cost (so you don’t go bankrupt from out of pocket costs), then single payer “expanded and improved Medicare for All” is only to go. All independent analyses agree, be they the General Accounting Office and Congressional Budget Office in the 1990s to the Commonwealth Fund/Lewin Group in 2009.

Obviously insurance works best to spread the risk when the pool is as large, generalized and unselected as possible - that is means all American, everybody-in; nobody-out.  Why is proposal that makes the most sense economically, and has 60 percent support among both the American public and physicians, be pre-determined and pre-compromised off the table? 

Mandate plans such as Obama/Baucus are in effect a bail-out of the private insurance companies that add no value to the health care system. Reducing the federal tax benefit such as Wyden and Republicans support, just shifts the cost from the Federal government to state government, employers and individual.

None of these proposals, other than single payer, actually controls total system costs, nor the risk of a big hit to individuals when they actually get sick and need care. None takes advantage of the benefits of the savings between the efficiency of 3 to 4 percent Medicare overhead, compared to the inefficiency of the 15-20% overhead inefficiency; the savings inherent in monopsony, in global budgeting and rationalized planning. 

While I support President Obama’s goal to move quickly and makre reform finally happen, I worry about what happens next when it fails. What will reform 2.0 be? If the Democrats do manage to pass the sort of plan being touted by Obama and Baucus and Wyden, what happens in a few years when costs are exploding and care is poor? Who will be blamed politically? Will it be assigned, as it should be, to Beltway centrist conventional wisdom that ignored single payer and forced us to accept more of the proven failure of private insurance companies, for-profit HMOs and hospitals?  Or, as I fear, will the blame somehow go to “liberals,” and send the U.S. back to even worse free market fundamentalism?   

For the record, I'm not sure I agree with his assessment of the Baucus, Wyden, and Obama approaches. In fact, I'm pretty sure I disagree, at least in part. I also think Don is wrong to dismiss the Obama reform vision as mere "budget tweaks." But that's a bigger discussion, for another day.

--Jonathan Cohn