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Putting single payer in the mix

<p>&lt;p&gt;Following up on an earlier item, President Obama spoke at length about the economy today, but he also fielded a question from the AP about health

Following up on an earlier item, President Obama spoke at length about the economy today, but he also fielded a question from the AP about health care and the Supreme Court. After talking a bit about post-New Deal precedent, Obama addressed the goals of reform in general.

"...I think most health care economists who have looked at this have acknowledged, is there are basically two ways to cover people with preexisting conditions or assure that people can always get coverage even when they had bad illnesses. One way is the single-payer plan -- everybody is under a single system, like Medicare."The other way is to set up a system in which you don't have people who are healthy but don't bother to get health insurance, and then we all have to pay for them in the emergency room. That doesn't work, and so, as a consequence, we've got to make sure that those folks are taking their responsibility seriously, which is what the individual mandate does."

As a substantive, policy matter, this is largely uncontroversial. Those familiar with the debate have known these basic truths for quite a while -- if the goal is to guarantee coverage for all Americans, the country has a few large-scale options: move towards a single-payer system (like the United States has with Medicare), a multi-payer system (like the United States has with the Affordable Care Act), or a government-run system (like the United States has with the V.A. system). The details matter, of course, but these are the alternatives from 10,000 feet.

It's inconvenient for Republicans now, but the GOP line has generally been to stick with Door #2. It's what moderate Republicans wanted in the '90s, and it's what Republican elder statemen like Bob Dole and Howard Baker recommended in 2009. Obama and Democrats agreed, only to discover that the GOP deemed a multi-payer system to be a Nazi/Communist/Fascist plot to destroy civilization. And if Republican justices on the Supreme Court agree, it will probably close one of the three doors, removing multi-payer from the list of choices.

I don't imagine Obama was hinting this afternoon, and we can explore this in more detail in the coming months, but his comments were nevertheless a reminder that "Obamacare" was the Republican-friendly approach to health care reform, proposed as part of a willingness to compromise and find common ground with a centrist/moderate reform package. If the GOP kills it, as now appears likely, those who care about providing health care coverage to Americans will have no choice but to pursue one of the other policy alternatives.

The president mentioned single payer today as one of the alternatives. Depending on what the Supreme Court says, he won't be the only one mentioning it in June.

Postscript: I'd be remiss if I neglected to mention that Republicans traditionally supported multi-payer, along the lines of "Obamacare," as a way to reform a dysfunctional system. But if/when multi-payer is dead, GOP leaders -- including Romney, McConnell, Boehner, and others -- don't intend to replace it with an alternative reform package; they intend to simply allow the dysfunctional system to continue indefinitely. "Repeal and replace" is dead; it's been replaced with "repeal and don't get sick."