What’s wrong with single-payer isn’t the cost; it’s the single payer.
Leon Trotsky — n.b., Millennials: He was Alexandria Ocasio-Cortez before she was — understood the power of single-payer systems: “The old principle: who does not work shall not eat, has been replaced with a new one: who does not obey shall not eat.”
The socialist powers of Trotsky’s time made good on that promise: They intentionally starved to death something on the order of 10 million Ukrainians and peasants in the other socialist republics who resisted the political project of “collectivization,” i.e., single-payer agriculture. Those fleeing the man-made famine were shot. Bringing the “New Socialist Man” into being entailed murdering many millions of the old kind.
F. A. Hayek, the economist and classical-liberal political theorist, understood the power of single-payer, too. Under comprehensive socialism, he argued, the state would be in practice the sole employer — i.e., single-payer labor — which would give its administrators powerful and probably irresistible powers of coercion over workers on the lines envisioned by Trotsky: Political dissidents could simply be excluded from the employment that would be the only means of material survival. There could be one big Holodomor killing millions, or millions of little holodomors stamping out a political dissident here, a critic there, a poet, a novelist, an artist . . .
Hayek, perhaps partially foreseeing our current witch-hunting environment in which the enforcers of political orthodoxy have recruited the employers as their instruments of discipline, worried about the rise of salaried employment as the standard model of compensation and the decline of the economically insubordinate class of the independently wealthy and unencumbered entrepreneurs. He was picking up the thread from John Stuart Mill, who worried about both official tyranny and “the tyranny of the prevailing opinion and feeling; against the tendency of society to impose, by other means than civil penalties, its own ideas and practices as rules of conduct on those who dissent from them; to fetter the development, and, if possible, prevent the formation, of any individuality not in harmony with its ways, and compel all characters to fashion themselves upon the model of its own.” I get into this at considerably greater length in my upcoming book, The Smallest Minority, but for the moment consider only the ways in which “single-payer” and other monopolistic systems of one kind or another create an entirely new class of “civic penalties,” e.g. the kangaroo courts on university campuses that suppress unpopular political views. It took a Supreme Court ruling — an opinion opposed by the so-called liberals on the court: Ginsburg, Kagan, Sotomayor, and Breyer — to liberate certain public-sector workers from the requirement that they affirm political speech with which they disagree as a condition of employment.
We have seen an emphasis on political policing in the licensed professions, e.g. Sarah Frostenson’s essay in Vox arguing that a physician’s party registration is necessarily relevant to his performance of his medical duties. She quotes Etan Hersh, a professor of political science (not a professor of medicine), who says his research confirms the relevance of politics to medical treatment: “Right now when you try to look up a doctor, it tells you where they went to medical school, because there is a belief that you’re going to get different quality care depending on where someone went to school. If what we’ve found is right, Democrats and Republicans treat patients differently and patients should absolutely be able to figure that out.” Consider the American Academy of Pediatrics’s effort to pressure its members into acting as surrogates for the gun-control movement for an example of how that is likely to play out.
When progressives such as Representative Ocasio-Cortez propose to create new benefits such as a single-payer health-care system or a universal college-tuition benefit, the most frequent conservative rejoinder is: “That’s a nice idea, but we can’t afford it.” The reality is something closer to the opposite: We can afford these things, but they are terrible ideas for other reasons. The United States has a GDP per capita substantially higher than that of Sweden or Denmark — we could easily afford a Nordic-style welfare state if the U.S. middle class were willing to accept Nordic levels of taxation. (It isn’t, and that, rather than the machinations of plutocrats, is what actually stands in the way of the Democrats’ daydreams.) We can afford these things in the sense that an irresponsible 19-year-old thinks “I can afford it” is a synonym for “I have enough money in my bank account to complete the purchase.” (Or, worse, “I have enough in my bank account and available credit to complete the purchase.”) Financial costs aren’t the only costs.
The case against a single-payer health-care system is not only, or principally, its cost. It is that government-enforced monopolies are undesirable for other reasons, from their propensity to abuse their monopoly positions to the fact that they cultivate an attitude of dependency — which also can be exploited for political purposes. Just as workers have more power in an economy with a large number of employers competing for their labor, would-be college students and health-care consumers are better off when they have a great range of choices offered in an environment of strong competition. (The best indictment of the U.S. health-care system, pre- and post-ACA, is that it does not actually produce or encourage such a consumer-empowering environment.) Monopolies in the public and semi-public sector are no more desirable than monopolies in the private sector.
Bureaucracies and their masters almost always abuse their privileged positions, and they do not much care for criticism of those abuses. Ask Leon Trotsky: The man who split his skull with an ice ax was awarded the highest honor offered by the socialist government he helped to create.