Single Payer? Take a Look At How South Korea Did It.

Joshua Holland writes in The Nation that progressives need to get serious about universal health care. In a presidential campaign, it might be OK to vaguely suggest full-blown single-payer with no copays, implemented by 2018. In real life, every country relies at least partly in private insurance. Every country also requires out-of-pocket expenses: no country literally pays 100 percent of all health care bills. Nor were any of these universal systems implemented instantly, even 50 years ago. Today, health care in America is a $3 trillion business. It’s not even remotely feasible to blow up the biggest industry in the country in only a year or two.

Holland is right about all this. If the reasons aren’t obvious to you, click the link. The takeaway should be pretty obvious too: the only feasible way to get to single-payer is to do it over a period of a decade or two. Holland mentions this briefly:

An obvious alternative to moving everyone into Medicare is to simply open up the program and allow individuals and employers to buy into it. We could then subsidize the premiums on a sliding scale. But recent experience with the ACA suggests that this kind of voluntary buy-in won’t cover everyone, or spread out the risk over the entire population

He then goes on to describe a “Medicare for More” plan from Jacob Hacker. But a better idea might be to look at how other countries have done it. South Korea, for example, began moving to universal coverage in 1977 and finished in 1989. Jong-Chan Lee explains how it happened:

How did Korea succeed in providing health insurance to the whole nation within 12 years? Before 1977, Korea had only voluntary health insurance. In 1977, President Park Chung-Hee and the legislature passed a law that mandated medical insurance for employees and their dependents in large firms with more than 500 employees.

Gradually health insurance coverage was expanded to different groups in the society: in 1979 to government employees, private school teachers, and industrial workplaces with more than 300 employees, and in 1981 to industrial workplaces with more than 100 employees. In the late 1980s, health insurance expansion became regionally based, first to rural residents in 1988 and then to urban residents in 1989. Each of these expansions was mandated by government.

This is roughly the model we need to follow. The first step might be Medicare as an option on the Obamacare exchanges. Then Medicare for everyone up to age 26. Then Medicare for all federal government employees. Then Medicare as an option for all state employees and retirees at a set price. Then Medicare as an option for small employers. Then large employers. Within a decade or two, private insurance would be, to borrow a phrase, so small you could drown it in a bathtub. At that point, the funding model would change—maybe gradually, maybe quickly—so that Medicare eventually becomes free for everyone, paid for fully by taxes.

Alongside all of this would be gradual changes to Medicare itself. Maybe we’d keep Medicare Advantage, maybe not. We should add long-term nursing care. Negotiated drug prices. Better preventive services. Prenatal and pregnancy services. Etc. Medicare’s 80 percent actuarial rate (i.e., it pays about 80 percent of your medical bills) is in the ballpark of what other countries offer, but because it’s currently aimed at the elderly it would need some changes to make it work well for everyone else.

I’m not offering this as a proposal, just as an illustration. There are probably better ways to phase in universal health care. But it’s at least feasible to do it this way, and it would be even more feasible (and faster) if we could actually legislate a timeline, rather than just adding bits and pieces whenever we can. That’s pie in the sky right now, but who knows what the future holds? Republicans might eventually get tired of hitting their heads against the health care wall.

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