With single payer, inventors will compete to get their inventions covered. And they’ll have to prove to a board that they’re better than existing modalities. Will it be perfect? No. Better than what we have now? Probably. Might it be worse? Maybe. Looking around the world, you should be able to find plenty of examples.

> private sector bureaucrats will generally give treatment
> to anyone who can pay the insurance premiums they require.

On what planet? There is a constant fight over “medical necessity” between private sector bureaucrats and docs/patients. And when that fight is fought, there is another one about how much to pay for the treatment. One problem the insurers face is that they basically can’t write a simultaneously useful and clear contract because of biomedical uncertainty, the pace of innovation, agency problems, and biomedical uncertainty. And the courts always construe against the stronger party to a contract. So whenever some sad case comes along, the insurer ends up paying regardless of all circumstances. And when the courts don’t do it, the legislatures will. Patients lobby to get an “any possible benefit” level of decision-making turned into “standard of care”. Every possible or impossible “provider” wants “equal access” to patient/insurer funds, making it impossible to write a contract that forecloses aromatherapy or whatever. They lobby legislatures to write insurance regulations to make it happen. If a healthcare board worked like the Fed, this would be more difficult and we’d probably end up with a market more competitive than the one we have now because the information asymmetries would be narrowed and the board would be more independent than even the insurers are today.

Besides, it is possible to socialize actuarial risk to address social justice concerns, and leave allocation decisions in the private sector. We could have an Enthoven-ish sort of system that is “single ultimate payer” but doesn’t create a huge government bureaucracy — it creates lots of medium-sized private bureaucracies.

As for choice, it is not the highest good. That said, I bet though that a system of socialized acturarial risk opens more choices people actually value than it forecloses in total scope. I know, I’m a heretic.

t