so, what's with this idea that you can just put single payer healthcare and private insurance on the table and have them compete with each other? isn't that reasonable? won't the best option work out?

this is an idea being pushed by buttigieg mostly, by i think also by o'rourke.

in canada, as well as other countries like the uk, we call this a two-tier health care system. and, we call it that for a reason - because we know the private insurance packages will provide better choice. see, and i think this is the cultural difference that probably explains why americans don't have a public system in the first place....

if you tell canadians or brits or most other europeans that a two-tier system will offer greater health care in the private sector, we'll react by saying that's unfair. so, we will reject the two-tier system because it offers an inequality of outcome, and we believe to our core that this is something we should all have equal access to. i haven't seen a study, but i'm not convinced americans will have the same reaction. rather, i might expect americans will prefer the option that gives them greater access over their fellow citizens, because they care more about maximizing their own self-interest. fuck your neighbour, right? that's the american way.

i consequently realize that i need to be a little bit careful about the language that i'm using, if i'm addressing a mostly american audience.

we have a case study, namely quebec. quebec was a french colony that was conquered by the british in the french & indian war, aka the seven years war, a mere couple of years before the american revolution. in a sense, it's kind of like texas or california - an area that was initially settled by a more latin culture, in our case french and your case spanish, before it was absorbed by the anglo-american empire. i don't know what kind of lingering influence that latin civil law has had in the southwest (or southeast, including florida....or, i guess just south including louisiana), although i can say i've never heard of a case in texas or florida or california being adjudicated over civil law, but the british largely let the french keep their language and laws upon the conquest. it's tricky, and i don't want to present myself as an expert in the topic. i'm a loud, forceful advocate of the common law system as fundamental to the existence of the freedoms that we enjoy in the west; i don't think we'd have this thing called western civilization if it was left solely to the civil law. but, the point i'm getting at is that quebec has a parallel system of law to the rest of the country, so sometimes things are determined a little bit differently there.

and, a few years ago, the highest court of jurisdiction in quebec, specifically, actually declared the single payer healthcare system (which is, by definition, a monopoly on health insurance) "unconstitutional" under the quebec bill of rights. so, it's unconstitutional in quebec, but not in all of canada. and, the reason they did that was that the complainant successfully argued that it prevented people from accessing health care through parallel channels, when forced to wait in line for care through the official channels. what the court actually did (and this is based on the precedent in our abortion jurisprudence, r. v. morgantaler) was give the state a choice: increase funding to cut wait times, or give people the choice to buy their way around it. see, the reason it was deemed a human rights violation is that the monopoly on insurance, in conjunction with the wait times, amounted to a denial of service (which was the same argument they used to strike down the abortion laws). so, they'd either need to cut the wait times down or give the patient an ability to buy around it, to alleviate the human rights violation. many, many observers believe the intention of the court was to increase funding (and while judges are powerful in canada, they don't have power over the purse, that's up to parliament), and that the parliament took it as an attack on their own powers, and suspended the law out of spite.

so, in quebec, and in quebec only, you have a two-tier system. and, that means we have data. and, you know i like data.

it's pretty brutal, actually. average wait times in quebec, which are what the ruling was supposed to address, are now, by far, the highest in canada. there are doctor shortages. it's a catastrophe. and, that is all happening while the private industry is posting shorter wait times and more comprehensive care.

again: would an american see that as a problem? that's not clear to me. but, canadians recognize that the two-tier system separates care by ability to pay. it essentially allows people to buy their way into the front of the line. so, you have one system for the rich which is very fast and exclusive because it siphons resources out of the public system, and another system for everybody else that is underfunded and slow as fuck.

so, can you set private and public insurance against each other and expect them to compete on a market and determine which is better? it sounds like something nixon would say to khruschev, and it's based on a fundamental misunderstanding of what competition is, as well as a fundamental misunderstanding of how the health care industry works.

it sounds reasonable at first, i get that. but, please do your research on outcomes of a two-tier system, including comparing quebec to the other provinces in canada. and, ask yourself that question: do you want a system with equality of outcome, like the rest of the developed world? or do you want a system that you can buy yourself a special place in, if you can afford to do it?