I firmly believe that "single payer" would get a lot more support if people stopped talking about it in grandiose themes and noble vignettes and started talking about it in real terms. All the liberals I know are in heavy favor of "single payer" without any of them knowing what the fuck it is.

HERE'S WHAT THE FUCK IT IS.

I've got a medical facility - Al's Medicine. Al's subcontracts to Betty the Biller and Cindy the Client Specialist. I operate in a state where my medical facility is covered by Medicaid. We also take private (employer-provided) insurance, which is underwritten by the following insurance firms: Q, R, S, T, U, V, W, X, Y and Z.

Al's must sign individual contracts with Q, R, S, T, U, V and W. These contracts are "take it or leave it" binding: they say that for ICD code 1, Q will pay Al's $7.50 but for ICD code 1.000000001, Q will pay Al's $0.00 because fuck you, Al's. Note that Q might pay Joe's $6.50 or $9.50 or pi.ie^2 for ICD code 1. Q is entirely within its rights to do so. Al and Joe, on the other hand, are contractually forbidden from discussing their rates for ICD Code 1. If Q gets wind that Al and Joe know what the other are getting, they can drop both because fuck you, Al and Joe. Also know that Joe might not get anything for ICD Code 1 because Q has decided that all of Q's contracted healthcare clients can drive 75 miles to Al's for those services because fuck you, Joe. Also know that Q can tell Al's they'll pay $7.50 for "services" verbally and in writing, but when the actual contract comes through the actual number listed is $2.25 because fuck you, Al's. Also know that they won't tell you what ICD codes they'll pay for, they'll just say "services" and let you resubmit your bills over and over and over again until you find the ICD code that pays out the most because fuck you. Also know that the ICD code they choose to pay for can and will also change because fuck you.

A few other notes: Al's might have to provide, for example, rhogam shots to prevent babies from dying from blood type incompatibiliy. These rhogam shots might cost Al's $28 but Q is going to pay $7 because fuck you, Al's. If you ever wondered why hospitals charge you $40 to hold your baby it's because they're trying to claw back the $21 the insurance company isn't paying for medicine they're required by law to administer (for example). Also note that your involvement, gentle consumer, starts when you get an "explanation of benefits" from the insurance company listing all the outrageous charges the doctor hit you with. It will provide no explanation. It will show how generous they were in all their disbursements and then show you that your doctor's office is going to bill you STILL MORE MONEY because they're such bloodsuckers.

This is where Betty Biller and Cindy Client Specialist come in. Betty makes 10% by pickaxing all the money she can get out of Q. Betty's whole job is knowing what Q pays out on. Betty knows which ICD codes Q pays out what on, and can turn your "normal child checkup" into 42 different codes that pay the maximum rate Q has contracted to pay. She is literally a medical billing bounty hunter. Betty is the back office side while Cindy talks to you, the client - here's what's coming, here's what it means, here's how to get your insurance to pay for this ahead of time, here's how to get preapproval for that.

For those keeping track at home, billing specialists outnumber doctors 2:1 in this scenario.

Multiply times insurance companies R, S, T, U, V and W, who all have their own rates, all have their own codes, all have their own geographic exclusion areas, and probably have seven or eight sub-plans so that it's not actually "V" it's V.a, V.b, V.c, V.d, V.e, V.f and so on. Suddenly, Betty and Cindy look positively useful and you will pay them gladly because the act of billing for care takes three to four times as many man-hours as actually providing that care. Betty and Cindy make good livings and their existence is entirely parasitic on the insurance companie's deliberately opaque, byzantine and antagonistic reimbursement practices.

Not Y and Z, though. Y and Z contract through Medicaid. Medicaid has no patience for that bullshit. They will pay the following amounts on the following ICD codes. Anybody who contracts through Medicaid bills those codes and gets that money. It is known. Y knows, Z knows, Al knows, Joe knows, and all of Al and Joe's clients can fuckin' look it up. And when Medicaid's reimbursements lag behind the real world, it gets turned into a bill that goes to the legislature that raises the rates for everyone.

Al's, in fact, might get better reimbursements out of Y and Z (because of medicaid) than they get out of Q, R S, T, U or V.

Unfortunately you as a patient don't get your insurance through Y and Z because you make more than the poverty level for your county. You get whatever insurance your job provides, which might be V.c, might be Q, might be nothing because you drive for Uber and fuck you.

As a provider, we get to choose who we contract with. We do not get to choose what those providers pay us. And if 50% of your clients work for Microsoft, you bloody well better be able to take V.c, despite the fact that they reimburse at exactly half what Medicaid reimburses at (which is funny, because all your Microsoft mommies make six figures). R, on the other hand, may decide that they'll never cover you because they have enough of your specialty in network, never mind that the nearest provider is a ferry ride away (because this way they don't have to pay for those services).

As an insurer, you get to decide who you contract with. You can pick the providers that are the stupidest, that will accept the lowest rates, that have the lowest conflict rate of you arguing over charges. And you get to discuss this with the HR reps of companies large and small, none of which have any background in medicine, medical billing, accounting or statistics. To no one's surprise, they choose on price.

But the poor people? They pay what the state says they pay, the insurance companies collect what the state says they collect, and they contract with the providers the state says they contract with.

THEY STILL MAKE MONEY.

They're still private insurance companies, privately managing your health care, privately paying out private doctors. It is not "socialized medicine." It is not "universal healthcare." It is not the National Health Service. The healthcare industry is something like a tenth of the US economy; you're never getting that. But you go single payer and all of a sudden things go from back-room knife fights between Q, R, Betty and Cindy to state-mandated pricing and state-mandated coverage.

My future is tied to health care. I've got more in a medical practice than you have in your house.

And I'm a big booster of single payer.

And so's Aetna, who in this example is R.