Do you know Sarah Kliff? I wish I knew her personally. She’s smart, she writes well, and she cares about things I care about. In December 2014, she wrote a great article about Vermont’s attempt to create a state-wide single-payer health care system and factors that brought that attempt to a screeching halt, namely $$$. As single-payer afficianados fan the flames of Medicare for All today, it’s worth re-reading her article.

I’ve read and listened to Kliff enough to know that she understands health care and can communicate its complexity in terms we can understand. The article linked to above contains a nice, short video explaining single-payer should you need a refresher course. Substitute “Medicare for All,” if you prefer, but Vermont’s governor felt that the term single-payer explained exactly the change he wanted to bring about.

If, as many of us know, our “million-payer” system diverts billions of our health care dollars toward insurance company and provider overhead, why is it that a single-payer system wouldn’t be cheaper just by eliminating those charges? Kliff describes the desperate attempts by economists and health reform professionals to tinker with the numbers to come up with a viable plan. Shift more costs to consumers of health care services; cover fewer services, etc.; but the plan people were hoping for was just too expensive.

Kliff explains how altering the way we pay for health care affects people in different ways depending on whether or not they are currently enjoying benefits through an employer or paying on their own, and on whether they are making lots of money or just getting by. Paying through progressive taxes shifts the burden to people who are better off, and many of them are smart enough to figure that out. This is one source of opposition to single-payer.

Ultimately, our current exorbitantly high health care costs make reform that much more difficult. Some reform proposals try to lower costs for healthy people by taking sick people out of the “pool” of insured people. In the past, many states created special health plans for high-risk people, i.e. people who were already sick and couldn’t get insurance. Those plans were problematic (often didn’t cover the condition that prevented people from getting insurance, and/or were exorbitantly expensive) and never covered more then a tiny percent of people.

Other proposals would remove or severely limit any mandated benefits, enabling companies to offer very skimpy plans. (When my husband had a bad bicycle accident while we were in college, our college plan had a total benefit of $1000. That was years ago, but a $50,000 plan today wouldn’t cover such an event.) Often plans prior to Obamacare didn’t pay for maternity care, hence half our babies were paid for by Medicaid. (And men, don’t set me off by complaining about sharing the cost of maternity care with you. How do you think those babies got there?)

Republicans love to talk up health savings accounts, and, in all honesty, I don’t have a big problem with health savings accounts. Except for the fact that they wouldn’t do anything for people with chronic conditions. HSAs would definitely help regular folks who break an arm once in a lifetime, or have kids who can only have an appendectomy once. They’d help lower premiums for people who don’t use the system much, and people would have a little personal pile of money that was dedicated to health care expenses. They’d be covered for occasional expenses from their HSA while having the security of catastrophic coverage for some big accident or cancer or heart surgery.

Once a person develops a chronic condition or needs care in consecutive years, the value of the HSA disappears. And really, HSAs can’t do that much to control our overall costs. They don’t decrease the complexity of a million payers; they don’t diminish demand for the many procedures and many tests that are covered once the deductible is met. And unless money is put into the pot for those less well off, HSAs don’t help low income families that can’t set aside the dollars for the HSA.

Personally, I think our best bet for now is to maintain the commitment we’ve made to cover people through Obamacare while doing all we can to strengthen its cost containment features. If we can find a way to control health care costs, single-payer becomes more viable. But, then, any scheme is more viable if we can control health care costs, so let’s get on it!