Even with Platinum coverage, you still get narrow networks

[OmahaBlueDog]

50. While I'm not against single payer, I think there is a seriously false premise here

...physicians are placed in an “ethical bind” as they practice under “a corporate medical model that threatens to squeeze the humanity out of our interaction with our patients.”

I don't see physicians as victims of a soul-crushing corporate system. I see them as equal players in a game that has four players: the physicians, Pharma, the for-profit health insurance market, and hospital networks. As with all games, the players are sometimes partners and sometimes opponents, but they all have one goal -- skim as much money from the system as possible.

Yes, all of these players, at some level, are there to help people and improve health outcomes -- in the same way that American Eagle wants to sell you trendy clothes or that Chipotle wants to sell you addictive, overly large burritos. However, the principal goal of all of these enterprises is to make money.

The narrow and ultra-narrow networks were a decision of the insurers, not us.

Look closer. The decision is partly driven by insurers, to be sure. However, the system is equally driven by hospitals and physician networks. Nowhere is that more evident than Nebraska: Alegent (a network of Catholic hospitals) and Creighton (the hospital associated with the Jesuit university of the same name) merged to form Alegent-Creighton Health. They have their own physician network, their own clinic, and their own pharmacies to which they try to steer you. This caused the Nebraska Medical Center (the University hospital in Omaha), Bryan-LGH (the hospitals in Lincoln), and Methodist to form their own counter alliance. So, now, money that could have been spend on improving patient outcomes is being spent on advertising campaigns. Hospitals invest millions in upgraded birthing suites to impress would-be parents into having their offspring in one network's hospital or the other, and then getting them hooked on taking their precious bundle to that network's pediatricians.

Insurers like physician network deals because they get a rate guarantee across specialties, and they get to offer customers something that doesn't have the annoying features of an HMO ("look Ma, no referrals&quot , but (in practice) offers them all of the benefits of an HMO.

I'd add one more thing. If you think single-payer in America would be see-any-doctor-you-want, get-any-procedure-you-need, and get-any-drug-you-want, I personally doubt it. Not even Medicare works that well. First, if government single payer comes, the likelihood is that it will look like the world's largest HMO. Being that this is America, a lot of doctors will simply opt out if they see this as a pay cut. They'll go private-pay only, or they'll leave and go care for ex-pats in Belize and Nicaragua. Many Hospitals will offer the cheapest, least amount of service they can get away with (to be fair, some do that now).

I'm not knocking you or your desire to see an equitable system (and I think it's a great post); I simply think greed is vastly underestimated as a factor in your last paragraph.

For better or worse, I think we'll end up with something like half-assed single payer Eventually, Republicans will "fix what is wrong with Obamacare". That will principally mean letting insurers sell across state lines and a bunch of tort protection. As with wireless companies, this will reduce the number of insurance players and increase the sizes of the companies. As with wireless companies, eventually we'll all choose from one of 4-6 networks based on cost and coverage. By coverage, I don't just mean conditions that are covered - I mean coverage area -- places where they do (and do not) have doctors. As with wireless companies, that won't mean much to urban dwellers, but will mean a lot to the rural and exurban.