The truth is that we could do just fine without them: an insurance system with community rating and universal access has no need of private insurers. In fact, the U.S. already has such a system: it’s known as Medicare. In most areas, it’s true, private companies do a better job of managing costs and providing services than the government does. But not when it comes to health care: over the past decade, Medicare’s spending has risen more slowly than that of private insurers. A single-payer system also has the advantage of spreading risk across the biggest patient pool possible. So if you want to make health insurance available to everyone, regardless of risk, the most sensible solution would be to expand Medicare to everyone. That’s not going to happen. The fear of government-run health care, the power of vested interests, and the difficulty of completely overhauling the system have made the single-payer solution a bridge too far for Washington, and for much of the public as well. (Support for a single-payer system hovers around fifty per cent.) That’s why the current reform plans rely instead on a mishmash of regulations, national exchanges, and subsidies. Instead of replacing private insurance companies, the proposed reforms would, in theory, turn them into something like public utilities. That’s how it works in the Netherlands and Switzerland, with reasonably good results. One could recoil in disgust at the inefficiency and incoherence of the process—at the fact that private insurers will continue to make billions a year providing services the government has shown, via Medicare, that it can provide on its own. But, messy as the reform plans are, they can still dramatically transform the system for the good. Reform would guarantee that tens of millions of people who don’t have insurance will get it, and that people who have insurance now won’t have to worry about losing it. And, by writing community rating and universal access into law, Congress will effectively be committing itself to the idea that health care, regardless of risk, is a right. If a little incoherence is the price of that deal, it’s worth paying.

I understand disaffected liberals....