Writing in the New York Times Magazine, Princeton University bioethics professor Peter Singer provides a very readable presentation of the case for using cost effectiveness criteria for “setting limits on which [medical] treatments should be paid for from the public purse.”

At the end of an otherwise thoughtful article, Professor Singer opines that sensible rationing based on the benefits and costs of medical treatment would permit a Medicare -type program to be extended to the entire population at very low cost. His experience in Australia notwithstanding, this conjecture is an enormous stretch. Medicare’s current cost (and enormous projected deficit) suggest that limitations on the types and scope of services would need to be quite stringent compared with the status quo to keep costs that low.

Professor Singer favors allowing people with” sufficient” private health insurance to opt out of “Medicare for all” (but not the required taxes), or allowing people to buy private, supplemental coverage.  Allowing people to opt out would be highly desirable.  Those who preferred could rely on decentralized, private sector contracting to determine what health services they obtain, as opposed to being at the mercy of government promulgated cost-effectiveness criteria.  Substantial private coverage also might help discipline any tendency for public coverage to become too stingy in order to keep costs down.

In reality, few politicians would consider pushing for Medicare for all in conjunction with meaningful cost-effectiveness criteria.  At the outset any Medicare for all program would likely be heavily subsidized with few limits on care, thus substantially crowding out optional private coverage through predation rather than rational cost control.  Tough cost-effectiveness criteria would come later.  It’s not clear how that type of “bait and switch” could be avoided — even if Professor Singer’s idea has conceptual merit.