On the Moral Superiority of a Single-Payer System

David DeGrazia has sketched out a health reform proposal that combines the monopsony purchasing power of a single public payer with managed competition among health plans and implicitly among providers, alone or in groups. The proposal differs from the archetypal "Medicare fee-for-service for all" model in creative ways, and indeed it is developed to address some of the standard fears about whether a single-payer system squelches choice and incentives for innovation. But DeGrazia's truly novel claim is that this version of single payer is the "most morally defensible reform model." That is a strong statement, and difficult to prove or disprove, not least because the paper does not argue that the features and predicted outcomes of the model are consistent with any particular theory of distributive justice or any other moral yardstick, scriptural or secular. Rather, the paper essentially argues that a single-payer system with managed competition would do a better job, on balance, of achieving the widely accepted goals of universal coverage, containing costs, protecting patient freedom, and delivering high quality care. I consider each in turn.