I don’t disagree with the fact that the perverse incentives are cripplingly serious(and the advantages amount too “if we launder it through Aetna, some people won’t accuse us of filthy socialism”, hence most of the ACA’s extra fun features); but as a strategic matter I’d avoid going after it too hard: my understanding is that in most if not all countries that do offer some sort of universal coverage, it isn’t forbidden for insurers to attempt to sell supplementary packages, or for people to buy them; which has the advantage of blunting the “zOMG, the collectivist death panel service is mandatory!” freak-out, since it isn’t.
Farming out a single payer scheme to private contractors requires a truly delusional level of faith in the efficiency of the private sector, given their demonstrated awfulness; but one gains little by trying to actively stamp out whatever supplementary coverage schemes people attempt to offer in the context of universal coverage (while, not terribly unexpectedly, assuring the vehement opposition of those in line to be stamped out); which isn’t much of a win when the objective is to fix the dire state of the risk pool and baseline coverage.
It’s sort of like the difference between opposing the “let’s destroy public education and send the cash to those innovative charter schools!” and “let’s forbid all private and parochial schools, period.” The former is pretty much necessary to avoid a massive smash 'n grab; the latter might prevent some of the abuses that are currently accomplished just by moving to a wealthy suburb; but at the cost of substantial additional opposition.
