Who will lose under universal health care?

A lot of posts in the last couple days. I blame it on the end of semester crunch. I'm on the computer all the time to do work, and then I get distracted by Google Reader and start reading things that are more interesting than a final paper on teamwork, and...then I have to write about them.

At Stand and Deliver, Rixa is has just posted about discovering (at 8 1/2 months pregnant!) that her insurance company is going back on previous promises and will not cover her midwife. It got me thinking about a presentation I went to tonight by Dr. Nick Gorton. He does a lot of work in transgender health, and as part of our school's Trans Health Week (I know, how cool is that?) he came and gave a lecture. He discussed who covers sexual reassignment (hormone therapy, surgery) and who doesn't. Who does: a few city and state governments, some universities, some employers, Medicaid. Who doesn't: everyone else - including Medicare and the VA.

One of the things that really got me thinking was his discussion of what areas could be the big losers under universal health care. He had 4 main categories: reproductive health, transgender health, non-punitive drug treatment, and 1 other that I'm forgetting at the moment (sorry!)

Obviously we hope that in a single-payer system, evidence-based medicine (e.g. midwifery care, access to birth control) would prevail. It seems to have prevailed to a greater extent in countries with that system - because it's cost-effective. But there are a lot of special interests in this country - we already saw them at work with Medicare Part D (drug coverage), essentially holding a government insurance plan hostage to the pharmaceutical companies.

There are also a lot of political third rails that the government will hesitate to touch. "I don't want my tax dollars going to..." has already worked for abortions under Medicaid, and just this year for reproductive health care funding. What else could it work for?

I want universal coverage as much as the next person, but Dr. Gorton did get me thinking about what might be sacrificed. If you're a transgender person seeking sex reassignment surgery, you probably don't have coverage for it. But in our current system, at least there's the possibility that you do, or could in the future. In a single-payer system, it's all or nothing. And that goes for every other kind of coverage, too. How can we protect a single-payer plan from special interests and political hot buttons?