Tuesday, January 10, 2017

Why Not a Single Payer?

As the GOP flexes its newly-found muscles, ready to exercise the mandate it thinks it has, one of the biggest issues on the table is the future of the American health care system. The GOP has thundered for years that the Affordable Care Act ("Obamacare") is the devil's tool and will lead to the utter destruction of America and all things we hold dear, and their mantra has been "repeal and replace." Unfortunately, while they are laser-focused on repealing the ACA, they have nothing with which to replace it. This is not comforting news for the millions of people who will lose their insurance if the ACA is killed without a working replacement.

One of the options for fixing health care in this country is the much-maligned single-payer system*, under which a single nationwide insurance system administered by a government agency replaces the existing array of private insurance plans. From a conservative point of view, the single-payer option is a horrifying, socialist plot that will destroy America and establish government-run "death panels" that will decree who will live and who will die based on the projected cost of their care. But is the single-payer option as bad as it's made out to be? I recently ran across an Internet meme that proposed ten reasons for adopting a single-payer system, which seems to be a good starting point for discussing the pros and cons of such a system. Of course, my comments have been added, and I have other comments at the end:

1. Everybody in, nobody out. The primary attraction of a single-payer system is that it provides universal coverage. It would be financed by a tax, much as Social Security and Medicare are today.

2. Portability: change jobs, get divorced, lose your job, etc - you won't lose coverage. With the current system, which relies on insurance purchased through and provided by one's employer, coverage goes away when the job does. A single-payer system, independent of one's employer, ensures continuous care ... although the loss of one's job means that the taxes which pay for coverage aren't being paid.

3. Uniform benefits for everyone. One of the problems with the current system is that people must buy health insurance coverage based on their personal calculus of ability to pay and perceived need. If you have a major medical issue that isn't covered because you could only afford the Chevrolet rather than the Cadillac policy, you're out of luck. A single-payer system can be designed to provide uniform coverage ... something not possible with a nationwide array of various providers and policies.

4. Enhance prevention. This isn't necessarily an advantage of either single- or multiple-payer systems. Any insurance plan can provide incentives for preventive care and maintenance of a healthy lifestyle - both of which reduce long-term costs by keeping people healthier and reducing the need for treatment of preventable illnesses.

5. Choose your physician. The current system generally allows one to choose a physician, but only within the list of those who accept one's insurance. A single nationwide system would include all patients and all doctors, and would allow full choice of physician, without regard to his or her membership in a particular insurance network.

6. Ends insurance company interference with care. One of the most popular arguments against the single-payer system is that it puts faceless government bureaucrats between you and your doctor. This, of course, is far worse than the current system, which puts faceless insurance company bureaucrats between you and your doctor. In an ideal system, the physician decides what the patient needs and then provides it, without the need to obtain the approval of an insurance company which is focused on the business bottom line rather than the needs of the patient.

7. Reduces administrative waste. This is not a given; it's based on the idea that a single, nationwide insurance system would require less administrative overhead and duplication of effort than the current array of separate, independent insurance companies. Whether or not this would actually be the case remains to be seen, but it seems plausible. Under the current system, doctors submit their bills to insurance companies - often multiple companies - in order to get paid. A single-payer plan could streamline this process, reducing the administrative burden on doctors' offices and speeding up payments.

8. Saves money. This relates to the previous advantage of reducing administrative waste. How much money, if any, would actually be saved depends upon many factors, including how well the program is managed and how strong the protections against fraud and abuse are. In general, though, one might expect costs to go down because of the price negotiating power of a single entity representing tens of millions of citizens. Of course, this also means that profits for the health care industry might go down in proportion, although some of this could be expected to be made up for by volume.

9. Common-sense budgeting - set fair reimbursements and apply them equally. There are many reasons why health care in this country is so expensive, and each reason is worthy of a detailed discussion all its own. The cost of medical school training for doctors, the cost of developing and testing new medicines, the cost of advanced medical equipment and tests all play a role. But it isn't difficult to imagine that a system of fair and equitable reimbursements could be developed as part of a comprehensive retooling of the whole system.

10. Public oversight, public ownership. The GOP has expended tremendous effort to convince Americans that their government is completely corrupt and inept and cannot be trusted to manage a two-car funeral, much less a national health care insurance system ... the sad state of the Veterans' Administration health care system is often used as an example of why government should not have anything to do with health care management. But I view this as less a problem of the inherent ineptitude and corruption of government than a lack of sound, results-oriented leadership and management that sets processes and goals, ensures they are met, and holds those responsible at all levels accountable for their actions.

There are other arguments both for and against a single-payer system. Conservatives and Libertarians object to it because it creates a large and, presumably, expensive government bureaucracy and limits the ability of citizens to decide whether or not they want to maintain health insurance**. Many also object to the idea that access to affordable health care is a right; they maintain it should be considered a privilege earned by those who work and pay for it rather than something to which they are entitled.

A counterproposal from opponents of a single-payer system suggests that individuals be granted tax credits or vouchers that would allow them to purchase an insurance plan that best fits their needs. I'm no economic expert, but as I've written in this space before, funding anything via tax credits and vouchers has a cascading negative effect, because those credits create a revenue shortfall elsewhere.

So, Dear Readers, what do you think? Is a single-payer system a good idea or not? Leave a comment and let us know what you think, but give us real reasons to think about ... arguments that just use sneering adjectives like socialist aren't arguments at all.

Have a good day. More thoughts tomorrow.


* This is the system used by most modern countries, with varying degrees of success.

** This is why they object to the Obamacare mandate to maintain health insurance coverage, although it was originally a conservative idea. And of course, nobody ever wants to pay for insurance until they really need it.


Gonzo Dave said...

We already have various forms of (almost) single-payer insurance already: the VA (as you mentioned), military health care, Medicaid, and Medicare. While none of these is completely single-payer, they come close (IMO and without a lot of research to back it up). It seems sensible to me that these could be used as potential models or templates for a national system.

Mike said...

Single payer for sure. We can call it Hillarycare.

allenwoodhaven said...

I've worked in Health Care for well over 30 years. Single payer with universal coverage is absolutely the way to go. It would solve most of the too many problems that get in the way of care. I see it everyday. Of course it would need to be done well; as you said, "This is the system used by most modern countries, with varying degrees of success." Unfortunately, there's a lot of money being made by health insurers so there will be a tooth and nail fight to change it. Do you see enough congressmen and senators taking up that fight? I wish I did.