The Virtues and Vices of Single-Payer Health Care

[eridani]

http://www.nejm.org/doi/full/10.1056/NEJMp1602009#t=article

The substantive virtues of single-payer programs are compelling. But so are their political liabilities. Medicare for All, which aims to constrain health care spending, faces intense opposition from insurers, the medical care industry, and much of organized medicine. It would trigger fierce resistance from conservatives and the business community and anxiety in many insured Americans fearful about changing coverage and the specter of rationing. The ACA’s comparatively conservative reform approach inspired false charges of “socialized medicine,” “pulling the plug on grandma,” and “death panels.” It takes only a little imagination — or a look back at the history books — to predict the reactions that an actual single-payer plan would evoke.

Single payer would also require the adoption of large-scale tax increases. Although Americans would save money by not paying premiums to private insurers, the politics of moving immense levels of health care spending visibly into the federal budget are daunting, given the prevailing antitax sentiment. Furthermore, converting our long-established patchwork of payers into a single program would require a substantial overhaul of the status quo, including the ACA. Then there are the familiar institutional barriers to major reform within U.S. government, including the necessity of securing a supermajority of 60 votes in the Senate to overcome a filibuster.

NEJM Interview with Dr. Jonathan Oberlander

http://www.nejm.org/doi/full/10.1056/NEJMp1602009#t=article

When we look at the entire patchwork of the American medical care system and our insurance system there’re still so many holes in it, there’s so much redundancy, and it’s so inefficient. And that’s why the single payer idea is going to resonate far beyond whatever the outcome of the 2016 election is. Because when you have a health insurance that leaves tens of millions uninsured, tens of millions underinsured, that is beset by administrative complexity and is governed too often by profit, there’s going to be an appetite for sweeping change. And whatever its political fortunes are, and I don’t think they’re particularly good, single payer is going to continue to speak to those who are disaffected by what’s going on in American medical care and are looking for something different, something better.

(The full 8 minute audio can be accessed for free at the link above.)

Comment by Don McCanne of PNHP: Although single payer advocates may be disappointed with Professor Oberlander’s conclusion that the best way forward now is to strengthen ACA and Medicare and to address underinsurance and the affordability of private coverage, we need to keep in mind that he has described the clear superiority of the single payer model, and that it still has widespread popular support. His pessimism is based on current political realities, which have been confirmed by over half a century of failure to advance comprehensive, universal single payer legislation.

Since single payer seems to be an imperative, why has it not been enacted? Oberlander writes, “Single-payer supporters have not articulated a convincing strategy for overcoming the formidable obstacles that stand in its way. Nor have they, despite substantial public support for single payer, succeeded in mobilizing a social movement that could potentially break down those barriers.”

He’s right, based purely on results to date. We have a lot of work to do.

My comment: Our biggest political problem is that most people do not get expensively sick. Many think they have perfectly good insurance, an opinion that is worth what their opinions on how good their fire extinguishers are--that is to say, not much. Only the 15% who account for 85% of health care costs in their demographic know otherwise.

[Herman4747]

1. The Experience of Other Countries:

1) Did not these other countries that implemented single-payer likewise face what are allegedly, "formidable obstacles," in the process of implementing single-payer?

2) Has any country, any at all, having implemented single-payer subsequently decided that single-payer is seriously flawed and hence rescinded single-payer, to go back to the way their health-care coverage used to be?

3) Are the citizens of other countries with single-payer happy or unhappy with their health-care coverage system?

[Angel Martin]

8. there is plenty of private health care in Canada

outside the Medicare system. What is not allowed is private health insurance. So, for example, if you are an ordinary person who does not want to wait months for an non-emergency MRI, you have to pay.

Of course the rich and the politicians have created a carve-out for themselves, which somehow skirts the definition of "insurance".

eg. https://www.medisys.ca/en-ca

[TreasonousBastard]

2. Spain, Canada, the UK, and Taiwan are the only nations...

to my knowledge that have single-payer systems, and none of them are the envy of anyone else outside of the third world. Other EU countries, and Japan, have mixed systems that use private insurance. Some of them put us to shame.

A major problem mentioned above is that we have such a ridiculous patchwork of systems that just making sense of them is a major project in itself. Having recently been covered by Medicare, the VA and a managed care system, I find none of them to be worth all that much. Certainly none are as good as employer systems I've been covered under in the dim past.

I do give the VA props for seeming to care and for excellent service for some things, but in others it falls dreadfully short. Choice is not an option, not choice of doctor, not of medication, nor of procedures. They do to you as they see fit, and that's that. If it works for you, and it usually does, it's great.

Managed care was the worst. Ridiculously inefficient and things that should have been done in one office visit took up to four visits and sometimes an operating room. For one problem, my copays were as high as the total I used to pay. Too bad the doctor I used to use retired.

Medicare is almost a joke, but for those who need it it is a lifesaver, but barely. The VA is happy because it seems to get Medicare money for us geezers, but my experience is that while I sometimes have better choices on my Medicare card than my VA card, I still have painful copays and things it won't pay for at all. And doctors hate it because they consider it a poverty program for them. They hate Medicaid even more, btw, since it pays even less.

My attitude for years has been the problem is not who pays, but what they pay. My parents, grandparents, and others had end-of-life expenses that were astronomical. Heroic measures to keep you alive come with heroic costs. And the system of doctors working with specific hospitals is insane-- when my mother had a major problem and had to use a hospital her doctor was not approved at, they did an entire, and expensive, workup since her records apparently weren't good enough, and the workup and proposed treatments for other things she had been dealing with for years ran into the swix figures. They did solve the immediate problem and gave her excellent care, but she was lucky enough to have cash and other coverage just for that.

I don't have any answers, as if anyone would listen to me anyway, but the future does seem to be to use Obamacare as a gateway to a better system-- if it isn't destroyed by the right as a hated government program and by the left because it isn't good enough.

BTW, did you know that one of the many government programs is the Indian Health Service? It puts clinics on reservations. The one I'm a little familiar with isn't that great, but it helps when there's nothing else. And does seem to do well for kids' care. Merging that with SCHIP, Medicare, Medicaid, the VA, any other public health and nutrition programs floating around, and imagine how Congress would screw it up.

[eridani]

3. In countries with private insurace, the governments generally dictate the terms

In France, for instance, the system is run entirely by the government, with a manual covering every procedure and specifying the cost. The only role private insurance has is in covering the 30% copayments.

When I finally got on Medicare, my health care costs dropped 80%, which has made me happy. It's major problem is that it doesn't have price negotiating authority over drugs, nor a true global price setting system.

[jwirr]

4. The Indian Health Services has an excellent clinic on our

rez and it is a part of ACA - the tribal health money pays for the costs. We also have a young woman who is on President Obama's advisory committee and travels around the country helping other reservations get their ACA programs set up. So that is a single-payer system inside ACA.

I am also on Medicare and liked it more when it was totally government run and we did not have to get on some insurance program.

[muriel_volestrangler]

5. Well, you say that, but ...

http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

So the UK system does work well.

[TreasonousBastard]

6. A lot depends on methodology...

http://www.who.int/whr/2000/media_centre/press_release/en/

And here is their chart showing the Brits a bit lower:

https://en.wikipedia.org/wiki/World_Health_Organization_ranking_of_health_systems_in_2000

Admittedly, a lot of things may have happened since 2000, but we don't know how many.

[muriel_volestrangler]

7. Even in 2000, the countries you list had positions 7, 18 and 30 in that list

all above the USA. Obviously your "only envied by 3rd world countries" was rubbish.