The Virtues and Vices of Single-Payer Health Care
N Engl J Med 2016; 374:1401-1403April 14, 2016
The 2016 U.S. presidential campaign has produced many surprises. One unexpected turn is the reemergence of single-payer health insurance on the public agenda. Senator Bernie Sanders has made Medicare for All a centerpiece of his platform. His opponent for the Democratic party’s presidential nomination, former Secretary of State Hillary Clinton, has criticized Sanders’s plan as unrealistic. An old debate has thus reopened. What are the virtues and vices of single-payer reform? Is it a realistic option for the United States or a political impossibility?
First, a note on language. “Single payer” is often used loosely to refer to everything from Canadian national health insurance to the British National Health Service (NHS) and even Obamacare — though depicting the Affordable Care Act (ACA) as a “slippery slope” to single payer is bizarre, given that it relies on private insurance. U.S. observers often mistakenly lump all foreign health systems together under the single-payer label — a classification that grossly oversimplifies the range of models in place elsewhere.1,2 In some rich democracies (Germany, the Netherlands, and Switzerland among them) people enroll in multiple insurance plans, which are typically highly regulated and are operated by private companies or nonprofit associations. Alternatively, in the NHS, the government traditionally owned most hospitals and directly employed many physicians.
Most U.S. single-payer advocates instead have in mind emulating Canada, where all legal residents in each province or territory receive coverage from one government insurance plan for medically necessary hospital and physician services. Canadians can obtain private policies for supplemental services not covered by the government plan. The government does not directly employ most doctors, nor does it own most hospitals, though their payments come from the single provincial insurance program. Canadian national health insurance arrangements — and Taiwan has a similar system — resemble traditional U.S. Medicare, with public financing for privately delivered services.3 Sanders is not the only presidential candidate to find this model appealing. Donald Trump has praised the Canadian program, though recently he suggested it wouldn’t work here.
Proposals for U.S. single-payer reform have a long history. A 1943 bill subsequently endorsed by President Harry Truman in 1945 envisioned national health insurance funded through payroll taxes. That bill and subsequent efforts by the Truman administration to pass universal insurance went nowhere. However, Medicare, conceived in the 1950s and enacted in 1965, embodied the single-payer model. Medicare’s architects saw it as the cornerstone of a national health insurance system. They believed that Medicare would eventually expand — with children perhaps the next group to join the program — to cover the entire population. That aspiration was never realized. Meanwhile, Congress created Medicaid as a separate program for some categories of low-income Americans, including families with dependent children, further fragmenting the insurance pool.4
Single payer enjoyed strong support during the early 1970s among liberal Democrats such as Senator Ted Kennedy (D-MA), yet it never came close to passing. Subsequently, its political fortunes faded. Democratic policymakers increasingly pursued incrementalism (primarily through Medicaid expansion) and more conservative models that relied on private insurance (managed competition) as the only feasible reform routes. Medicare itself underwent a transformation as the role of private insurers in the program grew substantially. The 2010 ACA represented both a landmark achievement in expanding access to insurance and the culmination of a turn away from single payer. In 2009, the House of Representatives did pass legislation creating a Medicare-like government insurance program that would be available to the uninsured in competition with private plans. But this “public option” couldn’t clear the Senate. Even with a Democratic president and large Democratic congressional majorities, a narrow remnant of single payer failed to pass.
Nevertheless, the single-payer approach enjoys a dedicated following among groups such as Physicians for a National Health Program, and Sanders’s embrace has generated renewed attention for the idea. Regardless of the outcome of the 2016 election, the single-payer debate will persist. The enduring appeal of Medicare for All is understandable, given the fragmented, inequitable, costly, profit-driven, and wasteful nonsystem that prevails in the United States. The ACA’s shortcomings are sufficiently serious, single-payer adherents argue, that Obamacare has left unsolved many of U.S. medicine’s major problems. For all the ACA’s considerable achievements, health insurance and medical care are still unaffordable for many people. In a country where nearly 30 million persons remain uninsured, where health insurance is increasingly thinned out by rising deductibles and cost sharing, where even insured patients face staggering bills and the prospect of medical bankruptcy, where myriad insurers and payment systems generate astonishing complexity, and where more money is spent on administration than on heart disease and cancer,5 it’s no surprise to hear calls for sweeping change.
The lessons of Canadian national health insurance are as straightforward as they are neglected. Having a single government-operated insurance plan greatly reduces administrative costs and complexity. It concentrates purchasing power to reduce prices, enables budgetary control over health spending, and guarantees all legal residents, regardless of age, health status, income, or occupation, coverage for core medical services.1,2 Canadian Medicare charges patients no copayments or deductibles for hospital or physician services. Controlling medical spending does not, the Canadian experience demonstrates, require cost sharing that deters utilization. The Canadian system is hardly perfect. All countries struggle with tensions among cost, access, and quality; at times, Canada has grappled with fiscal pressures, wait lists for some services, and public dissatisfaction.1 Yet its problems pale in comparison to those in the United States.
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.4Then 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.
In short, single payer has no realistic path to enactment in the foreseeable future. It remains an aspiration more than a viable reform program. 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. The pressing question is not about whether Medicare for All can be enacted during the next presidential administration — it can’t — but where health care reform goes from here.
It’s possible that some states could, through waivers that begin in 2017, consider adding a public option to their marketplaces or even adopt single-payer systems. Yet Vermont’s recent struggles to make a modified single-payer plan work underscore the challenges to state action. At the federal level, incremental steps toward Medicare for All, such as expanding program eligibility to younger enrollees, are conceivable — though challenging in this political environment. Moreover, the fight over Obamacare is not over. Preserving and strengthening the ACA, as well as Medicare, and addressing underinsurance and affordability of private coverage is a less utopian cause than single payer. I believe it’s also the best way forward now for U.S. medical care.
The Universal Notebook: Colin Woodard explains it all
Colin Woodard is Maine’s top journalist. To be more accurate, he’s Maine’s leading freelance intellectual, not only reporting on current events for the Portland newspapers, but researching and writing whole books about the political geography of America in attempt to understand what is happening to our country.
His early books include “Republic of Pirates” (which was the inspiration for the NBC series “Crossbones”), “Lobster Coast” and “Ocean’s End.” As his vision has become more ambitious in scope, Woodard has published “American Nations,” which explains the country’s 11 regional identities based on shared histories, and now “American Character,” which explains the political paralysis in this country through that same regional lens.
But don’t take my word for it that Woodard is the best. This year he was a finalist for the Pulitzer Prize for explanatory journalism for “Mayday,” his six-part series on the impact of climate change on the Gulf of Maine. In 2014, The Washington Post named him one of the best state capitol reporters in America. And in 2012, he won a prestigious George Polk Award for his investigation of the for-profit online education industry and how it helped the LePage administration create Maine’s digital education policy.
Last week, Woodard was in Paris, Brussels, and Belgrade (Serbia, not Maine), speaking to the European Parliament about the upcoming U.S. elections. But even abroad he kept an eye on Maine, regularly posting links on Facebook to articles about Gov. Paul LePage’s daily antics.
Politically, Woodard strikes me as a pretty progressive guy, although he strives for old-fashioned non-partisan objectivity as a journalist. Woodard is married to Sarah Skillin Woodard, who works on behalf of Hillary Clinton in Maine, so I’m guessing I know where his loyalties lie, if he knows what’s good for him.
I was attracted to “American Nations” when it came out in 2011 because Woodard’s historical reconstruction of regional identities confirmed my own experience in a long-running feud with my cousins in Georgia.
When Hospital Rooms Become Prisons
Michael (not his real name) had an entourage the second he walked in the door. His ankles were shackled to the bed. Police officers, nurses and sheriff’s deputies surrounded him. His blood pressure had been dangerously high and he was admitted to my service. Why was he in custody? People whispered softly as the collective speculation permeated the hallways. Was it armed robbery or murder? It shouldn’t have mattered — we are supposed to treat everyone the same. But it did.
Michael was also vomiting, having diarrhea and crying: signs of opiate withdrawal. He was homeless and had lost a lot of weight while living on the streets. In many ways, he was like other patients I had cared for. Except that his hospital room became the jurisdiction of the law enforcement agency.
Every time we spoke, a third body impinged upon our patient-doctor relationship. I took an oath to protect patient confidentiality, yet every guard knew the intimate details of Michael’s medical history, including his H.I.V. status. I felt myself whispering to protect whatever shred of dignity remained.
I assumed we were following the rules; I just did not know what they were. I had been a doctor for three months, but like most doctors had never received any training on the care of prisoners. Only after intensive searching on our hospital website was I able to find our hospital’s policies, months after Michael was discharged. As doctors, we expect black and white, but even those policies seemed open to interpretation.
Arizona Doesn’t Restore Federal Child Health Care Program
Arizona Doesn’t Restore Federal Child Health Care Program
PHOENIX — Lawmakers here early Wednesday reaffirmed Arizona as the only state to not participate in a program that offers health care to children of the working poor.
A proposal to restore the federal Children’s Health Insurance Program, known in Arizona as KidsCare, stalled in the State Senate this week as lawmakers passed a $9.6 billion budget. Senate leaders voiced concern that the federal government would eventually cut payments to the children’s health care program and that the state would be forced to assume the cost.
State lawmakers originally froze enrollment in the program about six years ago amid an economic slowdown. But supporters saw an opportunity to restore the program after Congress last year increased the states’ matching rate by 23 percent, which allowed 10 states, including Arizona, to receive full reimbursement because of their low per capita income.
Arizona’s Republican-controlled House voted, 47 to 12, last month to allow the program to restart, but permitted the state to suspend it if fewer federal dollars came in.
But the measure died Tuesday in the Senate when its president, Andy Biggs, would not allow it to come to a vote. He suggested that he did not trust future legislators to resist public pressure and cut off the benefit if the federal funds dried up.
Experts and activists discuss how to get “right care” for patients
Jeanne Lenzer reports on a growing movement aiming to overcome the medical and social barriers to appropriate care
The fourth Lown Institute conference held in Chicago, Illinois, in April brought nearly 300 doctors, patients, policy makers, and activists together to discuss barriers to “right care.” The focus was on how to tackle the problems of bad science, undertreatment, and overtreatment—and how to build a movement for change, which several speakers likened to the civil rights movement.
A recurrent theme among speakers and participants was that fee-for-service medicine and profit driven testing and interventions are major obstacles to right care. Speakers emphasized that this could be achieved only if we simultaneously address issues such as the wealth gap, social disparities, and corporate control of politics.
Shannon Brownlee, senior vice president of the Lown Institute, told The BMJ that the presence of a wide range of activists and organizations at the conference gives her hope that a genuine new social justice movement is emerging.
More money for less: the harms of finding things
Rita Redberg, editor of JAMA Internal Medicine, said, “We spend $3tr, far more than other countries, yet we still have millions and millions of people without access to healthcare.” She added, “The Institute of Medicine estimated that $1tr a year is spent on waste or overuse.” Both physicians and patients imagine that if some care is good, more must be better, and that a test can’t hurt.
Insurance coverage of unnecessary tests, said Redberg, contributes to overtesting and overtreatment: “The United States Preventive Services Task Force gave a grade D recommendation to PSA [prostate specific antigen] testing but Medicare still covers it, so it means a lot of men are still getting a test that is costing not just money, but lives.”
From the audience, Jill Wruble related her own experience with the unintended consequences of medical testing. A radiologist at the West Haven Connecticut Veterans Administration Medical Center and clinical assistant professor at the Yale School of Medicine. Wruble noted that tests may not only cause physical harms but have adverse medical, social, and financial consequences.
Wruble said she learnt the hard way. At a previous job, she idly gave herself a DEXA (dual energy x ray absorptiometry) scan when a patient cancelled an appointment. Despite decades of athletics, Wruble said that the scan, quite improbably, showed “borderline osteopenia at L1.” She casually mentioned this to a primary care physician at an annual physical exam. The physician noted it in Wruble’s medical record, which was later requested by an insurer when she sought to update her disability insurance. The insurer flatly denied her policy renewal. “I had to see an endocrinologist and take calcium,” and a year later was offered a higher cost, inferior, short term policy with a rider.
To gales of laughter from the audience, Wruble remarked that she deliberately has not had a physical exam in the 15 years since.
We need a culture change
Joanne Lynn, director of Altarum Institute’s Center for Elder Care and Advanced Illness, in Washington, DC, said that simply having good information isn’t enough: emotions, habits, and money “get in the way” of right care.
2000+ Doctors Declare: "It's Time for Single Payer to be Back on the Table"
'We can continue down this harmful path or we can embrace the long-overdue remedy that we know will work: a publicly financed, nonprofit, single-payer system that covers everybody.'
by Deirdre Fulton - Common Dreams
Despite limited advances provided by the Affordable Care Act, the U.S. healthcare system remains "uniquely wasteful" and profit-driven, leaving tens of millions without any insurance and even more underinsured.
As a result, say leading physicians, "the right to medical care remains a dream deferred."
In an effort to finally realize that dream, thousands of medical professionals across the country have signed onto the "Physicians' Proposal for Single-Payer Health Care Reform," calling for a publicly financed, single-payer National Health Program (NHP) that would cover all Americans for all medically necessary care.
The plan, unveiled Thursday in the American Journal of Public Health, aims to "remedy the persistent shortcomings of the current health care system," reads an accompanying editorial.
It comes as the 2016 presidential race has thrust the issue of healthcare back into the national spotlight, and while the proposal is non-partisan, it hews closely to Bernie Sanders' call for Medicare-for-All.
Drafted by a working group of 39 physicians and endorsed by more than 2,231 other physicians and 149 medical students, the proposal "would save enough on administrative overhead to provide comprehensive coverage to the uninsured and to upgrade coverage for everyone else, thus requiring no increase in total health spending," according (pdf) to Physicians for a National Health Program (PHNP), which is backing the effort.
http://www.commondreams.org/news/2016/05/05/2000-doctors-declare-its-time-single-payer-be-back-table
Hospitals aim to stop vote on how they’re paid
By Priyanka Dayal McCluskey GLOBE STAFF
Hospital industry executives are negotiating a deal with a major union for health care workers to stave off a November ballot question that could cost some of the state’s most prominent medical institutions hundreds of millions of dollars a year.
At issue is a proposed ballot initiative by the Service Employees International Union, Local 1199, that would dramatically change the way health care is financed, taking money from hospitals that are paid higher rates and giving the money to lower-paid hospitals, and to consumers through their insurance companies.
Backers say the ballot initiative could eventually lower health care premiums for some consumers and shore up struggling community hospitals. It is largely aimed at Partners HealthCare, the state’s highest-paid health care provider, which would lose $440 million a year if voters were to approve the ballot question, according to the SEIU. The parent company of Massachusetts General and Brigham and Women’s and eight other hospitals, Partners warns that the initiative could force it to cut thousands of jobs.
Partners confirmed Thursday that it has been negotiating with the SEIU local, and representatives for some of the state’s other hospitals said they are involved in the talks, too.
“We’re currently in conversations with many stakeholders, including the SEIU, in the hope that we can avoid a messy ballot fight,” Partners spokesman Rich Copp said. “Partners is opposed to the ballot initiative because it’s simply bad public policy, it’s poorly designed, and it does not help the hospitals that need help the most.”
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