Comment Rescue — Why Not Single Payer?

Filed in National by on June 21, 2009

Friday, Geezer asked a very good question that I didn’t have time to get to in the Frank Luntz thread. His question: Why should we be for a non-single-payer “reform” plan?

Before I get to that and ask you guys to weigh in, I want to put up some resources to look at and to think about. These are mostly comparisons of health care systems from industrial countries (and none will take much time to review):

I include all of this (and these are worthy descriptions and comparisons — no system is perfect and I remind everyone that anecdotes are not data) to broaden abit the scope of the conversation.

Part of the problem in listening to either advocates or critics of single-payer is figuring out what they are talking about.  Are we talking about recreating the entire system as single payer or just the portions that will cover the uninsured or underinsured?  Does that leave for profit insurance companies in place or does if make all of them move to not-for-profit status?  Critics of single payer frequently invoke the UK system as the single payer that advocates want, while spinning out their scary tales of the day.  Advocates almost never make clear the scope of their thinking — especially (as you can see from the resources above) single payer can take multiple forms.

The Public Option that was proposed by the House on Friday is essentially a Medicare for All program.  It would be paid for by premiums from its users, with the government subsidizing premiums for poorer people and families.  This part of the proposal is basically single payer, paid for by premiums.  It will offer insurance to those who don’t have it now and will provide a competitive choice for the rest of us.

As to why not full single payer?  Speaking for myself, it isn’t as important to get to single payer as it is to get everyone covered and get in a position to control costs.  Politically, a major transformation of the entire system to single payer — with its subsequent dismantling of much of the insurance business and new rules for participation in its funding — I just don’t see as possible.  Part of the problem is our politicians — few would be willing to get behind this kind of revolution in how health care is financed.  Besides, most people who already have insurance are mostly concerned with costs and maintaining access to health care as our own futures look shakey.  Most of us would agree that everyone needs to be covered, but those of us with insurance don’t want to be forced to give that up.  That adds up to a very big political problem for those who want single payer now.  As far as I’m concerned, the advocates of single payer — making the whole system single payer with insurance companies becoming not for profits — haven’t made an especially good case for that to the people who need to hear it.  And that is to the people who have insurance they are OK with now.  Laying down all of the chips on single payer now is a pretty certain path to not getting much of anything at all in terms of a system fix.

But if I cycle back to the info on how other countries get to universal insurance, the financing and administration model differ for all of them.  Given the already successful (in terms of both customer satisfaction and in health outcomes) and certainly cheaper models of these other countries, I don’t see the choice is not between single-payer and the status quo.  Many countries are using a form of the insurance model as the basis of coverage.  Switzerland’s model looks alot like Massachusetts, Germany is a hybrid and the French model looks like Medicare for all.  Each of these countries spends less per capita and as a percent of GDP than we do.  Each of these countries ranks higher on most measures of medical outcomes than we do.  Each of these counties insures everyone unlike us.  We can certainly create our own model that will work.

If we were starting from health insurance scratch, we’d have alot more options I think.  But a strong public option puts the survival of traditional insurance plans in their own hands.  They will now have to really compete for your business and for your employers’ business.  They will have to let go the games they play with their customers if they want to survive — because now you’ll be able to choose another reasonably affordable option.  They’ll have to be more customer focused and work harder at cost control, because they’ll want to figure out ways to keep you even if you no longer have the same employer.  It means that these companies need to completely rethink their model.  It means that these companies have to learn to live in a marketplace where customer satisfaction and cost controls are going to be highly valued.  Sort of the way most other businesses have to survive.  So if we ever get to a single-payer for all system, it will be because the insurance companies couldn’t figure out a way to compete.  Which plentyof them will find a way to do.

So what do you think?  A strong public option or single payer (and define how you use the term pls) now?


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"You don't make progress by standing on the sidelines, whimpering and complaining. You make progress by implementing ideas." -Shirley Chisholm

Comments (19)

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  1. anon says:

    Single-payer is nice if you can get it.

    Until then, ugly as it is, a public option is more progressive than what we have now, because the haves will be taxed to pay for coverage for the have-nots, who are currently not being covered at all.

    Once the taxes get high enough, the haves will rebel and look for cost savings, which will be found by moving to single-payer.

    (well, first they will try to cut service or kick the have-nots out to save money, but we won’t let ’em).

  2. Truth Teller says:

    The thing that sort of gets my goat is. When Dem’s appear on TV or discuss this subject they never use these facts or charts. All I keep hearing from most of them is that it coast too much or we may not have the votes.
    On one point they appear to be right if they don’t give us a public option come 2010 they may not get our vote.

  3. anon says:

    Democrats took single payer off the table. They arrested Doctors who wanted all the numbers shown to the american people. There are vast savings in the single payer system. The plan the democrats are offering is for you to ‘pay premiums”. If you cant afford to pay premiums to whom…the government? some HMO Co-op?

    It will not cost a dime more than we are spending already. In fact it will save billions a year. It will cover everything, including mental, dental, vision, long term, aids, prisons, you name it…from cradle to grave? No plan the demorats have put forward will cover any of those things. The money that should be going to pay for the extras, (as is done in every civilized, industrialized nation in the world), will be going to the administrators of yet another for profit system.

    We are being lied to every day. As single payer supporters demand the numbers be placed against any for profit plan in this country today, the democrats would have us believe it will cost over a trillion dollars. That is the biggest lie and a distortion of the facts.

    There is no rationing of health care, the emergency patients get treated first (as is done right now in every emergency room in the country). If you need an operation you will get it, and you will not receive another bill over and beyond what the insurance company will pay.

    In European countries like France, Denmark, Italy etc, there is no “accounting office”, you never receive a bill for anything. The savings under the single payer system in Europe has created new technology, new medicines that are not done quickly or efficiently in the US. All the profits now go back into insurance company coffers, not a dime towards health care. The percentage is 31-35% and rising. Much of that profit is going t0 shareholders, not back into the health care system.

    The record keeping of today is totally unneccessary. All can be done on computer, no need to fill out forms every time you see a Doctor. You have an insurance card….thats it.

    We have a single payer bill in the Dover legislature right now..SB 120, have you asked your representative to sign on? Dont you want to see the numbers for Delaware? Lets see any for profit health care currently in effect in Delaware and put the numbers up that single payer would cost against it. Do you think any democrat or rebiblican would actually do that?

    Pelosi says there will be a public option? What is the public option? Taxing you if your employer continues to pay for your insurance? What idiocy?

  4. cassandra_m says:

    Comment @3 is a big example of what is wrong with the single payer arguments as made — lots and lots of claims made for how much better it is, but no discussion on how it would be implemented here. Implementation is the battle and there is a reason Dems took it off the table. The politics does matter.

    And c’mon Liz — arrested doctors with data? Please.

  5. In honor of Delaware Liberal I did a video tonight on single payer and the public option.

    It will be available tonight and Thanks for being relentless on health care.

    I have traveled to all of the countries mentioned above and read all the studies. Implementation is important and we can cherry pick a lot from every country and produce a great system here.

    Stay tuned. I am not stalling but I want to discuss two things with my son who is an MD and he is not available till 8 pm.

    Mike Protack

  6. Perry says:

    Excellent review and discussion Cassandra. I learned a lot going through it all, including your links.

    Comparing the three different models, Beveridge, Bismark, and National Health Insurance, I note one significant distinguishing element compared to our hodgepodge system (except Medicare and Veterans Health Care), which is: The government controls costs either by fiat or by annual negotiations with providers.

    On the contrary, in our system the profits to doctors, insurance companies, hospitals, and other providers, plus the administrative ineffiencies, are all the root causes why our per capita costs are significantly higher, why our coverage is not universal, and therefore why some of our key health outcomes are not as high. We have to be ashamed and change this outrage against the American people!!!

    At a minimum, we need universal coverage, we need administrative cost reductions, and we need to take the profit out of health care provision.

    The public option plan being considered right now by the House, is actually the Bismark model, practiced with some variations by Germany, France, Belgium, the Netherlands, Japan, and Switzerland. There is our head start. We can pick and choose from these variations to suit our specific needs.

    Single payer (Beveridge model – Great Britain, Scandanavian countries, Hong Kong, Spain, New Zealand, Taiwan, Australia) has some strong attraction, but would probably never fly here politically due to the power of the right wingnuts, at least not right away.

    I agree with you, Cassandra, that we cannot immediately change radically our for profit insurance companies to non-profits. So the solution is to work out a time schedule for gradual change over a few years.

  7. Perry says:

    I think it is worth repeating this description of our American system, as I am not sure how many Americans appreciate the depth of our healthcare problems:

    “These four models should be fairly easy for Americans to understand because we have elements of all of them in our fragmented national health care apparatus. When it comes to treating veterans, we’re Britain or Cuba. For Americans over the age of 65 on Medicare, we’re Canada. For working Americans who get insurance on the job, we’re Germany.

    For the 15 percent of the population who have no health insurance, the United States is Cambodia or Burkina Faso or rural India, with access to a doctor available if you can pay the bill out-of-pocket at the time of treatment or if you’re sick enough to be admitted to the emergency ward at the public hospital.

    The United States is unlike every other country because it maintains so many separate systems for separate classes of people. All the other countries have settled on one model for everybody. This is much simpler than the U.S. system; it’s fairer and cheaper, too.”

  8. Perry says:

    Mike Protack is correct on this:

    “Implementation is important and we can cherry pick a lot from every country and produce a great system here.”

    The major problem, Mike, is that we have rich and powerful interests who have succeeded in opposing any change to our antiquated and drastically unfair healthcare delivery system for decades.

    I will be interested to read what you and your son would propose to do so we can overcome their ultimate power.

    Perhaps supersalesman Obama will be the change agent this time. I certainly hope so!

  9. cassandra_m says:

    Profits to doctors is difficult since most plans will provide a flat fee to physicians for the services covered and these flat fees don’t provide (typically) alot of margin. For Medicare and Medicaid there are practices whose costs are not met (forget about margin) by the set fee. On the other hand, in places like France, doctors don’t often have the overhead of our doctors — school loans and malpractice insurance to start. Where the doctors can be a problem is in the ordering of additional services — especially if said doctor is part owner of the lab or MRI or other facility where the work is done. I don’t think that doctor’s fees — as set by most insurance plans — are so much the problem. Insurance companies really are the low hanging fruit here — with their massive overhead and their need to retain as much of your premium as possible for shareholders. There is no incentive for health care there.

    But there is some hope here — most of the Top Rated Insurance Plans by US News and World Report are not-for-profit. The plans cited in this must-read New Yorker article I wrote about previously — Mayo Clinic, Geisinger Health System, Kaiser Permanente as excellent examples as how the system might work are not-for-profits too. There are more companies like these too, so the foundations for competition are really there.

  10. Perry says:

    The McAllen phenomenon is predominantly about attitude, gone awry, for the same reason that Wall Street goes awry, in cycles, until the bubble bursts.

    When there is no counterbalance, no competition, in that everybody in town tacitly agrees to do the same thing, milk the customer for personal gain, then there is not much that can be done to change the current healthcare context in this country. What surprises me is that there are not a lot more McAllen’s, or, maybe there are, maybe even right here in DE!

    I wonder how much of a factor is our chronic shortage of doctors, which the AMA controls by controlling the number of admissions per year to medical schools?

    There is no doubt that the government is going to have to step in to take some control, not only for the physical health of our citizens, but also for the fiscal health, or lack thereof, that we will be passing on to future generations, at intolerable/unsustainable levels, as per projections of our medical entitlement costs, a problem that we have totally ignored to date.

    Obama recognizes these situations, and is prepared to act. He is going to have a really hard time getting past the selfish powers who oppose change. We are already seeing this, especially in the Senate. And we don’t have the Lion on the floor these days either!

  11. cassandra_m says:

    The McAllen problem isn’t so rare, because the culture doesn’t have much incentive — other than ones they create themselves — to change. If the McAllen doctors had to compete with a local Mayo Clinic plan I wonder what they would do then? Real competition with a public option certainly provides plenty of incentive. And if they can’t make it, someone will.

    Medicare/ Medicaid are definite problems without good fixes on the horizon. A strong public option would bring in some additional users to the system who won’t be as demanding on the system (so the system can act like a real insurance plan) but long term cost controls are an issue. But I don’t think you can get to those controls without covering everybody.

  12. Sorry for the delay, a bit of interaction was needed. The link with the video is here:

    The systemic difficulty is the eternal conflict between the government, Doctors and insurance companies at the expense of the patient.

    There are over 1300 medical insurance options in the U S so the public option is simply one more which will have a Fannie Mae presence and the backing of the taxpayer.

    Watch the video and the others on health care to see what we need.

    Remember this fact in the health care debate, to be right I don’t have to prove you wrong.

    Mike Protack

  13. Joanne Christian says:

    Cassandra-you have given a well thought out, rational appeal for change. While I will honor, and agree anecdotes are not data request–I would caution–you have one mother, one spouse, (or significant other), one heart, one brain, one liver, two lungs, two kidneys, and a few pints of blood. Entrusting those limited resources to an overarching government distribution/oversight plan gives me great pause. Right now, if thinks get muffed up, I have appeal processes up to and including legal/government intervention. Starting w/ the government has just ceased any dynamic intervention in my or my loved one’s behalf. But I am open. If implementation is the snag, than I would propose the US pick two dates and drop the ax on some plan: one date picked futuristically “all babies born after January 1, 2011” and distantly, “all persons born from January 1, 1949”. It will soon enough give us a sketch of how we as a nation provide healthcare, the outcomes, and satisfaction. Just a thought. But your post is very well done.

  14. Joanne,

    As I see it we’re now entrusting our precious resources to bureaucrats who are in it for profit. I don’t think that’s any better, and in fact, way worse. The insurance companies make money by denying claims for sick people and only insuring healthy people. That’s why we have such a disfunctional system, IMO.

  15. cassandra_m says:

    Entrusting those limited resources to an overarching government distribution/oversight plan gives me great pause.

    So do the elderly in your family avoid using Medicare? Because that is what the public option would look like. I am not so sure why we think it would be OK for our parents to be on Medicare while avoiding this kind of coverage for ourselves. Especially if you have no employer options.

    And if the government is the problem, I’d love to hear how you think all of the countries who do have government support for health insurance are able to do it for less money than us and with better health outcomes.

  16. meatball says:

    Will Americans work for low pay as nurses?

  17. Joanne Christian says:

    Cassandra-this is where I am disarmed with data. It is perception of quality vs. quantity of life. The US has never been one to embrace death as a reality in life, and are the most uncomfortable in acknowledging it as a choice outcome. Hence, we have gazillions of dollars spent on heroic pre-life, and end-of-life interventional care in the name of “there has to be something you can do”…..while you’re fighting to have your gall bladder removed without that sixth signature. No one argues a need for a ventilator at the crossroads of life because this country is too bent on living forever, no matter how well played life and existence may have been. It’s compassionate care, not costly care. But the US trails distantly, any other country in acknowledging that, so must fund their obstinance. That mindset alone will always show our European counterparts as being cost-effective.

  18. cassandra_m says:

    No doubt that the costs of care for the elderly and at the end of life can be astronomical — and to some extent it is the system itself that encourages the aggressive medical treatments that prolong life. Palliative care options (especially home based) are not as well funded by Medicare (if funded at all) as are the medical and hospitalization treatments. In lots of families that means a choice between taking up these costs or letting Medicaid do what Medicaid will pay for.

    But if you are looking at health care outcomes, that is an indicator of long term health (not how long it takes you to die) and one reason that the outcomes are better is that everyone is covered. There’s much less reason for mothers to skimp on pre-natal care, for instance. There’s much less reason for someone with insurance to skip out on a colonoscopy because they’d have to pay for the anesthesia out of pocket.

    No country is immune to the cost control problem — but coverage for all gets them further along the curve to work on that problem than we do.