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Thursday, February 16, 2017

Universal healthcare and a single payer--definitely not the same thing.

I hear many of my progressive friends say that "obviously what we need is a single payer." That could work, but it is definitely not a sure thing. Overall what we want most is universal access to healthcare at a cost that is affordable.

Why, some may ask, does it need to be affordable? Why can't it just be free, like in Canada?

That's a wonderful thought, sort of. It also ignores the big truth that healthcare is like any other resource and is not free. It is always paid for by all of us. The difference between a single payer and multiple public and private payers, which we have now, is the degree to which we feel the pain of paying for it. Healthcare costs are paid by our employers, and thus from our wages, our taxes and directly from our purses in the forms of premiums and copays.

There are problems with universal access to healthcare, too. As a nation of people with various values, it is probably safe to say that most of us want sick people to be able to go to a doctor or hospital and get the help they need. And, if it makes it so that there are fewer people getting sick and thus more people who are happy and productive, we could probably agree that we want interventions that will prevent illness, things like vaccines and preventive testing for treatable diseases. But what about nursing home care and transplants and the newest drug therapy for chronic diseases and expensive medical devices? Is this stuff included in what we believe is essential to offer people in order to be a civilized nation? What about critical care interventions for people who drink too much or use injectable drugs and continue to do this despite developing health problems? What about smokers who get chronic lung disease and cancer and continue to smoke? What about the ravages of obesity, including diabetes and osteoarthritis? What do we do about the associated need for ever more costly new antidiabetic drugs and joint replacements? Is there a point at which we cannot reach consensus?

Having our diverse collection of private insurers does allow for some creative approaches to the above dilemmas. They can adjust the cost of their product based on certain unhealthy behaviors. They are free to develop programs to help people eat less, exercise more or go in for regular preventive maintenance. With multiple private insurers competing, this becomes less restrictive.

A single payer could build some of these same incentives and could potentially do some other things to reduce costs. It could negotiate with the various segments of the healthcare delivery system in order to reduce their charges. Many services are excessively expensive and prices could probably come down with some pressure from a single payer who was the only client available. If that single payer is the government, it could potentially do some innovative things to reduce costs.

If a single payer were to notice (as many doctors have noticed) that some of the most costly patients were ones who abuse drugs or alcohol, resources could be directed outside of healthcare to reduce those risks. Rehabilitation programs might be targeted for more funding, but more effective would be to support high risk communities where education is poor and there are few decent jobs available. This is something that a private insurance company has no ability to do.

What is kind of strange, though, is that we do have a single payer for a large portion of Americans: almost 1 in 3 of us is insured by either Medicare or Medicaid. But they don't negotiate prices of medications or devices or many services and they don't have fun and accessible programs to increase healthy behaviors and, as far as I'm aware, they don't target high risk communities for improvement projects as a way to reduce healthcare costs.

What makes our government unable to control costs, then? If we are thinking about having the federal government be our single payer, we should consider its success in managing the healthcare of over 100 million people now under its umbrella. It is possible that the existence of private insurers that will pay more than Medicare or Medicaid rates limits these government funded payers from lowering prices still further. I think, though, that the inability of opposing sides to work together to come up with solutions is at the heart of it. Our government has become one in which the two parties definition of success is to obstruct the ideas of the opposing party. The fact that congresspeople can serve many terms means that everyone is trying to appear to their constituents to be the most magnanimous and to make their opponent appear to be stingy and unkind. At the same time they are attempting to please powerful business interests, particularly in the healthcare industry, in order to benefit from generous campaign contributions. Ideas that would cut costs by limiting benefits or reducing reimbursement can also reduce the chance of being re-elected. Moving resources to underserved communities buys few friends among the powerful.

On the other hand, Medicare probably does deliver healthcare with lower administrative costs than private insurance. Although it is not free to recipients, most of them love their insurance, which is more than most private plans can claim.

So what, then, is the best route to a universal healthcare system that can control costs and encourage people to take better care of themselves? Our present system, under the affordable care act, has provided a framework in which increasing numbers of people were covered by a single payer, though Medicare and expanded Medicaid. It did not allow people to buy into Medicaid when they made more money than 138% of the poverty line, which would be useful. Instead, it subsidized private insurance to do the same thing which has run into some problems. Offering either Medicare or Medicaid for a fee based on a sliding scale for income would allow people to move further toward a single payer without taking away private insurance companies' ability to do business. Private insurance might continue to innovate in ways that larger scale federally funded healthcare could not do. Independent healthcare cooperatives such as Group Health/Kaiser Permanente could do the same. Cost pressures on federally funded healthcare might lead to price negotiations and attempts to address the social causes of the diseases of self neglect.

I and, I suspect, the vast majority of Americans would appreciate bipartisan work on patching together universal healthcare out of the unstable bits and pieces that are presently making a mess of it. That may require changes in government that seem far removed from healthcare reform, such as term limits and campaign finance reform. It is not going to be simple and will likely involve both compromise and willingness to make some sacrifices.


Icarus said...

long time subscriber, perhaps first time commenter. Just wanted to say please keep up the good posts. I know it can be hard to keep writing if you don't get much feedback from your readers.

Janice Boughton said...

Thanks! I checked out your blog and the other ones you follow and they are great. I didn't check all of them out, but just reading their names is a hoot.

herbert said...

What you wrote here really stirred some thoughts in my "big pot of healthcare stew"... and I'll leave a few here.
I wonder why the "healthcare industry" players have to make a Profit? Insurance, levied as a "use tax", makes it a little easier to swallow. And maybe I'm not the only one who feels that "paying something for 'nothing'" goes against the grain. What BC has done with "no-fault" auto insurance offers a great model: the actuaries estimate what annual payouts might be, and insurance is sold at that rate. If the actual costs exceed what was estimated, the Next year's assessments add in the overage. If the actuaries' guesses were pessimistic- and costs aren't as high as projected, everyone gets a pro-rated refund at the end of the year. In a way, having that insurance is actually an incentive that encourages everyone to be a safe driver, in hopes that there's a Refund!

Republicans don't want the "public" insurance programs to be Too successful... which is why they have passed laws against bargaining for bulk purchase prices for drugs and materials, the way other large entities do. (I think the VA may not have that restraint... which only makes it MORE hypocritical, in my eyes.)

The idea that "getting insurance through an employer is the BEST plan" is truly infuriating. It's as if the government is a monarch... and the TRUE "citizens" are the corporate "persons", with whom the monarch will communicate. But, just like the bad old days, the monarch assumes that the minions of the corporate personages will be "cared for" by their Corporate Person... and that reduces "citizenship" of the minions to a "2nd-class" status. I would FAR prefer dealing with a government- MY government- directly, without an employer OR an insurance corporation 'buffering' my interaction.

The cost of "Med School"-- and the exclusive nature of its structure-- has made it a "necessity" to draw out healthcare practitioners from other countries... which isn't fair to THOSE countries that they left behind. This is pure capitalism at work-- creating "scarcity" to keep a thing (service, etc) expensive. It's about "national priorities". Cuba has supplied doctors to a number of countries. I have noticed that our hospitals and clinics are employing a substantial number of people, immigrants from the former Soviet Union... which is a "double-plus" for some, in that they're well-trained, And they're White.
The actuality that our insurance industry has managed to co-opt Medicare (by virtue of the "Medicare Advantage" policies, and the increasing number of clinics and doctors who won't see a patient who 'only' has Medicare) is really sad. Probably it will come down to the only place a Medicare-only Part B card-holder will be welcomed is an ER... because it's better than NO insurance at All.

Now that the opioid scourge has manifested in the white suburbs, and it's "all about providing treatment" (and not cold turkey in a lockup, and a mandatory 5 year or better sentence for "the dissolute, the gangsta, the black criminal" "the hooker", etc) we may see some sensible solutions to drug use/abuse... except that an anti-drug zealot has just assumed the Attorney General post. *sigh*

My blood pressure has been 25 points higher ever since the election... even with a raise in my lisinopril intake, and descending cholesterol numbers, and an attempt at a vegetarian diet. I will continue to meditate... and put some Good-Hippie vibes out there for America... and Americans, in general... and not expect too much, in the near term.
Keep asking the questions, Doc! You're the goods! ^..^