Single Payer as a Policy Perspective


Sep 4, 2017 (San Diego) The United States is having a very spirited discussion on the future of healthcare. It is not just about the Affordable Care Act, which marinated the private insurance sector at the heart of the system. This is a system that the Trump White House wants to dismantle, never mind that it is at its heart a private system. This was the path taken because single payer seems to be a step too far. However, forms of single payer are used in developed economies with some private insurance available for some aspects, such as private rooms during hospitalization. 
The United States has resisted taking this path, partly due to ideological concerns. There has been a war from private interests to enact even a weak form of single payer, such as Medicare for All. It is fought even with the idea that it is some form of communism or socialism. Red baiting is part of the war on it.
What we have, even with the ACA, is the most expensive medical system in the world. If we had the best outcomes in the world it would be one thing. We don’t. Americans do not get the best care, unless they have the best insurance, or are very independently wealthy. Our system serves the best those who have resources. 
According to the Wharton School of Business:

By most estimates, the United States spends between $3 and $4 trillion on health care annually, a sizeable 17% of our GDP. According to a 2015 Bloomberg report, the U.S. is the third most expensive country for medical care, surpassed only by Norway and Switzerland. Yet when the report ranked 55 developed nations in terms of health care efficiency — based on life expectancy, healthcare costs per capita and costs as a percentage of GDP — the U.S. fell near the bottom at number 50. (It only beat out Azerbaijan, Algeria, Serbia, Russia and Brazil.)
Basically we’re paying more and getting less than citizens of other countries. Americans’ average life expectancy (78.8 years) is lower than that of Australia, Canada, Denmark, France, Germany, Japan, the UK, and several others, according to the Commonwealth Fund. And when it comes to infant mortality, the World Health Organization reports America’s rate of birth-to-five mortality as notably higher than most other OECD countries.

Part of this is the number of unnecessary tests ordered by doctors. They do not point to the other culprit. This is the use of defensive medicine. 
There are several reason medical care in the United States is so expensive. It is not just doctor’s practicing defensive medicine and ordering tests that are at times not necessary. This is actually a minor part of the problem. 
According to Investopedia the reasons in order of importance are as follows: Administrative costs, drug costs, defensive medicine comes in third, expensive mix of treatments, wages and work rules. 
A single payer system would remove the profit motive from medicine. In the United States until the Richard Nixon administration it was not legal to seek profit to begin with. That would mean that efficiencies of scale would have to be introduced into the system. With a single payer system branding would also go and the medical system would have to negotiate prices with drug companies from a position of strength. Price controls would also be posible. In fact, they could become necessary. 
Another thing that would have to occur is an emphasis on preventive medicine. The United States is not very good at presenting disease. We are very good at prescribing drugs for chronic illnesses. Never mind that preventing diabetes is cheaper for a medical system, than treating diabetes. People have been trained to take pills, including supplements, and not to do the work needed to maintain their health, This includes diet and exercise 
Experiments on this have been done, and those models have not succeeded. Why? The system is not set to prevent disease.
A national health care system will have to control costs by emphasizing this preventive health care and wellness programs. It may even have to reward providers for better outcomes not better drugs. 
Then we get into the sticky issue of value. Americans have been trained to think that things have to cost money. Moreover, co-pays are standard in our system. This is how we measure value. Never mind that these could be a barrier to access to people on the edge economically. A national system will have to give equal access to care regardless of income, and reward providers for changing outcomes. 
In the end, the United States is at a point where we will have to decide. Do we want a medical system that ultimately is faced with collapse, or systemic changes, that include an emphasis on wellness programs, and not on profit. 
California could provide a model for the rest of the country. But only if the political class decides to finally challenge economic forces that continue to benefit from this dysfunctional system, but ultimately will lead to collapse. In the end, none of us will have access to healthcare, because it will be ultimately unaffordable. 



Categories: Policy, healthcare, medicare for all

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