A Facebook friend who tirelessly advocates for anything that the Democratic Party tells him is “progressive” has found something he doesn’t like: Bernie Sanders’s single-payer system or “Medicare-for-all.”
- friend: What Hillary was saying: “The details very quickly get very messy.”
- me: Why would it be hard to implement? Medicare already has rates that it will pay for every medical service. Medicare and Medicaid are already about half of total health care spending in the U.S. Why couldn’t they double their transaction volume, most of which is handled by computer systems that double in performance every couple of years?
- friend: … Sanders is proposing to vastly expand the public’s risk margin by creating an untested system. I find that worrisome. I wouldn’t want to wait for weeks because a new system was full of glitches. Would you? What if your private health insurance option were taken away from your family by government fiat. How would you feel about that?
- me: Medicare/Medicaid is already running half of American health care. If it is unacceptably bad for the people already on it (50+ million on Medicare alone; see kff.org for 2012 data; plus another 72 million on Medicaid and CHIP) then we should probably do something about that. Countries that have single-payer systems don’t “take away” by fiat or otherwise the option to purchase health care or health insurance privately. They just make it unpopular (since most people prefer to use the system that they’ve already paid for via their taxes). Given that the U.S. has the worst of all possible health care systems, I don’t think that there is any chance of a Sanders plan making it worse. As I note in http://philip.greenspun.com/politics/health-care-reform, Americans would probably be better off if we shut down most of our health care system entirely.
- friend: I have worked fairly extensively in healthcare for going on 25 years, and it is definitely my opinion that there are many worse systems. For example, I worked with a British team not too long ago from a public hospital in a large city. The degree of staff alienation in that institution was truly tragic.
A single payer system would certainly simplify covering everybody.
But suppose you need a hip replacement. You can still walk, and do your job, but it hurts. So you go to your government health provider. The doctor examines you, and says, yes, we’ll schedule you for a hip replacement in March. March 2017, that is. (example).
With a single-payer system, leaving you in pain for a year is an acceptable trade-off for keeping the overall health care costs down. But for Americans with good corporate or union health plans, it would be a rude shock.
“Countries that have single-payer systems don’t “take away” by fiat or otherwise the option to purchase health care or health insurance privately.”
I am pretty sure this is not true in Canada, based on this 25-minute film about Canada’s healthcare system:
It’s been a while since I last watched it, so it’s possible I’m misremembering what it had to say about private health insurance in Canada.
Medicare does not have any power to contain costs. If it were expanded to everyone, it would surely be followed by some cost containment measures that would make a lot of people in the healthcare system upset.
For those up here in the frozen North, it is always a mystery why Americans reject single payer health care. Your friend’s arguments hold no water, except…
There is rationing. There are waiting lists, but only for the type of surgery that our demographic crisis is mandating: knee and hip replacement.
For anything critical, like cardiac or cancer treatment, the service is fast and excellent. My personal experience from the onset of angina on a cold November morning to my angioplasty was a week. I was in no danger during that time, and lying on the table I had a discussion with the technician, “Some guy comes in here on an EMS helicopter and you’ll be pushed back”. OK by me.
We carry supplementary insurance which costs me $350 per month for the two of us and provides 75% prescription coverage, semi-private hospitalization, dental, limited travel coverage, as well as ambulance costs if needed.
There’s also a $120/month provincial medical services premium, as my province likes the rule of user pay. If you are low income, you’re exempt, and your pharma costs are covered as well.
There are no death panels.
It is not in the best interests of your insurance industry, your pharmaceutical industry, your (overpaid, relative to the rest of the world) medical profession, or many of your politicians (collecting large “donations” from many of the above) to change your system so radically. There’s the biggest obstacle.
The second obstacle (in my opinion) is the risk of unemployment. There are a lot of people in the insurance business whose rice bowls would be broken if you went to single payer. And I’m not talking about the highly-paid people here.
Our single-payer system is a >long< way from perfect. We need better queue-management, more direct patient-specialist communications (rather than relying on referring GPs), more cost-efficient (read factory-model) clinics for common low-risk procedures like joint and hernia surgery, a faster adoption of tele-medicine, and better use of electronic record interchange. And lots more.
There are lots of different models for single-payer. I've often wondered if it could not be run on a pooled-risk basis, by auctioning off parts of the risk pool, rather than have the government health services underwrite the risk itself, as now happens. It would leave management of the payments in one place, and companies could choose or not to absorb risk (under contracted terms) over a longer term without the need for managing claims and payments themselves.
It's interesting to watch the debate on this issue.
Obamacare seems like a nightmare to me, but I have friends in the US who are very happy with it. Others not so much.
My bet? Mr. Sanders goes nowhere. His ideas go nowhere. How could your congress EVER support single-payer, even by simple downward extension of Medicare? There are too many of your elected people who are there because they've exploited paranoid fear in the electorate.
Anyway, sorry for the rant. Your country deserves better than you've been getting, on both sides of the political spectrum.
J: Yes it hurts to wait a year for a non-life-threatening procedure. But it also hurts to pay nearly 20% of your GDP every year! If you had a lifetime of wonderful vacations and then a year waiting for a hip that might be better than no vacations (because all of your discretionary income went to health insurance/health care) and an immediate new hip. In countries that don’t invest so much of their GDP in health care, citizens have choice. They can bank an additional 10 percent of their income every year against the day when they will fly to Israel or India and buy a replacement hip out-of-pocket. Or they can spend that extra 10 percent on an improved lifestyle and then wait a year for their hip. Unless you have infinite money (cf. Warren Buffett!) you can’t have everything…
Lynn: A quick Google search for “canada private health insurance” will bring up an array of sites such as http://www.bluecross.ca/en/products/products-individual.html
Gordon: “Your country deserves better than you’ve been getting”; Why isn’t it safe to assume that every country gets exactly what it deserves? If Americans aren’t good at organizing and running government then we will have to pay more for anything that the government touches. To the extent that we do pay more it is not because of an evil oppressor but because we just aren’t as good as folks in countries that are able to run comparable government services at a lower percentage of GDP. Do we “deserve” to be as good as folks in Japan, South Korea, Taiwan, and China at making flat-screen TVs? If the answer is “no” because those folks have worked harder and more diligently at making flat-screen TVs then why isn’t it the same answer for health care?
@philg: Aren’t we setting ourselves up for a %20 GDP spend AND a year wait for an operation?
Was your friend advocating for a single payer system before the Affordable Care Act (20% of GDP is affordable?) came along?
Larry: Yes, as it happens, he was passionate about a European-style single-payer system until Obamacare came out. Now he is apparently passionate about Obamacare.
I say let’s keep the things exactly as they are (“perfect” in Western Europe, “terrible” in US) so we don’t get those refugees even more incentives to come to the States!
“friend: I have worked fairly extensively in healthcare for going on 25 years” – oh, so you think healthcare workers get a worse deal on Medicare-covered patients than ACA/employer-covered.
J. Peterson: My guess is that quite a large majority of Americans who get hip replacements are over the age of 65, meaning that their hip replacements are paid for by something resembling a single payer system that goes by the name of Medicare. For some reason many Americans forget that their parents and grandparents have their health care provided by big government.
I didn’t have the time to thoroughly look at the offerings at http://www.bluecross.ca, but it appears the insurance sold covers services not provided by the provinces, such as acupuncture and hearing aids. However, it’s highly likely the private insurance would continue to be available in America as it in the UK and Australia. An American single payer system would thus become something like the public schools. Everyone could use the public system. Those with high incomes might continue to purchase private insurance.
Perhaps expanding existing Medicare to all could work if the resource allocators (physicians) didn’t have the conflict of interest introduced by being paid fee for service. This would make it easier to introduce cost saving changes into the system over time, and some administrative efficiencies would accrue pretty quickly.
Lynn and Vince are correct; it is illegal in Canada to offer private health care that competes with government health services. Complementary private health care is available for drugs, dental, eye glasses, etc. Offering for-pay hip-replacements in Canada would be illegal, but Canadians can and do sometimes travel outside the country to access private health care.
Those other countries nearly all have way less household income than American households, especially comparing among married households with children, who are quite high-income in America. Also Canadians carry more household debt (credit card and such) despite having “free” health care access.
American physicians are increasingly moving to salaried positions. The real leakage in health care spending in America is increasingly administrative jobs with zero patient facing/medical aspect.
If physicians are on salary but employed by organizations which are reimbursed on a fee for service basis that doesn’t really get at the conflict of interest problem.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC80881/ is “The illegality of private health care in Canada”
It seems that the law varies from province to province. It also seems that, if the government isn’t directly running the hospitals and clinics, without a lot of new laws there is the potential for market forces to work against government goals.
Well, if you want to reduce costs from 20% of GDP to say 8%, you will see major changes. I suppose the hope for savings is to fire huge numbers of health care bureaucrats everywhere, get rid of masses of legislation and rules that require those bureaucrats, shrink the private insurance market to insignificance, and substantially reduce the pay of health care workers. I expect that realistically it would also require reducing the actual health care efforts. As with Obamacare, you might be disappointed in the outcomes.
A centrally planned health care system of course has death panels. These panels for example decide on whether certain procedures, treatments and medicines are too expensive and won’t be implemented. Budgeting.
As someone who has most of my life partaken of the Swedish system (8%), which seems similar to the Canadian, I would say it’s okay but not great. But then you probably shouldn’t expect a lot more from a government service.
With that said, the American system indeed seems rather broken. (In particular the bizarre pricing menues apparently based on “how much have you got?”.) But Europe is not the only model.
How about the Singapore system? It seems to be an interesting blend of universal coverage, everyone pays something, progressive so that the poor pay less, and still employs market forces. Does anyone have first-hand experience with it?