One way or the other, a single-payer health care financing system looks like a non-starter in the current political climate. Personally, I think it is the best way of doing things, but it seems like we might as well shelve the idea for a while.
I do hope something comes out of the current discussion of reform, but I am growing pessimistic. The problem is that many of the reforms, like mandating coverage, forbidding insurance companies from excluding based on preexisting conditions, and so forth, only work if they all come in together. Mandating coverage is useless if insurance companies can turn people away for having preexisting conditions, and forcing insurance companies to cover preexisting conditions is silly without mandates. Without a mandate for coverage, but with a ban on excluding preexisting conditions, there is a strong incentive for people who think they're healthy not to buy insurance until they're sick. Conversely, with a mandate but no requirement that insurance companies cover people with preexisting conditions, people with preexisting conditions who are trying to obey the mandate may not be able to obtain coverage. For any reform to be effective, it has to be all or nothing. So who knows what will come of all this... Also one of the criticisms of the current reform ideas does seem to hold some water: there is very little in the current discussions that would help control costs.
Here's an idea for something that could be done right away, would help contain costs, and shouldn't be too controversial... Why doesn't the federal government take over paying for screening and routine management of chronic conditions that are relatively inexpensive and straightforward to screen for and manage, asymptomatic in the early stages and therefore rarely diagnosed in the absence of screening, and that when not managed properly, lead to enormous costs that are borne disproportionately by Medicare because even though the conditions may begin in adulthood, the expensive complications tend to arise in old age. I am thinking of diabetes types I and II, hypertension, high cholesterol, and maybe a few other things that I am not aware of.
Diabetes type II, hypertension, and high cholesterol are especially important here. These can all be screened for at relatively low cost, can be managed with existing medications, and if not properly managed lead to enormous expensive complications. Moreover, people are often asymptomatic for years, so unless people are specifically screened for them, they may not be diagnosed and treated properly until they do begin exhibiting symptoms, typically at later ages and often after damage has been done. Undiagnosed or poorly managed diabetes type II can lead to amputations, dialysis, blindness, and a variety of other conditions. Hypertension and high cholesterol, of course, lead to heart disease, stroke, and other conditions. Again, because these complications tend to emerge later in life, Medicare picks up a big portion of the tab.
My specific reason for the federal government to become involved with the diagnosis and management of these conditions for the whole population is in fact that it is already picking up the tab for the complications, and might be able to reduce expenditure on complications if these conditions were picked up earlier and managed better. We have a situation where people may develop these conditions in adulthood but may not be screened or treated for them because they don't have insurance, or they have insurance but aren't screened properly, but when they are old enough to qualify for Medicare, begin experiencing very expensive complications that Medicare pays for. In these situations, a small amount of money spent on screening and management in adulthood would reduce or at least delay substantial expenditures by Medicare in old age.
So my idea is that the federal government pay for universal screening and management of chronic conditions like diabetes, hypertension, and high cholesterol that can be identified and treated relatively cheaply in adulthood, but which lead to expensive complications in old age that are covered by Medicare. Set up a system where the federal government pays for diabetes, hypertension, and cholesterol screening for everyone, insured or not, and also pays for medications for anyone who is diagnosed. In this system, health care providers would send all bills for screening and management of these conditions to the government, to be paid for at some specified rate, and not send them to the patients' insurance companies, or bill the patients. I suspect that in the long term this would pay for itself by reduced Medicare and other expenditures, but in the short term it could be financed by a levy on insurance companies to reflect the money they would be saving by not having to cover screening and management of hypertension, high cholesterol, and diabetes type II. Even if it was politically impractical to ban insurance companies from covering all preexisting conditions, in this scenario, they could be forbidden from denying coverage based on existing hypertension, high cholesterol, or diabetes type II.
This would be a win-win situation. Medicare expenditures would be reduced because people old enough to be eligible for Medicare would be much less likely to have expensive complications that Medicare would have to cover. People would be better off by having access to screening and management for potentially debilitating chronic conditions. If the financing arrangements were done properly, this would be revenue neutral for insurance companies and health care providers.
In terms of selling an arrangement like this, the key is the likely reductions in Medicare and probably Medicaid expenditures, which in a few years would probably more than offset the costs of covering screening and management for working age adults. Think about the savings if there were a substantial reduction in the number of people requiring dialysis because type II diabetes had already led to kidney failure. And the savings, and increased tax revenue, if people who were debilitated by blindness or loss of their foot or other limbs by complications of diabetes could remain healthy, and continue to work. And so on...
The main reason for doing something like this would be a hard-headed cost-benefit analysis. This isn't about social justice, or any other existential, philosophical issues about equality or access or fairness, but rather about reducing Medicare and Medicaid expenditures in the long term by spending on screening and management of chronic conditions that we already know are 1) cheap and easy to screen for, 2) manageable with relatively inexpensive medications, and 3) if unmanaged lead to very expensive complications that the federal government, and therefore the taxpayers, already pay for. An $1000 investment in screening, statins, beta-blockers, and other drugs by the federal government might avert or at least delay $10000 in spending by Medicare, Medicaid, or private insurers to cover dialysis, amputation, disability, intensive care and so forth.
As a conclusion, I guess I would say that I am disappointed that so much of the discussion of health care reform is being framed in terms of abstract philosophical concepts like social justice and equity (from progressives) or individual choice and freedom (from conservatives). The concern should be about public health, and the implications of whatever we system for other features of the economy.
The real problem with the status quo in health care in the United States is that it is screwing up the economy, and affecting our competitiveness, by introducing complications and inefficiencies. Individuals are afraid to change jobs out of fear of losing benefits. Companies waste time and money in ongoing negotiations with insurance providers. Individuals and doctors waste time dealing with insurance companies, sorting out billing problems and so forth. All of these are sand in the gears of the economy.
Imagine an economy where individuals could change jobs without even thinking about their health insurance coverage, and where companies could focus on their products and their customers without needing to devote personnel to negotiating with insurance companies. The main reason to fix the health care system isn't some abstract concern about equality and social justice, or individual choice and freedom, it should be about making American companies more competitive by letting them focus on their customers, their employees, and their products, without wasting time negotiating with insurance companies to cover their employees.
I should clarify that when I propose federal government coverage for screening and management of chronic conditions like diabetes II, hypertension, and high cholesterol, it isn't because I think of this as some sort of clever thin end of the wedge that will eventually lead to a single-payer system, but because I think it would result in substantial net savings to Medicare and Medicaid and private insurers. We shouldn't be so blinded by an obsession with 'individual choice' or 'freedom' on the one hand or 'social justice' on the other hand that we let it dictate our preferences for policy, we should be doing a hard-headed calculation about what is best for the economy, in terms of reducing government spending, or improving competitiveness.
As I said at the outset, I would prefer a single-payer system, but I am realistic enough to conclude that it just isn't in the cards right now. My preference for a single-payer system isn't based on some sort of hazy concern with social justice, whatever that is, but rather based on a belief that anything else is inefficient, and ends up being a tax, direct or indirect, on the economy.
We should think about the time that Americans spend on health care, whether it is time spent trying to find coverage, find a provider that their insurance will pay for, sort out billing questions, as an indirect tax associated with the current system, and think about the improvements if people didn't have to spend minutes or hours on hold with their health care provider or insurance provider on questions related to billing or coverage, if companies didn't have to devote time to negotiating with insurance providers, if doctors didn't have to spend time filling out paperwork for insurance companies, and so forth. The real virtue of a properly implemented single-payer system is the time it saves for companies and for individuals. I would like to see the conservatives who advocate for market based solutions that include private companies as insurance providers at least acknowledge that patients and doctors waste with billing, negotiations, and so forth is in fact a tax, paid not with money, but with time. But I am realistic enough to think that a single-payer system is not in the cards, and we should be thinking about other, incremental changes.
One thing I would add is that when we discuss single-payer systems, we should look at examples beyond Canada and England. I think the Canadian and English systems work very well for serious conditions, but acknowledge that they probably don't do quite so well for chronic conditions that affect quality of life but are not by themselves life threatening. Knee surgeries and hip replacements shouldn't be thought of as a luxury that people have to queue months or years for, since these are debilitating conditions that impair productivity. We should be looking at other systems as well, like in Taiwan, and the Scandinavian and Northern European countries, that are also single-payer, but at least to my knowledge don't seem to generate the same numbers of complaints as the Canadian and English systems. I'm not an expert on those systems but the point is that the Canadian and English systems are not the only game in town.
I was particularly impressed with the Taiwanese health care system during my visit there in December. I needed to have something checked out. I ended up going to Taiwan Adventist in Taipei. I was absolutely amazed that all of my appointments started right on time, no paperwork was lost or misplaced, the staff were uniformly efficient and courteous, and everyone seemed to be on the ball. Since as a visitor, I wasn't covered by the national insurance system, I paid cash for everything, but the final bill was ridiculously low. Several consultations plus a number of tests that in the states would have cost somebody thousands of dollars cost only a few hundred dollars. My in-laws who live in Taiwan and use the national health insurance all seem pretty pleased with the care they are receiving. So maybe we should be looking into what the Taiwanese have done.
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