How will healthcare change when, not if, we switch to a European style single payer system?

Great Debates
21

It’s already been pointed out that different European countries’ health care systems are all different, and the NHS was described as one example. Here are my answers with respect to Canada, which ought to be (but probably won’t be) a good model for the evolution of UHC in the US because the two countries are so economically and culturally similar. It’s been said that there is no single Canadian health care system, but a bunch of individual ones in each province and territory. That’s true, but for purposes of this discussion the differences are minor, and I’m describing the system that is governed nationally by the Canada Health Act.

Absolutely, which is something you cannot do today in most cases where the insurer insists on their own “network” of providers. In single-payer and equivalent systems, all provider fees are the same, so it makes no difference to the single-payer system who you see. In the present US system, costs are not only all over the map, but they’re variable with circumstances and almost never publicized – they’re essentially secret.

That said, it seems virtually certain that the US health care system will evolve into a public/private model, and that poses a risk that the best doctors and facilities will migrate to the private sector and only be accessible to people with private insurance, leaving the publicly funded sector with lesser resources. Canada addressed this problem head-on by simply outlawing private insurance and exclusionary private access for any health care that is medically necessary. In the US, boutique and “concierge” health care – better health care for more money – is becoming increasingly prominent.

There is always some kind of limitation that can be construed as “rationing”, but the greatest rationing of all occurs under private insurance, because the insurer’s profitability and even their very solvency depends on controlling costs, which means rationing their payouts. They do this through means like annual or lifetime payout caps, deductibles, co-pays, and of course limiting access to those who can afford to pay the huge premiums, either directly or indirectly through their employers.

The important concept here is not the obvious fact that finite resources have to be prioritized and properly managed, it’s the fact that in the Canadian system, and in the health care systems of all civilized countries, the right to the highest quality of all medically necessary procedures is considered sacred, enshrined as a fundamental human right.

No. That is the case in some systems, but not in Canada. Doctors are typically either self-employed individual entrepreneurs or members of a partnership sharing an office, similar to the partners in a law office. Significantly, doctors are also given the responsibility of being trusted gatekeepers to medical resources; that is, if a decision needs to be made whether or not you receive a certain treatment, the decision is based on some combination of your wants and needs and the advice of your doctor, unlike the private insurance system where the ultimate decision-maker is the insurance bureaucrat who may decide not to pay for it based on some sleazy fine print in the insurance contract.

22

At the very least, #1 should read “some people will need to pay extra to get the same level of healthcare”. Every country has a private health care system that offers additional service not covered by their universal health care system.

23

I’m curious – what happens if there are no GP practices in a catchment area that are accepting new patients? Also, what happens when the only GP practices taking new patients are a hardship in terms of travel for a prospective patient?

(I admit, most of the reason I’d like to know is on the offhand chance you’ve got a better way of dealing with this situation than we do. Because sometimes there aren’t any in-network doctors taking new patients here, and AIUI a common response from the insurance company pretty much comes down to, “Gee, it must suck to be you.”)

24

Either the new UHC plan includes significant cuts in spending, or it won’t save any money.

If it does include those cuts, then doctors and hospitals and health care providers in general, and drug companies, will have to figure out a way to deliver care when their revenues have been cut by 25-40%. If there is the equivalent of Medigap insurance, then premiums on that insurance will go up enough to replace the lost revenue. If enough patients can afford and are willing to pay the premiums, then Medigap insurance will be very expensive. If not enough patients can afford and are willing to pay the premiums, then health care providers will have to adjust to the lower revenues. And so will patients. Maybe the doctor will be booked six months in advance, and doesn’t want to work the same number of hours at a lower compensation. If the patients don’t want to wait, then maybe they will go to the emergency room instead, and you will see increased utilization of PHPs and emergency room visits, as we did under Obamacare.

If UHC covers everyone, then there will be increased utilization of the health care system, which will add to the issue.

Which is not to say that it can’t be done, or that it will have much effect on life spans in the US. Most of the problems people go to the doctor for are self-resolving. And we could certainly do a better job of managing end-of-life.

But I don’t think people will like it. Doctors with a lot of medical school debt won’t like it either, which may lead to a decrease in the number of specialists and so forth.

I suspect it will be a matter of de facto rationing, not a planned approach.

Regards,
Shodan

25

I think the “better system” is that in a single payer world, there’s really such thing as an in-network or out-of -network doctor. I’ve encountered doctor’s who were “not accepting new patients” before , and in my experience they come in two flavors :

1 Doctors who are not accepting any new patients because they plan to retire or cut back to part -time. You’ll have these even in a single payer system.

2 Doctors who are not accepting new patients with ABC insurance. They will participate in insurance ABC for established patients, even established patients who just switched to that insurance. They will accept new patients with insurance XYZ or DEF or self-pay, just not ABC. Because ABC pays less or is more of a hassle than XYZ or DEF and they are only willing to do it for established patients. I don’t think you’ll have many of these in a single payer system as it would be financially - I suppose there might be some boutique doctors , but if everyone is covered by the single payer, then pretty much every doctor will have to accept it.

26

I’ve never heard of it happening. I guess the catchment area for one outside the area would be changed if that was found to be the case. We’re just not that spread out, and the catchment areas are big.

Friends who live very rural have complained about having to go some distance, or feeling stuck with the one doctor in the village who they don’t like, but that’s due to lack of transport, not lack of option. I don’t think there’d be anywhere in England which was only in one catchment area (the NHS is Scotland is run differently, some of the smaller islands may be).

Out of curiosity on the website SanVito posted, I picked a remote spot in the Lake District where I used to go for walks and there were 66 options given for there.

There were 94 options for where I live, though no dentists… Dentists have no catchment area though, so I’m registered with one in another county.

In theory we’re supposed to be given a choice as to hospital for appointments now (of course you can use any emergency department if needed), but every time I’ve been given the ‘choices’ form when I’ve been referred, there’s been a grand total of 1 option.

Lack of hospital choice can be a problem in some areas; I currently live in Cornwall, and although there are hospitals here, there are no paediatric ones. Seriously sick kids get taken to Bristol Children’s Hospital, which can be 4 hours drive away from the furthest point of Cornwall- there’s a helicopter to transport patients, but not for visiting parents. With a kid that’s a patient for, say, 6 months, especially for families with other children, it’s a problem.

27

I like the idea of a “hybrid” system, where a government-backed single payer covers all costs above a certain threshold, and individuals are free to buy coverage (or not) up to that threshold.

In my poorly-thought-out model, the threshold would be 10% of your individual or family adjusted gross income, with the usual battery of exceptions, exemptions and modifiers. (Hey, this is government stuff – nothing can be simple.) Now your “average” family with $60K income knows their worst-case annual healthcare costs are $6000. There should be plenty of private insurers offering affordable policies to cover $6000 annually.

How do you mollify the current health insurance industry? They essentially become re-insurance companies, and the government awards coverage to them as contractors.

I know there are a gazillion details to something like this, but I like the combination of individual choice and responsibility with fail-safe coverage for all.

28

Right there is a difference between Canadian and US expectations of government. Of course government programmes can be simple, without loads of “exceptions, exemptions and modifiers.”

  1. I get my health card in the mail.

  2. I get sick.

  3. I go to the clinic down the street and ask to see a doctor.

  4. Receptionist asks me for my health card. I give it to her and she takes down my number and asks if my address and contact info are still current.

  5. I say “yes.” She says please wait for a doctor.

  6. I wait, and usually within 15 to 30 minutes, I see a doctor.

  7. After that, I leave to get my prescription filled.

Simple, because it’s a government-run single payer that covers all residents.

I guess I’m missing something. What is the benefit of “individual choice” in this proposal? :confused: (not trying to be snarky - I really don’t get what benefit you see in paying a premium of $6,000?)

29

Yep, the most likely scenario for universal healthcare in the the is expanding Medicare to cover everyone. Also healthcare is already heavily rationed in the US, it’s just that people are oddly more comfortable with bureaucrats at private companies doing instead of bureaucrats at government agencies.

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30

Well, it makes his wallet lighter, easier to carry.

31

From my experience with no insurance, out of pocket medical expenses in France and in Spain, it is much better there. Great care, very personal service, and cost that are actually not a issue at all - feels more like a extravagant tip then a actual bill, doctors, specialists and Rx prices. The more I travel the more I know we in the US are getting screwed hard, very hard, and also we are lead to believe we privileged.

In the case of medicare/medicade yes, other then that they are denied care for business reasons in the case of private insurance companies…

32

I haven’t ever heard of someone not being able to find a doctor at all, but your question peaked my curiosity so I did some digging on the NHS site. It seems that in 2015 they changed the rules, so that you can now go outside your catchment area if you prefer (eg if you wanted a GP near to work). It also has a link to the NHS contact centre for anyone who’s struggling to find a doctor, so presumably they will help you.

I think the point is - the NHS is there to help the patient, not the GP or an insurer, so they’ll get you a GP somehow.

The information on how to register is here, should you be so inclined.

33

Interesting you say ‘settle for single payer’. The NHS is so highly thought of and valued in the UK, that no one regards it as ‘settling’. It isn’t a basic system - it’s fully comprehensive. It’s worth noting that even if you took out private healthcare (many employers offer it as a perk for professional positions), you would only use it for minor ailments - seeing a physio without joining a waiting list, or getting a smart private room if you need hospital treatment for example. For anything serious - major surgery, or cancer treatment for example, even if you’re seeing a private consultant, you will be treated by the NHS, as it has all the ‘big expensive kit’ and expertise.

I’ve had private health insurance for 10 years through my work, and I’ve never used it, though I see my NHS GP regularly for routine care and prescriptions, and have visited hospital for an endoscopy. My wife used it when she had sciatica and wanted to fast track a session with a specialist consultant (1 week wait instead of 4).

34

Hermitian, I appreciate you say you don’t have any cites, but I’m just curious why in your opinion you assume your health care would be worse under UHC?

35

There are a couple of benefits, but I’ll grant that they may not be worthwhile:
[ol]
[li]It costs less to insure people for every dollar of health spending. Cost will be a big factor – maybe the biggest – in getting any version of universal healthcare passed in the U.S.[/li][li]There’s a perception that if you cover every dollar, people will run to the doctor for every little sniffle and scrape. Having a 10% deductible removes this possibility. (It also, I know, disincentivizes well visits, so maybe we cover those outside the 10% deductible.)[/li][/ol]
Finally, there’s a resistance in the U.S. – and not just among hardcore right-wingers – to having the government completely “take over” an industry. I’m not saying it’s rational or right, but it’s there. Keeping “individual choice and responsibility” in the equation may be an essential part of finally getting single payer passed here.

36

job switching will be much easier because you don’t need to ask about the health insurance at a job that you might switch to.

37

Not to mention, you won’t have the headaches when your employer switches health coverage because the outfit you were with last year wanted to raise your premiums 71%.

Yes, that’s exactly what happened to me this year. I love my company and they do their best to give us great coverage, but the carriers make it a chore. I’m sure our COO would gladly pay an extra 5% corporate income tax to get health insurance off his plate.

38

That is something I like. also if you want to be self employed.

39

Another huge benefit. 10 percent of American workers are self-employed. I was a freelancer for a while myself, and I can tell you the health insurance premiums (even under the ACA) were crippling.

40

Medicare for All might be a tougher sell than you might think.

Cite. As usual, people love the idea of getting something for nothing.

If politicians can come up with a credible plan wherein people pay the same, or less, in taxes than they do now in premiums and deductibles, AND get the same level of care, it might fly. I don’t think that can be done, absent significant cuts in spending. And thus the question becomes how to deliver the same level of health care with significantly less spending. Which, again, I don’t think can be done.

Maybe single-payer is a great idea, or maybe not. But TANSTAAFL.

Regards,
Shodan