Medicare For All / Single Payer system. Pros, Cons, versus our current system and other systems?

Great Debates
1

What are the pros and cons, and what are the debates for each pro/con. The gist of the arguments to be made to my understand are the following. A) It costs too much and B) It will make medical quality worse. Are either of these things true why or why not, and how true are they compared to other similar single payer systems, and how do these single payer systems compare to non-single payer Universal Healthcare systems, and how do they all compare to our current system.

My belief is healthcare shouldn’t be for profit, private health insurance hurts businesses, and it causes upward 600,000 people to go bankrupt each year due to medical expenses and lack of coverage. I think healthcare is one of the fundamental ways of reversing the rate at which wealth inequality grows. Small businesses can use the money they would have spent on covering their employees on expanding, people will have more preventive care lowering the number of people waiting until an emergency to go see a doctor which keeps millions of people at work being productive and not being forced onto gov assistance. With more people going to family doctors and having preventive care there will be less people in emergency rooms. Veterans will get the care they need without needing to go through the hassle of proving their eligibility to have the government pay for their medical needs that are the result of their service to the country. And of course there will no longer be middle class families losing their status and falling down to the poor class because their dad got sick and went into debt.

Would like some opinions on all of this.

2

You have to start by defining how your proposed new system would work, in terms of both clinical and financial decision-making, what performance standards (both clinical and financial) you would hold it to, and how those - and the inevitable trade-offs between them would be managed.

There is no off-the-peg, one-size-fits-all, model of UHC. What would best fit US voters’ expectations, and what could US voters’ expectations best be managed to accept?

3

The U.S. has by far the most expensive healthcare system in the world–but this system doesn’t provide universal coverage and health outcomes are mediocre compared to the other industrialized countries.

4

The system in Canada is single-payer, but it is not not-for-profit. If I need an X-ray or blood test outside of a hospital, I go to a stand-alone clinic that runs on a fro-profit basis. My doctor rents an office with about 10 other doctors, pays receptionists, nurses etc. and manages his own profit on the net.

The biggest difference is that I present my health card at each visit and the province gets billled. There are no medical coders, accounts receivable clerks, rebillers between providers.

The downside is that budget is managed through allocations of resources. My 80 year old mother has been waiting for major surgery for spinal stenosis since about April, she is scheduled for next month. I gather if this had happened in the US and she was well insured, the surgery would have been within weeks of meeting with the surgeon.

5

And if she was in the US and had crappy or no insurance she would never have the surgery unless she could scrape up the cash for a grossly inflated price or convinced sufficient other people to contribute, usually via “spaghetti dinners” or GoFundMe or the like - basically, begging for the money for the operation.

6

Oh, I fully understand that. I spent close to three months in hospital and rehab in 2000. My total cost was about $30 a day for the private room (my insurance covers semi-private), TV, and phone. It would likely have been $500,000 if I was in the US and uninsured.

7

Don’t forget that different systems have evolved in relation to the surrounding culture (hence my point about expectations above), so there will probably be different ideas about what constitutes an upside and a downside. What features about the US system as it stands are particularly valued (or people might be most fearful of losing), and how could they be preserved in a UHC system?

As far as my own national system is concerned (the NHS), the key features that most people value are

  • free at the point of use (we don’t have to deal with bills or the associated bureaucracy, and we can be sure that doctors don’t personally stand to gain or lose by one treatment or another, and therefore are making decisions on clinical criteria)
  • we don’t have to run around choosing which doctor we need to see for which ailment, or (for the most part) having to liaise between different specialties in the system: everything starts with the GP, who is not only the primary diagnostician and gatekeeper to the specialist parts of the system, but also a personal health adviser and, to some extent, one’s champion in dealing with the different parts of the system

But that is bound up with a culture of, for the most part, trusting professionals’ judgment and needs to go along with accepting that (a) one has some personal responsibility to take as much care as possible of oneself and to use the system wisely, (b) that one can’t have whatever one thinks right just for the asking, © that one may have to wait one’s turn for less urgent problems and (d) that this is all part and parcel of acting together as a community in the interests and to the benefit of all, or as near all as possible: all to some extent reflective of the 1940s wartime and postwar socio-political atmosphere in which it was founded. It’s also worth noting that it isn’t a wholly nationalised system, as I understand Canada’s to be: to set it up, the government of the day had to placate the doctors by contracting with GPs as self-employed partnerships and placing them at the heart of the “patient journey”, as they saw themselves already (at least for those who could pay), and by allowing hospital specialists a certain amount of time for private interests.

Downsides are that

  • the overall funding envelope is decided in government, and tends to go through a lag-and-catch-up cycle, depending on all the usual pressures in the political process; this can mean (whatever the set performance targets) build-ups of staff shortages and delays
  • we are expected to be registered with a GP practice (their contracts depend on being paid an annual fee per patient registered, whether they ever see them or not), and to stick with that practice rather than shopping around (though there is plenty of encouragement to use pharmacists or the national telephone helpline as a first port of call for minor problems, wherever possible); since these are nowadays almost all quite big group practices, we have to accept that they will decide which doctor or nurse we should see - if one insists on sticking to one specific doctor, getting an appointment within the 48-hour target period is difficult to impossible.

That said, well over 90% of us rely on the NHS at some point in our lives and see it as the first or only port of call; the private sector tends to be used only as a means of getting prompter treatment (and maybe a bit more hotel-style flimflam) for less acure problems, or cosmetic treatments. If they have any problems, it’s the NHS that picks up the pieces.

8

Basically, there are four models out there. Each has its own bells and whistles and has evolved different features from the others, but basically:

Beveridge. Scandinavia, the UK, Iberia etc uses Beveridge. Its your basic NHS style setup with government budgets and doctors determining the most medically efficient way to allocate the resources. In terms of results it tends to get the most out of the money and results per dollar spent are very good. Norway uses a lot of markets, and Sweden is very devolved.

Bismarck. Germany, Switzerland, Netherlands. Basically insurance-allocated healthcare. For-profit in some cases, non-profit in others. You have many actors albeit unlike the US they all operate inside the same regulatory system. The Bismarck type systems tend to be a bit more responsive to patients and have shorter queues. They also are quite a bit more expensive on the average than the Beveridge style systems. If the US health care expenses per person were the size of the average Bismarck style system, the US would save less than twice its military budget each year compared to present expenses.

Beveridge systems would say that if they could spend the amount of money Bismarck systems do, they’d be more responsive too. And in any case, Americans tend to misunderstand how waits work, because they are used to a system that allocated resources according to other priorities than medical need. Waits in Beveridge systems are inversely proportional to medical urgency.

National Insurance. Canada, Taiwan, Japan I think. Rather effective. Canada is unusually negative to private healthcare, which is a fairly basic part of the healthcare sector in other nations and tend to score low on waits. Americans often think both are features of all other systems than theirs, because Canada is the nearest developed country to theirs.

Out of pocket. A lot of the third world, though not all of it. Fee for service, free market sort of thing. Mostly poor people pay what they can, get care that may or may not be related to medical treatment, and the rich fly to foreign nations.

There are a few hybrid setups where for example, everyone has basic coverage and some people get insurance for gold plated stuff, and its part of the system.

The US has all of them. Albeit the brakes and controls have often been taken off. Medicare is National Insurance. The VHA is Beveridge, although without the media attention that works as a corrective elsewhere. Insurance through work is Bismarck, without the legislation that keeps people from falling outside the system. And the uninsured are out-of-pocket. A big part of the US extra costs are all the bureaucracy of the different systems and them trying to interact with each other.

9

For the record, the French system evolved from a situation pretty much similar to the current American system. Some people had coverage through their employers (generally large companies or the public sector), the others were out of luck (the main difference being that French insurers were typically small non-profit organizations, generally created by employer organizations or workers’ unions, while current American insurers are huge for profit companies). It was basically imposed to all other employers and workers to contribute to the newly created health care system, ran by representative of employers and workers, as people who had coverage and their employers previously contributed to and regulated their individual schemes. Health care wasn’t even truly universal in France until around 1990, since it was tied to employment/retirement status and people unemployed for more than two years weren’t covered anymore.

10

What happens if I’m unhappy with my current GP? Don’t I get to shop around? How does it work in practice?

11

If you are unhappy with your GP, you can see another doctor at the same practice (most practices have several doctors).
If that isn’t possible you can see if another practice’s catchment covers where you live and register there. This easier in towns & cities. Can be impossible in rural areas.

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12

Couple of minor nitpicks.

  1. If she was in the US, she’d be on Medicare which is our single payer system for people over age 65. So what you’re describing isn’t so much an argument against single payer since 80 year Olds here in America are on single payer also.

  2. Considering how much the us spends on health care, if Canada spent anywhere near that much they wouldn’t have wait times.

So what you’re describing isn’t an argument against single payer so much as an argument against underfunded health systems.

13

So, which doctor you can see is based on geography, a bit like school districts in other countries? With sometimes several practices covering the same area?

What happens when someone just out of medical school wants to set up shop? He must enroll in an existing practice or replace another doctor retiring?
I must admit that I don’t like at all the idea of not being able to freely choose my doctor. I’m quite picky about them and absolutely want someone I fully trust and have a good relationship with. Even though I’ve had the same two GPs for 20 years because I’m happy with them, I shop around for specialists.

14

I thought the French system had changed to restrict all that shopping around for doctors and pill popping.

The system It was very popular with the patients, but at huge expense to the state and rather a rather cash cow for Big Pharma. Patients swapped the business cards of their favourite doctors and getting lots of expensive tests ordered and take more prescription drugs than any other country in Europe. It encouraged a culture of hypochondria and a comprehensive system paid for by the state and insurance cover.

The perception of illness and the need for medicine is very connected with culture. Different countries have different expectations of their doctors and how healthcare should be delivered. For some a trip to the doctor is simply part of their social life whether they are ill or not.

The UK system is cheap and free at the point of delivery. Patients seldom ever see a bill, except a modest, flat admin charge for prescription medicines. So too are the ambulances. Nonetheless it is system that seems permanently the centre of one crisis after the next. To the British people it is something like a secular religion and it is a brave politician that messes with it. How it manages to be so cheap in terms of national GDP at 10%, cheaper than France and Gernany at 11 to 12% despite the NHS employing 1,5 million people is quite remarkable. It is a very unusual organisation. Though it is centrally funded it acts like a lot of local health organisations and does not obtain all the economies of scale that it could. There is no centralised procurement, for example. There is, however, a central body the approves drug treatments that keeps Big Pharma from overcharging. That and the single payer feature may explain its economy.

The aging population trend in developed countries is putting the strain on most healthcare systems. The UK system has a structural weakness because of a historic difference in funding responsibility between healthcare and social care. The NHS pays for the healthcare and the local government pays for social care (but has far less funding). Sadly elderly patients tend to bounce between the health and social care systems.

If the UK government was not so busy arguing with itself about Brexit it might find the time to fix this persistent problem. :mad:

15

Two comments about the Canadian system:

  1. It’s not entirely government operated. The doctors are private parties and run their own clinics and practices, self-employed. They get paid by the single-payer in the province they work in. There’s some variation in ownership of hospitals. In my province, the hospitals are all owned and operated by a public agency, but I gather that in other provinces, there are public hospitals, and also non-profit hospitals that are not operated by the province.

  2. My guess is that the reason Canada is so negative towards private health-care is that it’s seen as a foot-in-the-door from our southern neighbours, and will ultimately result in private for-profit companies drastically changing our health care system.

16

FTR, existing thread on exactly the same subject that has been going on for nearly five months.

17

Spoilsport! Why can’t we just re-hash it all from the beginning?!?

18

Where I live in London, there are half a dozen GPs in the practice I’m registered with, two other group practices within walking distance and, I think, a couple of other practices in the catchment area. And you can ask the local NHS organisation to find you a practice if there’s some real difficulty. But obviously if you live in a small village, there’s realistically not likely to be much chance of a choice of practice because the numbers of patients just aren’t there. The NHS has for a long time discouraged “sole practitioners”, so even in the country there’s likely to be more than one doctor in a practice.

19

Ability to shop around for doctors is generally restricted by availability of doctors, not the health care system. If you chose to live in a place where there is one doctor and a hundred miles to the next one, you don’t have much choice. If you live in the capital, you do. Northern Exposure gave me the idea its similar in the US, exept you may be restricted by your insurance in the US?

20

As a practical matter, yes, medical insurance in America does restrict access to doctors. Like in other places, if you’re in an urban area there where be sufficient overall numbers of doctors that you still have some choices but as you go further and further out into the boondocks there are fewer and fewer choices.

Some areas of the US have no doctors over extensive regions. Others are served by doctors working for the US government in return for forgiveness of medical school debt - my old college roommate did that and worked seven years in remote locations (150 miles to the nearest store where you could buy food sorts of locations).