Some (but not all) posters are conflating “universal healthcare” with “single-payer healthcare” or “socialized medicine.”
Scott Lemieux at the Lawyers, Guns, and Money blog does a good job of unpacking this confusion and showing why universal healthcare need not rely on single-payer or socialized models. Here’s one blog post to start with: The Path to Universal Healthcare I: Let’s Clarify Our Terms – Lawyers, Guns & Money
True, but the OP did ask about single payer plans.
That’s a worthwhile clarification, and while I certainly understand the differences, I have myself sometimes been guilty of using “single payer” to mean “a public health care system that works like de facto single payer even when there are multiple payers, because regulation forces them to all work the same way”. By extension, then, one could also use the term (albeit not technically correctly) to refer to systems with hybrid public/private payers where the private sector is a small and (as in Germany) often restricted part of the overall system.
But, yes, your larger point is a good one in that it would be a mistake to think that the only way to rescue the US health care system is to institute a single-payer system exactly like Canada’s. What’s important is to have a public health payment system that is universal and community rated. Whether there is a single payer or multiple regulated payers or whether there is also a private sector is irrelevant as long as both public and private systems are well regulated, so that the public system doesn’t turn into a second-rate morass that nobody wants. The risk that this might happen in Canada because of intense commercial pressures, mostly from south of the border where health care is high-profit big business, is why pure single-payer was formalized in law in Canada. Absent such pressures, European countries successfully run regulated hybrid systems.
Ok, there’s no reason for me to assume that. It seems to be the preferred model of single-payer but not the only one. It seems safe to assume, though, that the government will take on the role of insurer for whatever number of people, paying claims currently being paid now by Blue Cross, Aetna, et al. It will not have cost-sharing and subscriber fees anywhere near what private insurers charge, so there will have to be other sources of funding. Or is that also a matter of debate?
I would say that yes, it’s very much a matter of debate. Assuming that “there will have to be other sources of funding” assumes that cost reductions (at least in the long term) will not be sufficient for existing public expenditures (plus some small portion of private expenditures, as in all countries, for supplementary and other services not strictly medically necessary) to be able to cover. But since they cover them in all other countries, why wouldn’t they in the US? Enormous savings would come from (a) elimination of insurance bureaucracy and paperwork, (b) elimination of horrendeously inefficient and expensive programs like EMTALA and Medicaid, © elimination of Medicare, itself pretty damn complex, (d) inclusion of the entire population as the actuarial risk base, and (e) ability to create uniform negotiated fee schedules at rates reflecting the new lower-cost reality, in which medical providers get paid in full without a single one of the hassles and losses that so hugely dominate their practices today.
The key point here is that the costs in the health care system that are attributable to insurance companies is not due to their own profits, which is a drop in the bucket in overall health care costs; it’s due to their malign systemic influence on the way the whole system works, where their parisitic influence increases costs on absolutely everything they touch.
I am not entirely sure what you mean by paying claims, cost-sharing and subscriber fees. However, earlier in the thread I made this post:
This should give some kind of glimpse into why UHC can be run so much cheaper than what you do at the moment.
We don’t do the gatekeeping thing. Every legal resident is entitled to medically necessary healthcare. If you have a personal number, roughly equivalent to a social security number, you are covered for what your doctor says you need. You have a very large number of people in your system working gatekeeping, which basically means determining who is covered, what they are covered for, and who pays.
We don’t filer for fraud, because everyone is entitled to what they need, and people tend to find health care processes like colonoscopies and surgery sufficiently unpleasant that getting people to visit their doctor often enough is more of a problem than people doing it too much. The money streams tend to be salaries and some purchasing. In the US system, there are massive revenue streams running around in very complicated ways partially to provide profits. The financial ecosystem is just much more hospitable to fraud in the US.
In the US, you have people working with insurance. Claim histories, payments, coverage, liaising with the hospitals, bargaining determining what is covered appeals, etc. And what is really, really bad, the providers have to deal with a number of different systems for people covered under different insurers. Anecdotally, some hospitals have more people working with claims than they have beds.
We don’t do any of that. Nada. Pointless middleman don’t add anything.
Once again, consider how you deliver basic education, and how that would work if you were to do it in the same way as you do health care.
My comment is that as long as you keep using the language of insurance, you are not really thinking of single-payer as a government service, which is the mental paradigm shift that you need to make.
For instance, if you call the police because of a home-break-in, do you ever speak of the police as being an insurer? Are you putting in a claim for police services? Do you have any cost-sharing or subscriber fees that have to be paid as a result of calling the police?
Same for public education. Do you use those terms when you describe your kid going to school?
Or do you in both cases view the police and schools as a public service, paid for from general tax revenues?
That’s the mental shift you need for single-payer. As long as you think in terms of health insurance, you’re not really understanding single-payer.
(I’m not trying to be snarky here, Tee. It’s just that in past discussions about single-payer, some posters who keep using the language of insurance just have trouble getting the concept of single-payer. Using the vocabulary of insurance is a hindrance.)
That’s good to know, and we should get to that soon.
Did you not see your countryman up there talking about “uniform negotiated fee schedules” and such? It’s easy to get tripped up here by Canadians, and I mean no snark either.
All true, those are negatives in our system. But, my insurance *is *actually insurance, it protects against the high costs of cancer treatment, heart attack or whatever else may befall me, because nothing else does. It’s that simple. My health care is an arrangement composed of private parties: me, the provider, and my insurance carrier. If I didn’t have insurance, the arrangement would be that I pay whatever the providers want me to pay, or avoid treatment.
Since the perception of the industry here is almost uniformly negative - interfering bureaucrats, malign influencers, pointless middlemen, etc. - you’re not getting the full picture without understanding how much people rely on the industry.
20+ years ago when I was in the hospital for leg surgery, the ortho ward was all private rooms. Which was fine by me, and when my insurance company tried to leave me on the hook for the “increased cost” of a private room, I pointed out that I was at an in-network hospital and had zero choice in whether I was given a private room. They gave up and covered it.
But “we” (i.e.- the different sides of the health care debate) have had that discussion about cost impacts of single payer (or UHC in general, if you prefer) many many times here. The facts about other countries are clear; facts don’t lie, and health care economists have understood the facts for a very long time.
Perhaps my statement “it’s very much a matter of debate” was a bit misleading. I meant to say that your assumption about new sources of funding having to be found to deal with increased costs was just dead wrong according to the accepted understanding of the economies that accrue to a properly managed UHC system; there is a “debate” only because the health insurance lobby, the unconditional pro-business faction, and those that they have bamboozled with anti-UHC propaganda insist on making it a debate, exactly the same way that there is a “climate change debate” about whether or not AGW is real, despite the overwhelming scientific evidence.
I’m talking about uniform fee schedules for what the public payment system pays medical service providers, which is not unlike what any organization might negotiate to pay to any fee-for-service provider for any services. I don’t see how that’s in any way inconsistent with what Northern Piper said about single payer being a radically different concept from traditional health insurance. I would argue, however, that there is value in comparing it to traditional private health insurance in order to understand what the differences are, and how incredibly fundamental they are.
The problem with people accustomed to private insurance thinking of single payer as “government-run health insurance” is that they think of all the problems they’ve had with their insurance companies, and then they think of government bureaucracies, and they might naturally conclude that this would just be an even bigger bureaucratic fiasco. But the reality is, it’s a completely different model, and happily, it exploits the one thing that governments do very well: the routine, systematic paying of bills according to established protocols. Hence the phenomenon of Reinhardt’s Irony that I mentioned in post #53: the absence of clinical meddling in the doctor-patient relationship, something that plagues the private insurance model and always will, because each and every claim is carefully scrutinized for potential cost savings. No such bureaucracy – and indeed no such general job function – even exists in single payer systems.
Well, -ish or up to a point. The basic system is that they get a basic capitation fee for each patient registered with them (whether or not they ever see them), plus all sorts of adjustment for providing services like smoking cessation and diet/exercise advice and support, and for various local demographic factors with known associations with medical need. But it’s all contentious and any changes to reflect supposed changes in needs can meet a lot of political complaint.
I admit, I don’t know the exact balance between the different elements (and there are several different contract options for doctors to agree with the NHS, including a new one designed to involve GPs more in the management of all sorts of additional community care services), but the basic point is that, short of outright and easily-detectable fraud, doctors don’t have a personal financial incentive to treat (or not treat) in any particular way. Their “gatekeeper” function probably means they have a moral incentive to be careful with the budget, though, but that raises much wider and more nebulous questions about general cultural expectations in relation to health and medical care.
I’m probably wrong in trying to align the expansion of Medicare with single-payer concepts, but I have no investment in the term or its arguments. Call it whatever you want.
The point is that most of the mentions of single payer plans, pertaining to the US, in this thread and elsewhere involve the expansion of Medicare, which is insurance. And, every such plan I have seen suggests raising new revenue via taxes. The Bernie Sanders plan, the John Conyers plan, the California plan - all recognize the large cost increases associated with covering the general public. It’s hard to believe this is disputed, and I’m still not completely sure that it is.
In any case, so what? It costs more. It’s a great time to capitalize on the bad press our legislators have been getting and try to up our investment in public health.
Did you not see your countryman up there talking about “uniform negotiated fee schedules” and such? It’s easy to get tripped up here by Canadians, and I mean no snark either.
[/QUOTE]
The uniform fee schedule doesn’t mean that it’s an insurance system. It means that it’s a set fee-for-service, paid by the provincial medicare commission to the doctor.
Here’s why it’s not insurance, compared to the US model, which is insurance.
US: Tee goes to a doctor or a hospital. They provide Tee with medical services. Tee owes them that money. Tee is covered by insurance. Tee’s insurance company pays the medical bills on Tee’s behalf, to the extent those bills are covered by Tee’s insurance policy. Things that aren’t covered, Tee has to pay himself (e.g. - one of the doctors who had involvement in Tee’s care isn’t in his insurance company’s approved network).
As you say:
Canada: Piper goes to a doctor or a hospital. They provide Piper with medical services. Piper does not owe them any money. Piper is a resident of the province and covered by medicare. The provincial medicare commission owes the doctor or hospital for Piper’s care. The provincial medicare commission has a set fee schedule for all medical charges and procedures. The provincial medicare commission pays the doctor and hospital in full for the the medical charges and procedures. Piper is not on the hook for any of the charges.
It’s not an insurance system in Canada. I pay no premiums, I’m not liable personally for the cost of the care, and I have no contractual relationship with the provincial medicare commission. The provincial medicare commission is liable directly to the doctor and hospital and pays directly, not on behalf of me. It’s a government service, paid out of general tax revenue, not an insurance system.
Thank for illustrating the differences, Piper. I appreciate that.
You’re welcome. It is confusing, though, because the Canada Health Act does use the language of an “insured”, but the complete absence of any contractual relationship between the individuals and the provincial medicare commissions means it’s not insurance, at least by any normal legal definition of insurance. I don’t know why they chose to use that term.
When thinking of health insurance, I have found it helpful to distinguish between types of insurance.
For example, ‘Financial or Risk Management Insurance’ - typically voluntary and is paid for by contractual premiums to corporations.
and ‘Social Insurance’ - always mandatory and paid for by taxes to a government entity.
(note that the only ‘contingent and uncertain’ items here are disability and unemployment.)
AFAIK, universal healthcare - single or multi-payer is always ‘social insurance’ without a commercial contract like auto, fire or theft insurance.
The “social insurance” distinction is a useful way of looking at it. While I completely agree with the distinctions that Northern Piper is making, in common parlance the single-payer systems in Canadian provinces are frequently referred to as “insurance”, and not just in the Canada Health Act. For example its official name in Ontario is the Ontario Health Insurance Plan, and in NP’s own province (the originator of single-payer in Canada, to its everlasting credit!), while the plan itself is simply called Saskatchewan Health Services, the government eHealth electronic records department states that among its responsibilities is “issuing health cards to people for insured health services”.
There are enough similarities to traditional insurance that it’s a useful word to use for it, even though as NP says there is no contract for it and little or no explicit premium payment for it.
I think that’s correct for single-payer, but not necessarily for multi-payer. My recollection from past threads is that both Germany and France use commercial contracts of insurance, but so heavily regulated (particularly in Germany) that the benefits and costs are uniform, regardless of insurance carrier.
You make it sound like the recall song for the Rodger Young in Starship Troopers!
Sadly, we’ve lost the useful distinction between “ensure” and “insure,” but this gives us the opportunity to claim that “insurance” is synonym for “ensurance,” this what is really meant is the “Ontario Health Ensurance Plan.”