The System is Baroque, We are Powerless, Single Payer Will Empower Us

(I have recently been engaging in an e-conversation about Single Payer with several psychologists and psychiatrists.   This has produced, I think,  some interesting points …)

Single Payer is a good idea.   But like all good ideas--  Independence from England, Civil Rights, Anti-War, the New Deal, the GI Bill,  Medicare/Medicaid…-- it requires involvement, action and stewarding in order to make it a bettering reality.   The development and structure of single payer calls for and will require our active participation.  We, all practitioners, must have significant seats around all the tables.     

COLLECTIVE BARGAINING

A major concern is that Single Payer will even further concentrate the power of the payer and leave practitioners even more  helpless in regards reimbursement and  administrative requirements than we are now against the power of the insurance corporations and government regulations.   CL stated it as being beholden to the  directives of Senate subcommittees.   Additionally, of course, the baroque multiple insurance systems and the confusing array of flying buttresses erected to support them is an administrative nightmare.   It represents 20-30% of healthcare costs that we should not have to direct away from clinical services. 

His recommendation  is “a legitimate socialized national health plan, i.e. one in which providers of care are employed by the state or federal government…”   This would allow for unionization and collective bargaining.   (Even here, of course, we would have to fight against the concentrated effort to disempower unions and public employees.)

I certainly could not agree more with the concerns about the external controls of our profession—and who the controllers are.  Managed care, at all, let alone in the hands of the insurance corporations or government structures is not our friend.   

 

But, I don’t think the only answer is a UK style NHS employment by government and unionized representation of clinician employees.   The key component is collective bargaining.    As it happens, Single Payer legislation—at least in NY and CA—call for just that.   (The two national bills—HR 676, Conyers/Ellis and S 1804 do not mention collective bargaining.  HR 676 does talk about fees being negotiated through state level “representatives of physicians”.)  

Assuring the legality of collective bargaining and developing the structures to represent various clinicians and assure sufficient leverage is, of course, a challenge. But, then, what isn’t?   The key is to move the clinician in to the middle of the process not the administrator. This is  true bargaining power—whether it is through unionization and/or professional trade groups.   Note that Clinicians United is a chapter of SEIU in Massachusetts and has already introduced legislation to allow for independent practices to collectively bargain with insurance corporations.   

COSTS

GH  asks—How much will Single Payer Cost in U.S. ?

Estimates of current costs and projected increase services and  savings vary.  I would be happy to present  a more thorough review at another time.  But the general ballpark is that the U.S. is spending around $3.3 Trillion annually (CMS 2016) or over $10,300 per capita.   The average OECD  country pays less than $4000 and Canada less than $5000 per capita--- with better quality.  The U.S. is spending around 17% of our GDP on health care ( soon to rise to 20% unless we enact single payer) while other countries typically spend no more than 10 or 11% and the OECD average is around 10%.

Estimates for a U.S. single payer system also vary but every study for U.S.  or state level Single Payer systems shows a significant decrease in overall costs.   Updating a 2015 estimate of Bernie Sanders’ proposal--The  current $3.3 T  would be reduced by 20% ( to about $2.65 T) .  Adding  back 5% of the original for current underutilization and expansion of services = $165B .  This comes to about $2.82T.   An overall savings of at least $500B annually.  (For the mathematically estimate inclined take any current cost and reduce by 15% for the cost under single payer.)    There are multiple explanations of the savings—decreased admin, better planning, earlier access to services, reduced pharmacy and institutional costs.  By the way—value-based/outcomes reimbursement is NOT one of the positive factors—and fee-for -service is.  (See Kemble articles)  But that is a matter for a more full exploration another time.  

In California,  the UM-Amherst study of the latest legislation for Single Payer (SB 562) shows a current total healthcare cost in CA at $370B.   The estimate for a Single Payer system, improving and expanding services to all residents,  is $320B.   (If you heard $400B--  that was a “back-of-the-envelope”  estimate produced by a legislative agency,  literally over-night and just included expanded service costs and not accounting for any systematic savings. )

Now, I have some problems with some of these estimate.   Many of them are based on Medicare rates—and we ( the SB 562 campaign) have directed UM to review with higher rates.   However the numbers crunch, we clearly get more services and more control under single payer.

WHO WILL PAY

But where will this money come from if we eliminate insurance corporations and premiums, deductibles, co-pays and other  payments?  Most likely a tax structure will be utilized. This could include a financial transaction tax. I prefer that along with a   simple straight forward use of a progressive income tax and a payroll tax that is also progressive. (As a candidate,  part of Sanders’ proposal was an across the board  6.2% payroll tax.  We ought to be able to add some progressivity and minimum pay exclusions.)   Again, much more to illuminate here, but overall estimates show 95% or more will pay less in taxes than they currently pay or lose to premiums and other costs. 

There will be no premiums, or other expenses.  There will be no point of service payments.  It will all be paid for by a progressive taxing structure.    Our system already taxes those that have more to provide for those that do not.  Unfortunately the long term Reagan revolution has been efforting  to make this a bad thing and reduce our caring for others and, in the process, demonize government. This has  led to a Gilded Era like inequality  and to forgetting that we are better as a we society than a me society. 

WHO WILL BE IN CHARGE

The  reality is that the insurance corporations and government administrators are now in charge and, in general, have no clue about the delivery of clinical services.   What they know is outcomes and value based number crunching.   And what they know is wrong.   Such approaches  make logical and administrative sense but not only make no clinical sense--  they are destructive clinically and socio-economically.

Single Payer will empower us.  Practitioners  and practitioner organizations  will be members of governing boards—not just advisory boards.  We will have the power to collectively bargain.

The question arises is how  would the insurance corporations be persuaded to cede authority.   They would not and could not be persuaded.  Single Payer will basically eliminate them.  Yes, it is a power/political struggle.  In fact, that is all it really is.  The debate on all other levels-- financial, intellectual, service delivery, consumer access, etc.  is really over.  Single Payer wins.  Underneath all the counter arguments is just the powers that be not wanting to give up their huge salaries,  stock market positions and outrageous profits.

We will not persuade--  we will progressively win.   We will not, as has been done in the past, allow a program like Medicare to be incomplete and need subsidization, or takeover, by private corporations.

Some  call for more heavily regulated insurance corporations, as in Germany or Switzerland--the so-called Bismark plans.   That ignores the very same question about the power of the insurance corporations.  As long as the corporations continue they will increase in power and resist true regulation.  Experience has  consistently shown us that no matter what public policy/regulation we try to create, somehow the insurance corporations in their Byzantine ways end up making more money, health care quality decreases and inequality of services increases. 

CHOICE

There has also been expressed a concern about “choice” and the power of the market place.  

I think many of us have  seen enough of public health to see how the so-called consumer choice is really  more a leverage for private corporations to cut out substantial public dollars away from services and towards  their profits.

The choice most people in the private market have is what insurance plan they will buy/can afford/best balances needs and costs.   And even those choices are limited by employers or whoever is providing the choice.   And then the choice of practitioners is further limited by the policy’s network.

In Single Payer, yes we do not have the choice of what insurance plan we can put between us and our healthcare needs.  But we then have the choice of any practitioner for any health service that is covered. What is covered will be substantially more than the typical plan that is available now.

IF HEALTHCARE IS A RIGHT THEN WE SHOULD MAKE SURE EVERYONE HAS IT

Being in  social welfare and public health delivery we see more than our share of those who aren’t and/or can’t contribute as much as we would like.   A few, probably,  by their nature, most by having been beaten down may not seem to “cut it.”  Leaving aside who decides what is an adequate contribution we certainly should not build a health care payment system around the limits of those less able--  but around the appropriate level of care that everyone needs.   

I can’t speak for New York—but it is clear that California is a much more prosperous state since it has returned to the management  of even   moderate Democrats and their expansion of health care, education and  social services. As inadequate as they are, they demonstrate that the we society is so much richer, in oh so many ways, than the me society.