Single-payer is still the best way to achieve universal health care

By Adam Gaffney, M.D.
Jacobin, Feb. 11, 2016

As the Democratic presidential primary race tightens to a virtual tie nationally, the debate over single-payer health care is growing increasingly tense — and consequential.

In the past several weeks, Hillary Clinton and a host of pundits and policy wonks have articulated an evolving set of arguments about why “Medicare for All” is not affordable, achievable, or worth the effort. A number of rejoinders have made the case that it is, on the contrary, all of these things. More recently, a new line has emerged: yes, current reforms fall short of universal health care, but no, single-payer isn’t necessary to achieve it.

Clinton argued as much at the most recent debate: “I don’t want us to start over again . . . I want to build on the progress we’ve made. Go from 90 percent coverage to 100 percent coverage.” Scott Lemieux outlined a similar vision in a Guardian article last Friday headlined “Americans don’t need single payer healthcare to get universal coverage.” “Single payer healthcare,” Lemieux writes, is not interchangeable with “European-style healthcare.”

He notes that some continental European countries have non-single-payer systems that achieve universal coverage through a combined public/private model. We could thus follow the same path by expanding the Affordable Care Act (ACA) rather than charting a new, more disruptive one (i.e. single-payer).

But while the incremental approach might sound appealing, staying on the track set out by the ACA would be the wrong move. As other countries show, trying to achieve equitable, universal health care within the confines of a private insurance system is bound to result in disappointment.

The Dutch Road

Perhaps more than any other, the Netherlands’ health system is held up as a potential model for the US. Lemieux mentions it as a possible framework. And Paul Krugman describes the Netherlands (and Switzerland, which has a similar system) as having “near-universal coverage even though they rely on private insurers.”

This isn’t a novel pitch. In 2008, as health care reform was under intense debate in the US, an article in the journal Health Affairs noted that “Americans may be interested in the Dutch system” insofar as “it combines mandatory universal health insurance with competition among private health insurers.”

The Netherlands archetype is fairly new. Before 2006, Dutch health care wasn’t single-payer, but it was predominantly public: a social health insurance program covered some two-thirds of the population, and the wealthier minority relied on private insurance.

Though two-tiered, as André den Exter describes in “The Right to Health at the Public/Private Divide,” insurance status at this stage affected neither hospital reimbursement nor waiting time (and benefits were basically the same). Thus, he notes that “there was no incentive [for providers] to treat patients differently.”

If the concern was greater equity, the Dutch could have moved toward a single-payer system, perhaps by first extending the social insurance scheme to everyone. Instead, as Exter describes, the “radical” 2006 reforms did the exact opposite: the social insurance scheme was replaced by an individual mandate–based system for everybody, “carried out by for-profit insurance companies.”  In other words, Obamacare before Obamacare: a regulated, subsidized marketplace of competing private insurance plans (that, to be sure, cover more of the population at a lower cost than in the US).

The 2006 Dutch reforms were based in part on a school of health policy thought associated with the US economist Alain Enthoven, a man who got his start analyzing military strategy for the Pentagon before becoming the foremost proponent of competing private-sector health plans (so-called “managed competition”).

Outside the Netherlands, Enthoven’s ideas have influenced health reform efforts in both his home country — first under Bill Clinton, then President Obama — and in Britain, where Margaret Thatcher began the push to marketize the National Health Service (NHS) in the late 1980s. The 2006 Dutch reforms should therefore be seen as part of a wider, if uneven, neoliberal transition in health systems internationally.

A 2011 article in the New England Journal of Medicine captures the flaws of the Dutch system well. It counts four main shortcomings. First, the 2006 reform did not control expenditure growth — instead, the unwieldy attempt to introduce quasi-market competition “produced high administrative costs and complexity.” Second, uninsurance was not fully eliminated, so some residents still defaulted on their premium payments (and could then be dropped by their insurance company).

Third, the system of “consumer choice,” in which the Dutch are expected to shop around for new insurance plans, didn’t deliver higher customer satisfaction. In a poll cited by the authors, 65 percent of those insured said they had “low or very low levels of trust in private plans.” And finally, while the reform was intended to introduce more market competition, it still brought heavy doses of regulation and bureaucracy.

A less critical September 2015 review in the Journal nonetheless offered some similar conclusions on the Netherlands’ turn away from a public system: “Almost 10 years in, the reforms have not led to the desired cost containment or a leap in quality,” while at the same time “individuals increasingly worry about cost-related access problems.”

The reality is that fragmented, multi-payer systems invariably demand costly administrative apparatuses. A recent comparative study of hospital administrative costs in the US, Canada, and several European countries makes this particularly evident. Among other high-income countries, the United States was found to spend the most on hospital administration. Not far behind it, however, was the Netherlands:

Himmelstein DU, Jun M, Busse R, et al. “A Comparison Of Hospital Administrative Costs In Eight Nations: US Costs Exceed All Others By Far.” Health Affairs (2014).

Nor are these sums chump change. Indeed, in 2010, according to this study, 1.43% of US GDP went to hospital administration alone.

Now, it might seem surprising that England is right behind the Netherlands — doesn’t it have a single-payer system? To a large extent it still does. But as previously noted, Thatcher and her successors worked to inject an “internal market” into the NHS that — along with other pro-market initiatives — has created a much more administratively wasteful and privatized NHS in England. In contrast, the two nations with the lowest administrative spending — Canada and Scotland — have straightforward single-payer systems. The investigators thus conclude:

“In the United States, administration consumes an increasing share of hospital budgets — a share that is far higher than in nations with simpler and less market-oriented payment schemes . . . Reforming the US health care system so that it operated on a single-payer basis could result in large savings on administration.”

Equity and Solidarity

Not all universal health care systems are created equal. Genuine universal health care includes the following four features, at a minimum: universal coverage (i.e. none left uninsured or uncovered), the elimination of financial impediments to care (i.e. no copayments and deductibles), comprehensive coverage (including services currently uncovered or poorly covered in the US), and no inferior “tiers” of access for particular economic or demographic groups.

Achieving this would cost real money. Yet the transition to a single-payer system could achieve efficiency savings that would, as health policy scholars Steffie Woolhandler and David Himmelstein note in a recent op-ed, be “enough to cover all of the uninsured and eliminate co-payments and deductibles for the rest of us.” They estimate upwards of $400 billion annually in efficiency savings.

In contrast, reforms that fall short of single-payer — whether it’s the Dutch model of managed competition, “all-payer” initiatives, or even the “public option” — would not (among other shortcomings) generate those savings, making it more difficult to achieve universal health care worthy of the name.

Yet there is also a much larger political and philosophical issue at stake. For egalitarians, a just health care system must treat all equally. This is difficult — if not impossible — in systems with upper and lower tiers of coverage, with barriers that impede access to particular facilities or doctors for particular groups, and in which a for-profit ethos encourages excluding certain individuals or treatments. Exter raises similar concerns about equity in the case of post-2006 Netherlands:

“[T]he new liberalized health insurance scheme has resulted in preferential health care arrangements that significantly challenge the notion of equity or solidarity within the Dutch health care system . . . Given the limited options of unhealthy and more needy individuals, a substantial inequality in access to health care between several socioeconomic groups will likely emerge over time in the Dutch system.”

The same outcome could be expected in the US.

The Dutch system’s deficiencies also reveal the pitfalls of counterpoising a private US system to the “universal” systems of other high-income nations. Even if European countries’ health systems outperform the United States’, speaking of “European” health systems in the aggregate obscures more than it reveals.

If the Netherlands model demonstrates anything, it’s that some forms of “universal” health care are less worthy of emulation than others. Expanding access the Dutch way (itself based on US policy ideas) would leave intact much of the waste of the current system — without achieving the equity implied by the term “universal health care.”

A single-payer national health program must therefore remain a central goal for progressives and the Left. Placating the private insurance industry isn’t a price we can afford to pay.

Adam Gaffney is a physician whose work has appeared in Salon, Dissent, and In These Times. He blogs at theprogressivephysician.net.

https://www.jacobinmag.com/2016/02/gaffney-single-payer-sanders-healthcare-obamacare-aca-clinton/

PNHP note: Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.

News release
Single Payer News, Feb. 16, 2016
 
The National Executive Council of the American Federation of Government Employees (AFGE) has unanimously endorsed HR 676, national single payer legislation sponsored by Congressman John Conyers of Michigan. The resolution was submitted by AFGE National Vice President Arnold R. Scott of District 6.
 
With 1,100 local unions, AFGE is the largest federal employee union and has 670,000 members across the country.
 
The text of the AFGE resolution is below:

Union Resolution in Support of HR 676, National Single Payer Legislation, Expanded and Improved Medicare for All

Submitted by:  NVP Scott
 
Whereas, America’s health care system is in deep trouble.  In spite of efforts to regulate the insurance industry for-profit health insurance companies are finding ways to skirt the law.  The Affordable Care Act, passed in 2010, made it possible for some of the uninsured to find coverage, but did not resolve the problem that health insurance companies are pricing care beyond our means, and
 
Whereas, unions have battled to achieve the highest standards of health care for members and their families, and those gains have lifted up health benefits for all workers, even those who have no union.  All of these achievements are now under constant attack as costs rise and employers seek to shift those costs to workers.  Union multiemployer health plans are struggling under the unfair advantages allowed to non-union companies.  Rising copays and deductibles make it more difficult for those who have insurance to get the care they need.  The excise tax of 2018 will make things worse, and
 
Whereas, employers seek to drop health benefits for early retirees, for spouses, for part-timers.  Some corporations use bankruptcy laws to shirk their contractual health care obligations.  The rising cost of health insurance is blocking progress in wages and other areas, and
 
Whereas, insurance companies rather than patients are deciding what doctors we can see and what hospitals we can use.  Drug company profits soar as, so far, congress has not used the power of bulk purchasing to bring down the prices.  The US spends double per capita what other industrialized nations spend, yet ranks far below in life expectancy and infant mortality, and
 
Whereas, we deserve better.  It doesn’t have to be this way.  Firefighters don’t ask us to pay before they save our families from burning houses.  They just proceed to do the right thing.  Health care is just as important as fire protection.  Lives are at stake and all of us should have the best care that this wealthy nation has the ability to provide.  Our tax dollars subsidize the research, the medical schools, and the hospitals.  Unions led the way in other industrialized countries to assure universal coverage with good care through a form of single payer, and Congressman John Conyers Jr. (D-MI) has introduced HR 676, Expanded and Improved Medicare for All.  HR 676 will establish a single payer health care system by expanding a greatly improved Medicare to cover everyone.  It will restore our right to choose our physicians and free us from insurance company interference in medical decisions.  It will free our health care from corporate control, and
 
Whereas, HR 676 will cover everyone for all necessary medical care including dental, prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care, chiropractic, eyeglasses, hearing aids, other medical devices and long term care.  HR 676 will end deductibles and copayments, and
 
Whereas, HR 676 will save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry and by using our purchasing power to rein in the drug companies.  The transition to national health insurance would apply the savings from administration and profits to expanded and improved coverage for all, and
 
Whereas, standing up for all working people and leading the effort to win healthcare for all we will affirm labor’s rightful role as a leader in the fight for social justice.  Bold action by our unions can rally the nation to pass HR 676.
 
Therefore be it resolved, that AFGE wholeheartedly endorses Congressman Conyers’ bill HR 676, “Expanded and Improved Medicare for ALL,” a single payer health care program.
 
Be it further resolved, that AFGE will work with other unions and community groups to build a groundswell of popular support and action for single payer universal health care and HR 676 until we make what is morally right for our nation into what is politically possible.
 
And that AFGE will send a copy of this resolution to Congressman Conyers, to all members of the US House and Senate, to the AFL-CIO Executive Council, and to the news media.
 
And further, that AFGE will take other actions to mobilize our members and our community at the grassroots to encourage other members of the House to sign on as co-sponsors of HR 676 and to encourage Senators to introduce a companion bill in the Senate.
 
Passed unanimously by the National Executive Council of the American Federation of Government Employees, November 2015.
 
#30#

HR 676 would institute a single payer health care system by expanding a greatly improved Medicare to everyone residing in the U.S. Patients will choose their own physicians and hospitals.

HR 676 would cover every person for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental (including oral surgery, periodontics, endodontics), mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care and correction, hearing services including hearing aids, chiropractic, durable medical equipment, palliative care, podiatric care, and long term care.

HR 676 ends deductibles and co-payments. HR 676 would save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs. In the current Congress, HR 676 has 60 co-sponsors in addition to Congressman Conyers.

HR 676 has been endorsed by 623 union organizations including 151 Central Labor Councils/Area Labor Federations and 44 state AFL-CIO’s (KY, PA, CT, OH, DE, ND, WA, SC, WY, VT, FL, WI, WV, SD, NC, MO, MN, ME, AR, MD-DC, TX, IA, AZ, TN, OR, GA, OK, KS, CO, IN, AL, CA, AK, MI, MT, NE, NJ, NY, NV, MA, RI, NH, ID.
 
For a list of union endorsers, or a sample endorsement resolution, contact:
 
Kay Tillow
All Unions Committee for Single Payer Health Care–HR 676
c/o Nurses Professional Organization (NPO)
1169 Eastern Parkway, Suite 2218
Louisville, KY 40217
(502) 636 1551
 
Email: nursenpo@aol.com
http://unionsforsinglepayer.org
https://www.facebook.com/unionsforsinglepayer

By David U. Himmelstein and Steffie Woolhandler
The Washington Post, Letters, Feb. 12, 2016

The Jan. 29 editorial “The real problem with Mr. Sanders” alleged that Sen. Bernie Sanders’s (I-Vt.) health-care plan “rests on unbelievable assumptions about how much he could slash health-care costs.” That dismissive claim was based on a deeply flawed analysis by Kenneth Thorpe, an Emory University professor and former Clinton administration official who, like Democratic presidential candidate Hillary Clinton, has done a recent flip-flop on the facts about single-payer.

So what has changed? In 2003, Thorpe calculated that single-payer would achieve huge administrative savings — more than 10 percent of total health spending, equivalent to $350 billion this year alone. Now he has cut that estimate by more than half, even though the costs of bureaucracy in the United States have continually climbed, while they’ve remained low in single-payer nations.

Thorpe previously predicted that single-payer would cause a modest uptick in the utilization of care. Now — despite the fact that fewer are uninsured — he has decided there would be a huge increase.

Finally, Thorpe says nothing about savings on drug prices, despite the fact that every nation with a national health-insurance program gets discounts of about 50 percent.

The old Kenneth Thorpe — like the old Hillary Clinton — acknowledged the facts about single-payer. The new one ignores them. The editorial board should know better.

David U. Himmelstein and Steffie Woolhandler are professors of health policy and management at the City University of New York School of Public Health and lecturers in medicine at Harvard Medical School. They reside in New York.

https://www.washingtonpost.com/opinions/the-flip-flop-behind-the-flawed-attacks-on-sanderss-single-payer-plan/2016/02/12/32e82bd0-c9d8-11e5-b9ab-26591104bb19_story.html

PNHP note: Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office. For a more detailed critique of Kenneth Thorpe’s flawed analysis, see this article by Drs. David Himmelstein and Steffie Woolhandler in The Huffington Post.

“It’s indisputable that single-payer systems in other countries cover everyone for virtually everything, and at much lower cost than our health care system,” PNHP co-founder says

By Nadia Prupis
Common Dreams, Feb. 12, 2016

During Thursday night’s Democratic presidential debate, Hillary Clinton criticized Bernie Sanders’ proposal for a “Medicare for All” healthcare program, stating, “the numbers just don’t add up.”

“A respected health economist said that these plans would cost a trillion dollars more a year,” Clinton said, likely referring to a recent analysis by Emory University professor Kenneth Thorpe, who helped craft a single-payer healthcare system in Sanders’ home state of Vermont, which said Sanders’ proposal was off by an extra $1.1 trillion annually.

“So if you’re having Medicare for all, single-payer, you need to level with people about what they will have at the end of the process you are proposing,” Clinton said. “And based on every analysis that I can find by people who are sympathetic to the goal, the numbers don’t add up, and many people will actually be worse off than they are right now.”

But according to other healthcare experts, both Clinton and Thorpe are working with false calculations.

Dr. Steffie Woolhandler, a professor in public health at City University of New York at Hunter College and co-founder of the advocacy group Physicians for a National Health Program, said Friday that the “numbers on single-payer do, in fact, add up.”

“It’s indisputable that single-payer systems in other countries cover everyone for virtually everything, and at much lower cost than our health care system,” Woolhandler said. “Experience in countries with single-payer systems, such as Canada, Scotland, and Taiwan, proves that we can have more, better and cheaper care.”

For example, “if the U.S. moved to a single-payer system as efficient as Canada’s, we’d save $430 billion on useless paperwork and insurance companies’ outrageous profits, more than enough to cover the 31 million Americans who remain uninsured, and to eliminate co-payments and deductibles for everyone,” she said.

In January, Woolhandler and her colleague Dr. David Himmelstein authored a response to Thorpe’s analysis that found it to be based on “several incorrect, and occasionally outlandish, assumptions,” including “administrative savings of only 4.7 percent of expenditures” and “huge increases in the utilization of care, increases far beyond those that were seen when national health insurance was implemented in Canada, and much larger than is possible given the supply of doctors and hospital beds.”

“Moreover, it is at odds with analyses of the costs of single-payer programs that he produced in the past, which projected large savings from such reform,” the professors wrote.

Woolhandler said Friday, “A single-payer system could save even more money by bargaining with drug companies for discounts on drugs. Other countries get discounts of about 50 percent, and as the biggest customer we could have the bargaining power to get similar savings…Finally, single-payer systems have been better at controlling costs over the long-haul.”

“Our medical arms race—with hospitals competing to offer expensive high tech care, even when they don’t do enough to be good at it—has driven up costs and compromised the quality of care. In contrast, single-payer nations have used thoughtful health planning, to invest in expensive high tech care where it’s needed, not just where it’s redundant but profitable,” she said.

During Thursday’s debate, Sanders rejected the argument that his plan was “unachievable.”

“Every major country on earth, whether it’s the UK, whether it’s France, whether it’s Canada, has managed to provide healthcare to all people as a right and they are spending significantly less per capita on healthcare than we are,” he said. “So I do not accept the belief that the United States of America can’t do that.”

“Please do not tell me that in this country, if—and here’s the if—we have the courage to take on the drug companies, and have the courage to take on the insurance companies, and the medical equipment suppliers, if we do that, yes, we can guarantee health care to all people in a much more cost effective way,” he said.

The charge that the numbers for a sweeping healthcare reform plan “don’t add up” is one that Clinton herself has been hit with in the past, regarding the Health Security Act—dubbed ‘Hillarycare’—introduced in 1993 under President Bill Clinton’s administration.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License
 
http://www.commondreams.org/news/2016/02/12/fact-argue-experts-sanders-medicare-all-numbers-do-add

PNHP note: Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.