By Colleen M. Flood and Allan Rock
Chicago Tribune, September 24, 2017
The United States is about to debate the merits of Bernie Sanders’ proposal for a single-payer health care system. While cost will be an issue, evidence shows that many countries provide access to quality care for all their citizens through a single-payer model while spending far less than the U.S. does now.
How can this be?
Single-payer systems are often promoted as a means to achieve social justice. But they are also more economically efficient than the private market alternative. Having one payer simplifies the administration of health care by avoiding multiple insurers processing claims.
Costly administration is one reason why the U.S. spends by far the greatest percentage of gross domestic product on health care in the Organization for Economic Co-operation and Development (while having the largest percentage of uninsured).
But not all single-payer models are created equal.
As Americans consider Sanders’ proposal, they should examine the successes and failures of single-payer systems elsewhere. Canada’s actual experience (and not the make-believe version portrayed by idealogues) might help Americans craft their own, better version.
We offer five lessons from Canada that Americans should take to heart.
• First and most important, a single-payer system does not and should not cover everything — just everybody. All health systems have their limits. But there must also be a process for deciding what services are insured. That list must change to keep pace with innovations and emerging needs.
Canada’s single-payer system is weak in this respect. It was created when health care meant doctors and hospitals, and so the Canada Health Act reflects that long-ago world.
The Sanders proposal is more modern, including long-term care [1], prescription drugs and other items important today (not covered in the Canadian model). But Sanders’ plan should include a fair process to periodically re-evaluate the services and treatments that are insured.
• Second, a single-payer system need not mean bleak government hospitals staffed by underpaid doctors. Single-payer can include a vibrant private sector both within and ancillary to the public plan.
Mythmaking aside, Canada’s system accommodates a major role for the private sector within the public system. Nothing in the Canadian model prohibits the private delivery of publicly paid services.
Indeed, most Canadian doctors are not salaried state employees but private contractors who are well remunerated — and who don’t have to manage multiple payers, chase accounts receivable and treat patients who can’t pay.
The private sector is also a complement to Canada’s public system, insuring services left out of the public plan. Some Canadians would prefer an even greater level of privately-insured care, which is an ongoing debate. Each single-payer system manages the public-private balance to best suit that country’s needs, values and priorities. Americans should consider how others have established that balance before determining their own.
• Third, single-payer need not mean reduced patient choice and increased wait times. Canadian patients can choose their own physicians and hospitals without the restrictions imposed by American “managed care.” While it is sadly true that Canada has struggled with wait times that are too long for some services, the problems derive not from the single-payer system itself but rather from issues of system management. The proof is found in many other single-payer systems that do not face the same issues.
Concerns with wait times should be addressed up-front in a U.S. single-payer plan, emulating successful models and setting maximum wait-times based on clinical evidence.
• Fourth, single-payer need not mean funding the system only from taxes. Canada’s experience is that tax funding alone can make the system vulnerable when economic downturns require steep government cuts. Wisely, the Sanders plan is in line with European models with a mix of funding sources, including premium payments by employers and employees together with some funding from tax revenues.
• Finally, the U.S. can learn from Canada’s vexed experience with federal-provincial negotiations about health care. If the federal government goes it alone in funding health care — as the Sanders plan seems to suggest — the difficult dynamic of federal-state negotiations will be avoided. But if the final plan involves federal grants to states, federal funding must have a guaranteed floor and be adjusted over time to fairly account for changing needs and technologies. There must also be a way to speedily resolve federal-state disputes when they arise.
As Canadians can attest, the single-payer health care model has enormous social and economic advantages. But its success in meeting the needs of a nation depends on its wise design and deployment. By considering the experience elsewhere, Americans have the historic opportunity to create a model that will be uniquely their own while capturing best practices everywhere.
Colleen M. Flood is associate vice president of research and director of the Centre for Health Law Policy and Ethics at the University of Ottawa. Allan Rock is president emeritus of the University of Ottawa and is a former Canadian minister of health.
PNHP Endnote:
1. In Sen. Sanders’ plan, long-term care would be administered by the states only for low-income individuals, similar to Medicaid today. PNHP believes long-term care should be provided to all as part of a national health plan.