Single-Payer is the American Way

Single-Payer is the American Way

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As is customary for every administration in recent history, the Trump administration chose to impale itself on the national spear known as health care in America. The consequences so far are precisely as I expected, but one intriguing phenomenon is surprisingly beginning to emerge. People are starting to talk about single-payer. People who are not avowed socialists, people who benefit handsomely from the health care status quo seem to feel a need to address this four hundred pound gorilla, sitting patiently in a corner of our health care situation room. Why?

The all too public spectacle of a Republican party at war with itself over repealing and replacing Obamacare is teaching us one certain thing. There are no good solutions to health care within the acceptable realm of incremental, compromise driven, modern American solutions to everything, solutions that have been crippling the country and its people since the mid-seventies, which is when America lost its mojo. To fix health care, we have to go back to times when America was truly great, times when the wealthy Roosevelts of New York lived in the White House, times when graduating from Harvard or Yale were not cookie cutter prerequisites to becoming President, times when the President of the United States conducted meetings while sitting on the toilet with the door open and nobody cared. Rings a bell?

Single-payer health care is one such bold solution. Listening to the back and forth banter on social media, one may be tempted to disagree. We don’t have enough money for single-payer. Both Vermont and California tried and quit because of astronomic costs. Hundreds of thousands of people working for insurance companies will become unemployed. Hospitals will close. Entire towns will be wiped out. Doctors will become lazy inefficient government employees and you’ll have to wait months before seeing a doctor. And of course, there will be formal and informal death panels. Did I miss anything? I’m pretty sure I did, so let’s enumerate.

Single-payer is going to bankrupt the nation

We have $3 Trillion in our health care pot right now. We have 325 million Americans, men women and children of all ages. First grade arithmetic says we have almost $10,000 per year to spend on each American, the vast majority of whom is either young or healthy or both. For comparison, Medicare spends on average around $12,000 per year for the oldest and sickest population. Last year a platinum plan for a 21 year old cost less than $5,000 per year and this includes the built in waste of private health insurance. So please, tell me again how we can’t afford to pay for everybody’s health care needs at a Medicare actuarial level, which is slightly less than commercial platinum.

And no, we need not increase taxes either. You keep paying what you’re paying. Your employer keeps paying what it is paying. The government keeps paying what it’s paying. But instead of dispersing all that cash to all sorts of corporate entities standing in line with their golden little soup bowls ready to catch the last drop, we put it all together in one big beautiful barrel, and pay for care directly to those who provide care – one pool, one budget, and one accounting system for all. This is a national endeavor. It is irrelevant that Vermont failed and California bungled the whole thing. Do you think California and Vermont could afford to provide for their own armies, air force and navies? I didn’t think so.

Single-payer will cause millions to lose their jobs

Hundreds of thousands of people work for commercial insurers. Claims need to be processed, money needs to be collected and paid out, books need to be kept, customers and service providers need to be supported, computers have to be maintained, audits need to be performed, contracts need t be managed, lots and lots of labor and lots and lots of decently paying jobs. Do you have any idea how Medicare administration works? Or are you under the impression that Medicare runs itself with no human labor? Have you ever heard of Noridian or Cahaba? No? Then I respectfully suggest that you should refrain from opining about the horrors of single-payer.

Medicare is run by private administrative contractors called MACs, each assigned to specific geographical regions and specific portions of Medicare services. In addition to the MACs there are slews of functional contractors that specialize in one or more types of supporting services to the MACs. These are private entities no different from Boeing, Lockheed Martin, Hewlett-Packard, Booz Allen Hamilton, GE and many more. They employ thousands of people and if Medicare becomes our single-payer, there will be more MACs, more functional contractors, and hundreds of thousands more private employees.

That said, it stands to reason that consolidation from many payers to one, will introduce some efficiencies and the total number of available jobs will be reduced, so here is a solution to this potential problem. Currently all insurers including Medicare and Medicaid are offshoring claim processing and in the case of private insurers other functions, including clinical, as well. Change the regulations and bring those jobs back home where they belong in the first place, and offer them to those who will lose their commercial insurance jobs. This administration is especially well positioned to effect such changes to CMS regulations.

Single-payer will take away our freedom

What if Sam’s Club only carried General Mills cereal and Costco only carried Kellogg’s?  What if you had a Costco membership but stopped by another store to pick up some Cheerios and were charged ten times as much as Sam’s Cub sells it for? No it’s not exactly the same, but you get the idea. Would you consider this to be freedom of choice? Or would you rather have one big huge market where all brands sell their products directly to you competing against each other? The latter is how single-payer could work. Freedom to shop for an insurance plan is freedom to shop for your preferred rationing scheme and ultimately your own flavor of death panel.

Traditional Medicare allows you to choose your doctor and your hospital and it pays for all medically necessary services. No commercial plan can say the same unless it’s one of those platinum things nobody can afford. Traditional Medicare can do that because it sets the prices for all health care providers, instead of negotiating with a few preferred vendors. Medicare can take these liberties because it’s big enough and because it’s a Federal program. But Medicare doesn’t pay for everything. That’s why most seniors purchase supplemental plans if they can afford them, and if they are poor enough, Medicaid kicks in as the secondary payer. Being the safety net for the fixed price single-payer should be the sole function of a new and federally administered Medicaid.

Single-payer will destroy our health care

I think American medicine is the best in the whole world. Not because it’s expensive and not due to the corrupt ways in which it’s being financed, but in spite of these things. Finding a better way to pay our medical bills has nothing to do with the quality of American medicine. The concern here is that once Medicare becomes the only game in town, it will unilaterally cut its fee schedules and all hospitals will go bankrupt, all doctors will be driven into homelessness, no new drugs will be developed and we’re all going to die. On the other hand, the Federal government is the sole purchaser of aircraft carriers, stealth bombers, and weaponry of all types. How cheap are those items?  How powerless and decrepit is that industry?

Precisely because of the lessons learned from the mighty military industrial complex, single-payer reform will have to change three things in the structure of our current so-called health care system. First, all hospital consolidation and acquisition of physician practices will need to be rolled back. Second, petty regulations, vindictive carrots and sticks strategies and crude attempts at social engineering by clueless bureaucrats, will have to be dismantled brick by brick. Third, physicians will need to form a union of independent small contractors to negotiate fees and terms alongside the already powerful hospital associations. I have been a longtime proponent of a physicians’ union, even in our current system, to serve as check and balance to corporate greed and government arrogance. A single-payer system cannot and will not succeed without unionized independent physicians.

Single-payer is not the American way

We have been conditioned by large corporations to think that what they do to us is the nature of free-markets, and thus the only way to achieve prosperity for all. I would submit (for the millionth time) that what Apple is doing to the world has nothing to do with Adam Smith’s free markets. The actors in classic free markets must be approximately equal. When sellers are so big that they need artificially intelligent tools to even notice the existence of buyers, there is no free market. When the price of products sold exceeds the lifetime incomes of most buyers, there is no free market. When no one can muster enough moral turpitude to publicly say that if you’re poor, your babies should die, there is no free market. There is no free market and there can be no free market in health care.

There can however be competition. Perhaps not in sparsely populated areas, and perhaps not for highly complex procedures, but there can be competition for most health care services in most places. The uniform single-payer price should be set so that innovative hospitals and entrepreneurial physicians can thrive by charging less and those holding themselves in higher than usual esteem, or those who choose to provide luxury, are free to charge more. If all sellers are small enough, and if the standard single-payer price is fairly negotiated, we will have a real market, because people will shop to save money (in a rewards system like credit cards have) and some will shop for status and vanity.

Will there be a role for private insurance?  There could be, but private insurance should not be allowed to cover any services covered by the single-payer because that would take us back to where we are today. Let private insurance cover stuff nobody needs, but wealthy people like to flaunt, like fresh baked brioche for breakfast after having a baby, or executive physicals in palatial settings, and let those things become frightfully expensive, as these types of things usually are in a free market.

Single-payer will create a new set of losers. Health care executives making tens of millions of dollars every year for no particular reason will be losers. Perhaps they can find new careers at Boeing or Lockheed Martin seeing how their expertise is easily transferable. Health insurance stocks will tank and improperly managed pension funds will also lose bigly. People running for elections will see a major cash cow go dry after the initial struggle is over and done with. There will be powerful losers and it won’t be easy.

But Obamacare has its losers too. Hard working, taxpaying middle class citizens were the designated losers of Obamacare. Some by commission and most by omission, because Obamacare made no attempt to solve the health care problems facing the vast majority of workers with employer sponsored health insurance. That bomb keeps ticking away at a steady pace. The newly empowered Republican Party has nothing to offer either, and I can’t blame them. There is nothing more we can do here. We tried everything else, and now it’s time to do the right thing. It’s the American way.

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107 Comments on "Single-Payer is the American Way"


Member
Aug 14, 2017

A disability discrimination suit in #Massachusetts involving medical marijuana receives a shocking new twist that’s the first of its kind. Could the tides be changing for how we view medicinal marijuana use? http://bit.ly/2f5JbVI

Member
Dr. Jim
Aug 30, 2017

I don’t care if people want to get high – really, I don’t. If enough people want marijuana to be legalized, then it will be. If not, it won’t.

But, please, for God’s sake – stop this nonsense about medicinal effects.

Member
William Palmer MD
Aug 3, 2017

Health care financing is a tremendous world puzzle. It is actually fun to play with intellectually. At its root, it seems to be about the level of altruism we want to express. But the army of stakeholders keeps butting in and swaying our thoughts….E.g. there are so many people on the insurance side of the sector, that it is difficult to talk about making portions of health care a public good.

I think we are going to have some orthogonal health care problems hitting us–problems that we did not anticipate coming to us from right angles–that will clarify our path forward: possibly a tough flu strain and epidemic; astonishing discveries in the biology of aging and cancer; a molecular solution to depression, perhaps even a shutting down of demand because of unaffordable prices; some terrible war, whatever….add your own guess here.

When puzzles are too tough, good advice is to work on some other problem on the edge of the big puzzle.

Member
Aug 3, 2017

War with North Korea. Coming soon. Trump’s ultimate Bright Shiny Thing. Rally Behind The Manly CIC.

Member

Great minds 🙂 Writing about precisely THIS right now….

Member
Peter
Aug 3, 2017

Reading the comments about why we could not repair perceived unworkable single pay problems in other countries, I would think, since Americans have a need to keep reminding themselves they live in the greatest country in the world, that we could design the best single pay system in the world, learning from other countries.

Member
Aug 2, 2017
Member
Steve2
Aug 2, 2017

I don’t really see anything magical about single payer. There are many countries with single payer with high quality medicine and costs lower than ours. Other countries do not have singe payer and still have high quality. Commonalities that I suspect are important would be that they have essentially everyone in the same system, there is more rather than less government involvement (or at least more trust in it) and a belief that health care for everyone is of value.

Will have to say it is interesting to see zombie ideas percolate through the thread. Ideas like people hate care in Canada, when we know that patients there like the care they get better than people here like ours.

http://www.gallup.com/poll/8056/healthcare-system-ratings-us-great-britain-canada.aspx

Steve

Member
William Palmer MD
Aug 2, 2017

What are the nascent problems of health care finance…i.e. those problems that are built into the structure of our health care system (and many in the world)?

Guesses:
1. Too much technological imperative. The science and our altruism demands that we try to do too much for our resources to fund easily.
2. Moral hazard and almost infinite demand. Patients in general, and because of education, want too much medical intervention in their lives, thinking it will bring happiness.
3. Provider and stakeholder induced demand. Everyone except the patient–and sometimes including the patient–wants more money to circulate through the health care sector.
Our consuming one sixth of the GDP means essentially that we are feeding 1/6 of the folks in the country.
4.Third party payers. Means no patient or doctor really cares about prices and costs because it doesn’t hit our picketbooks directly.
5. Too many patents are issued to bio-equivalent drugs and devices and 20 years for intellectual monopoly rights seems a little long.
6. Government regulations add thousands of distracting costs and opportunity costs. E.g. meaningful use.
7. Tax deductibility for employees and their employers is inequitous and unfair and adds to total demand.

Are there others? Which are most important?

Member

I think there’s something else. This is a good list of supply & demand issues and certainly it is important, but the sheer existence of such list is indicative of something less tangible and perhaps as important.
Medicine is quickly becoming more and more scientific and transactional to the point where it is somewhat dehumanized. Gone are the days when a trusted doctor could say “it’s time” and the patient/family would accept that because they knew the doctor most of their lives. Now it’s Google and some big box “team” of strangers that must deliver that message, so nobody believes them. Why would they?
There is always another expert and another website and another news article and another unlikely miracle that may be possible….and no one in a position to check technology induced optimism.
Google is “working” on immortality, seriously working on the holy grail, with business plans and billions of dollars. Others are too…. It’s easy to buy into this crap, because we want it to be true and they are exploiting this human condition all the way to their banks in the Cayman Islands.

Member
Aug 1, 2017

You are proposing France, which is a mostly fine system.The private insurance system on top of the assurance maladie provides enough breathing room to not have massive queues like the NHS. It’s only flaw is that despite the breathing room the federal assurance maladie is still constantly over budget.

But whether it’s feasible is irrelevant, because it’s unethical. 35% of Americans are obese, why is it American for me to involuntarily pay for their healthcare? 20% of Americans are smokers, why it it American for me to involuntarily pay for their healthcare? 8% of Americans are alcoholics, why is it American for me to involuntarily pay for their healthcare? No madame, I much prefer we move into the direction where you pay for your care and I’ll pay for mine, instead of permanently enshrining this cross subsidy nonsense.

Member

Yes, the French system is supposed to be excellent, so maybe we can learn a thing or two. It is over budget because they don’t budget enough, I would assume.

But I really want to talk about your second paragraph. Every person paying for their own care means no health insurance at all, right? Because if you buy private insurance, you are ultimately paying for all those disgusting sinners.
So here are a few questions: should those obese, smoking alcoholics, pay for the tennis & basketball courts, bicycle paths and hiking trails of the pure and righteous? Should they pay for the tax exemptions of the YMCA?
Many of “those people” and their children probably didn’t go to college, should they be paying for State universities? Should bad people have to pay for libraries, museums, symphonies, opera houses and all those things that highly educated good people use?
Who should pay for ballparks? Playgrounds? Airports? Public transit?
Who should fight in wars and die to “protect our freedom”?
Why do we need a country at all? Or are we there just to take what we cannot provide for ourselves easily. We are taking those things from someone and logic says that we should return the favor.. In my humble opinion…..

Member
Aug 1, 2017

Besides being a strawman argument, this series of comparisons is incorrect because it pretends that health is a public good. Health is a private good. Each one of us is the sole owner of our bodies and therefore the sole owners of our health and the only ones responsible for maintaining it. With the exception of infectious disease the majority of health is an exclusionary good. There is absolutely no benefit to me when you maintain or improve your health and there’s no way for me to access those improvements. Cross subsidies are not at all like taking taxpayer money and investing them into an open access park, it is taking taxpayer money and giving it to an individual to buy a private yacht, that only they can use, and nobody else has any rights to. Furthermore, public goods only work because they are protected by the law. If an individual starts destroying a park, they can be arrested. Should we be arresting the obese and forcing them to exercise in health gulags? No, obviously not. So if I have absolutely no means of benefiting from others health, no means of forcing them to behave constructively, no means of punishing them for behaving destructively, how exactly do you justify me paying involuntarily for their healthcare?

Member

I do, because you do benefit from their health. It’s really not that different from immunizations. No one individual is important, but all of them together are. It’s the herd that counts. And for general health, it’s the “work force” that counts. If enough people are sick, or enough people are depressed because their children are hurting, or enough people stay up at night worrying what will happen to their family if they get sick, work force productivity goes down the toilet. I assume I don’t have to explain what happens to your economy when labor productivity is low. Whether you like it or not, economies are structured by country. If our country becomes a cesspool of despair, there will be no profits for capital, no investments, no opportunities, no nothing for anybody else. So you see, our best bet is to keep each other safe and sound, so all of us can enjoy the freedom to pursue our happiness. We figured that out 250 years ago.

Member
Aug 1, 2017

This collectivist rhetoric would be more palatable if it had any evidence to support it. All the economic data, however, points to the contrary. If universal healthcare had large and important benefits to social stability and productivity, wouldn’t we expect at least one European country outperform the US economically as a result of this competitive advantage? None of them do. In fact, they’re all substantially behind. Despite being at the same level as the US in 1980, Germany and France today have the same gdp per capita as the US did in in 2004 and 2000, respectively. Despite the US waging two stupid wars and being the home of two major crashes, France is still 17 years behind us! If they were were ranked against US states, they would be the 40th and 48th poorest states in the union. So the reality is quite contrary to what you’d like it to be. There is no economic competitive advantage from collectively improving the health of the herd, such a thing never materializes. On the contrary, the redistributive policies in these countries are an enormous burden on growth that ultimately punishes the regular people by keeping them poor and stuck.

Member

Yes, well, I’m afraid the validity of your arguments is rather questionable. The number of confounding variables in your comparative theory is large enough to render the conclusion meaningless, and I think you know that.

Member
Aug 2, 2017

The confounding argument is specious because any data that could be used to show economic benefits of health redistribution would suffer from the exact same confounds. So one must use the confounded data, the data that exists, or dismiss and forget universal healthcare as an idea entirely because there’s no way to test whether it is beneficial or harmful in a true experiment.

Member

Why not start a company and make sure you employ sick, depressed and insecure people? See how that works out in terms of productivity and profits. Some things don’t need experiments.

Member
Aug 2, 2017

“Some things don’t need experiments.”

We used to say that about bloodletting and radical mastectomy as well. No madame, everything needs to be tested and determined scientifically, because modern healthcare has no room for faith healing. But it is important to return to basics, because the fundamental point remains; there are enormous parts of the population living carelessly in sucrose and nicotine induced baths of serotonin, while I and many others toil away on rice and beans and five kilometer jogs. And as punishment for their biologically luxurious living, it is I who is expected to pay for their healthcare? Absolutely not, it is unjust and unacceptable.

Member

We are not talking about health care here. We are talking about benefits accruing to you from living in a relatively healthy society. This is about health money, not health care.
And I am starting to get a funny feeling that if we take this discussion to its logical conclusion (and I’ve been trying to avoid that), we will end up discussing Mr. Darwin in one context or another.

Member
Allan
Aug 2, 2017

The abilities of the medical profession to ensure health are limited; to cure the depressed and insecure are even more limited.

For the most part medicine treats significant medical illnesses such as cancer and heart disease. In general it doesn’t rid the body of disease except where a pathogen is concerned or a part of the body is removed surgically or otherwise.

Member
Aug 1, 2017

Like a lot of social topics, health care suffers acutely these days from the “Ich/Du/Sie” problem:

(Ich) I deserve first dollar indemnification from life’s misfortunes;
(Du) YOU need to have Significant Skin In The Game to keep you from driving up MY costs;
(Sie) HE/SHE is a mooch, a parasite, egregiously impinging on MY Freedom.

More broadly, it is again ascendantly fashionable to deny the very existence of a “commonwealth,” a “society.” As Margaret Thatcher once patronizingly clucked, there IS NO “society,” only a huge n-dimensional mass of economically transacting dyads.