Single payer debate no so easy

Over the years I've seen misrepresentations and down right lies about single payer systems but both advocates and critics. Few discuss the ow they really compare, and it's likely a push concerning costs. And wait times need context. If I can't afford a treatment or not get one, what difference does a slightly longer wait time mean to me? And there are other such questions. But I saw this and thought it might start a conversation that is less convoluted with misinformation. Anyway:

But the bigger problem with Trump’s comparison is that switching to a single-payer system would mean shifting the ultimate payer for health care services from the patient and the employer to the government. Why is that important? Because even as federal expenditures for health care rise under a single-payer system, the expenditures by individuals and companies would fall, potentially canceling each other out.

https://www.politifact.com/truth-o-...1/how-expensive-would-single-payer-system-be/

Agreed, it's not as simple an issue as either the "for" or "against" teams want to make it out to be. My oversimplified summation of the good and bad of this approach would be:

Pros

1. Universal coverage. The obvious one: nobody gets left out.
2. Administrative simplicity. Providers would no longer be negotiating fee schedules and contracts with dozens of insurers, no longer going through multiple credentialing processes, etc.
3. Unified policy direction. Much of the current effort to improve our care system is about fixing bad incentives baked into the way care is paid for, which subsequently impedes how it's delivered. But to really address the problem you need all or most boats rowing in the same direction. A dozen payers each trying to fix it independently, each with their customized and branded program, isn't necessarily helpful.
4. Rate-setting. In many markets, high health care prices seem to be at least partially an artifact of health care providers having negotiating clout over insurers. On paper, the ability to set prices and constrain their growth could help to mitigate that issue.

Cons

1. Cost. The single-payer wouldn't erase the high costs of the American health system, it would inherit them. Never has anyone tried to install single-payer on top of a system with such a high cost structure and constituting such a large percentage of GDP. The trillion plus dollars in premium revenue flowing through private insurers right now would instead have to flow through the treasury. That's a big tax issue, a tall order and responsibility for the federal government, and a philosophical and political tinderbox.
   
2. Politics. If part of our predicament has been that we've collectively avoided hard decisions for decades, I don't see much hope that single-payer would solve it. There are many reasons we pay so much for health care: we employ 'too many' people in that industry (including blue and white collar jobs), we pay them wages that are 'too' high, we get 'too many' services and have 'too much' capacity, we use 'too many' medicines, and have access to new drugs and new technologies 'too quickly.' And so on. [Note that it's the promise these "problems" will be fixed that leads to the constant discussion of increasing wait times.]
   
   If we've collectively decided that this isn't worth the cost and we're willing to give it up (and I don't believe that we have agreed this), then we're still going to face individual defections from those conclusions. Maybe we in the U.S. have too many hospitals, but your local Congressman and local politicians certainly aren't going to be in favor of your local hospital closing. The politics of hospital closures and layoffs will be even tougher than the politics of base closures, affecting every single Congressional district in the country. Putting tough decisions about cold, hard realities in the political sphere seems to me less likely to produce needed outcomes, not more.
3. Rate-setting. Putting aside the question of how desirable or feasible it is for a single authority to decide pricing levels and the degree to which competing facilities "deserve" to enjoy pricing differentials (Maryland at least seems to have made this work for the past four decades), there are concerns here. Many single-payer advocates view price-setting authority as a silver bullet for addressing high prices--a surefire way to depress prices and suck money out of a bloated health care system.
   
   The problem is, using newfound pricing authority to deliberately take a wrecking ball to our health sector is a potential economic calamity waiting to happen. Health care is increasingly what we as Americans do. It's where the job growth has been, where it's projected to be, and is now the single largest employment sector. It anchors entire communities, not to mention produces some remarkable innovations. Folks in the political sphere would be constrained in how much they could really use this power to push down spending (see previous bullet on politics--they might well use it to push up spending where it benefits their communities)--but the mere fact that this prospect is even on some people's minds is alarming.

For the most part, I don't think either side is particularly realistic about what single-payer will look like when it comes.

Green beard, I have to comment on the “cost” portion of your previous post. While it is true that initially there would be a great cost of shifting to single payer, in the long run, we would see cost savings. Statistics tell us that other countries provide universal health care with less costs and better outcomes.
While the ACA was a small step in the right direction, and needed plenty of shoring up, the one jewel of the act was that it encouraged preventative health care which would reap millions in savings. That, along with the other benefits of single payer, would bring us cost savings in years to come.

barbarap said:

Green beard, I have to comment on the “cost” portion of your previous post. While it is true that initially there would be a great cost of shifting to single payer, in the long run, we would see cost savings. Statistics tell us that other countries provide universal health care with less costs and better outcomes.
While the ACA was a small step in the right direction, and needed plenty of shoring up, the one jewel of the act was that it encouraged preventative health care which would reap millions in savings. That, along with the other benefits of single payer, would bring us cost savings in years to come.

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Certainly we know how we could cut costs to get closer to the OECD average. There's lots we could do!

We could close some of our hospitals.

The smaller average size of US hospitals and relatively lower hospital utilization also play a role in driving up US inpatient costs. The United States has 23 percent fewer beds per hospital than the OECD average, reflecting the fact that capacity is distributed over more hospitals in the United States than it is in other countries. Because many fixed costs, such as high-cost machinery and administrative functions, must be incurred in each hospital regardless of size, being subscale increases US fixed costs per bed.

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We could cut pay .

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We could deliver fewer services and get rid of some of our 'excess' capacity.

Compared with the average OECD country, the U.S. delivers (population adjusted) almost three times as many mammograms, two-and-a-half times the number of MRI scans, and 31 percent more C-sections. Also, the U.S. has more stand-by equipment, for example, 1.66 MRI machines per 6,000 annual scans vs. 1.06 machines. The extra machines provide easier access for Americans, but add to cost. Similarly, occupancy rates in U.S. acute care hospitals are much lower than in OECD countries, reducing the likelihood of delays in admissions, but building that extra capacity adds to cost. Aggressive treatment of very sick elderly also makes the mix expensive. In the U.S. many elderly patients are treated in intensive care units (ICUs), but in other countries they would receive only palliative care. More amenities such as privacy and space in hospitals and more attractive clinics also add to U.S. costs.

While the U.S. mix of services is disproportionately tilted toward more expensive interventions, the other OECD countries emphasize a “plain vanilla” mix. Compared with the U.S., the average OECD country has 30 percent more physician visits and more than 30 percent more hospital days per capita.

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We could cut back on our use of new medicines and technologies--or at least wait longer for them.

Overall, Americans use more medicines than people in other developed countries. They rank first for their use of antipsychotics as well as drugs for dementia, respiratory problems and rheumatoid arthritis. This is partly explained by medical needs: The burden of disease in the U.S. — as measured in “years of life lost” — is higher than in many OECD countries for the most common forms of heart disease, chronic obstructive pulmonary diseases, diabetes, and Alzheimer’s. Several factors may explain this, including high levels of obesity and high rates of diagnosis.

Americans also have faster access to new drugs than patients in many other countries. That’s in part because the U.S. has always been a very attractive market for pharmaceutical companies: It’s big, accounting for 34 percent of the world market; has low levels of price regulation; and offers few barriers to market entry once FDA approval has been secured. (By contrast, in some other countries there may be a time lag between clinical approval of a drug and the point when it is added to official lists of reimbursable drugs.)

The result is that companies often choose the U.S. to launch new products. And, because the US market is so big and profitable, investments in research and development have long been steered towards meeting its clinical needs.

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The problem, I suspect, is that most people don't want to do those things. "Costs" is a nice abstract way to discuss our system. If get down to the level of talking about what those costs are--people, paychecks, places, things--it's a lot harder to jettison them. Hence the challenge.

Green beard, I think I didn’t articulate very well where costs would be cut...

We won’t have to close hospitals or deny services. Single payer just costs less once it is in place.

Consider this...
A pregnant woman who can’t afford basic standard pre natal care never goes to the doctor.
She delivers her child three months early due to a medical condition that could have been diagnosed and treated if she had pre natal care.
Now her child will spend weeks/months in neonatal intensive care. The cost of intensive care far outweighs the cost of prenatal care. Since she doesn’t have the money to pay for intensive care, the cost gets passed on to the taxpayer in the form of Medicaid.
I would much rather my tax dollars pay for prenatal care.

This same senecio is played out in many other ways.

I’d rather pay the bill up front and save money in the end.

barbarap said:

Green beard, I think I didn’t articulate very well where costs would be cut...

We won’t have to close hospitals or deny services. Single payer just costs less once it is in place.

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But single-payer doesn't just magically cost less. There's some one-time savings to be had from administrative simplification when we eliminate those jobs, but many proposals tend to immediately give those savings back by making the coverage more generous than anyone has today. (Rhetorically this concept sometimes surfaces when a politician implies that job losses on one side of the ledger, e.g. in insurance or provider administrative functions, will be offset by job gains in clinical care delivery or elsewhere in the health system. Less politically fraught but a scenario in which savings aren't realized!)

It does not follow that if (1) single-payer exists someplace else and (2) that particular someplace else spends less on health care that (3) the U.S. will spend less on health care if it adopts single-payer. There are trade-offs to be considered--something has to be given up. The question is always: are we willing to give it up? My second point under the "cons" list above was getting at the fact that moving that question fully into the political sphere may well make it less likely that we choose to give anything up. Which again doesn't bode well for cost control.

Consider this...
A pregnant woman who can’t afford basic standard pre natal care never goes to the doctor.
She delivers her child three months early due to a medical condition that could have been diagnosed and treated if she had pre natal care.
Now her child will spend weeks/months in neonatal intensive care. The cost of intensive care far outweighs the cost of prenatal care. Since she doesn’t have the money to pay for intensive care, the cost gets passed on to the taxpayer in the form of Medicaid.
I would much rather my tax dollars pay for prenatal care.

This same senecio is played out in many other ways.

I’d rather pay the bill up front and save money in the end.

Click to expand...

Prevention is good! Keeping people healthy and better serving them is a legitimate function of our health system and universal coverage (one of the "pros" I listed above) can certainly facilitate that.

But prevention isn't really what differentiates us from the other OECD countries, particularly if we're talking about the difference in cost structure.

First, we're not that bad on prevention. International comparisons like The Commonwealth Fund's "Mirror, Mirror" series which tend to rank the U.S. low overall in international comparisons actually find that we do pretty okay on prevention.

The United States ranks in the middle on Care Process (5th), with stronger performance on the subdomains of prevention, safety, and engagement. The U.S. performs slightly below the 11-country average in the coordination subdomain.

The U.S. tends to excel on measures that involve the doctor–patient relationship, performing relatively better on wellness counseling related to healthy behaviors, shared decision-making with primary care and specialist providers, chronic disease management, and end-of-life discussions (Appendices 2A–2D). The U.S. also performs above the 11-country average on preventive measures like mammography screening and older adult influenza immunization rates.

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Second, just to consider this particular example, pregnant women have always been eligible for Medicaid coverage at higher income thresholds than the rest of the eligibility categories under that program. The barriers to getting care extend beyond simply having insurance coverage. Things like the local provider landscape or other factors that impact individual behavior and uptake of recommended services still need to be addressed. Single-payer isn't a silver bullet.

Third, many of the major cost differentiators are the sorts of things I mentioned in the post above. Prevention is a good thing from a quality-of-life perspective but it's not going to get us to where other systems are cost-wise.

Greenbeard said:

But single-payer doesn't just magically cost less. There's some one-time savings to be had from administrative simplification when we eliminate those jobs, but many proposals tend to immediately give those savings back by making the coverage more generous than anyone has today. (Rhetorically this concept sometimes surfaces when a politician implies that job losses on one side of the ledger, e.g. in insurance or provider administrative functions, will be offset by job gains in clinical care delivery or elsewhere in the health system. Less politically fraught but a scenario in which savings aren't realized!)

It does not follow that if (1) single-payer exists someplace else and (2) that particular someplace else spends less on health care that (3) the U.S. will spend less on health care if it adopts single-payer. There are trade-offs to be considered--something has to be given up. The question is always: are we willing to give it up? My second point under the "cons" list above was getting at the fact that moving that question fully into the political sphere may well make it less likely that we choose to give anything up. Which again doesn't bode well for cost control.



Prevention is good! Keeping people healthy and better serving them is a legitimate function of our health system and universal coverage (one of the "pros" I listed above) can certainly facilitate that.

But prevention isn't really what differentiates us from the other OECD countries, particularly if we're talking about the difference in cost structure.

First, we're not that bad on prevention. International comparisons like The Commonwealth Fund's "Mirror, Mirror" series which tend to rank the U.S. low overall in international comparisons actually find that we do pretty okay on prevention.



Second, just to consider this particular example, pregnant women have always been eligible for Medicaid coverage at higher income thresholds than the rest of the eligibility categories under that program. The barriers to getting care extend beyond simply having insurance coverage. Things like the local provider landscape or other factors that impact individual behavior and uptake of recommended services still need to be addressed. Single-payer isn't a silver bullet.

Third, many of the major cost differentiators are the sorts of things I mentioned in the post above. Prevention is a good thing from a quality-of-life perspective but it's not going to get us to where other systems are cost-wise.

Click to expand...

I agree that part of the savings from a single payer system would be in cutting salaries and reducing excess capacity. And politically those things are hard. But personally I have no problem with that

Green beard, I am typing on an iPhone so it is difficult to respond to every point you made.
I will address just the cost issue... you state that people will lose jobs if we made a switch to single payer. I don’t think so... there will be a shift in jobs that is for sure. But I think most in health care would be able make that shift and still maintain employment.

As for the cost in terms of Medicaid... not every pregnant woman is covered completely by Medicaid services. (True of any individual with any condition)
Some people on Medicaid pay a share of cost. This especially true for the working poor. The out of pocket expenses for that working poor person is often times enough to keep them from seeking preventative and regular maintenance health care.

Greenbeard said:

Agreed, it's not as simple an issue as either the "for" or "against" teams want to make it out to be. My oversimplified summation of the good and bad of this approach would be:

Pros

1. Universal coverage. The obvious one: nobody gets left out.
2. Administrative simplicity. Providers would no longer be negotiating fee schedules and contracts with dozens of insurers, no longer going through multiple credentialing processes, etc.
3. Unified policy direction. Much of the current effort to improve our care system is about fixing bad incentives baked into the way care is paid for, which subsequently impedes how it's delivered. But to really address the problem you need all or most boats rowing in the same direction. A dozen payers each trying to fix it independently, each with their customized and branded program, isn't necessarily helpful.
4. Rate-setting. In many markets, high health care prices seem to be at least partially an artifact of health care providers having negotiating clout over insurers. On paper, the ability to set prices and constrain their growth could help to mitigate that issue.

Cons

1. Cost. The single-payer wouldn't erase the high costs of the American health system, it would inherit them. Never has anyone tried to install single-payer on top of a system with such a high cost structure and constituting such a large percentage of GDP. The trillion plus dollars in premium revenue flowing through private insurers right now would instead have to flow through the treasury. That's a big tax issue, a tall order and responsibility for the federal government, and a philosophical and political tinderbox.
   
2. Politics. If part of our predicament has been that we've collectively avoided hard decisions for decades, I don't see much hope that single-payer would solve it. There are many reasons we pay so much for health care: we employ 'too many' people in that industry (including blue and white collar jobs), we pay them wages that are 'too' high, we get 'too many' services and have 'too much' capacity, we use 'too many' medicines, and have access to new drugs and new technologies 'too quickly.' And so on. [Note that it's the promise these "problems" will be fixed that leads to the constant discussion of increasing wait times.]
   
   If we've collectively decided that this isn't worth the cost and we're willing to give it up (and I don't believe that we have agreed this), then we're still going to face individual defections from those conclusions. Maybe we in the U.S. have too many hospitals, but your local Congressman and local politicians certainly aren't going to be in favor of your local hospital closing. The politics of hospital closures and layoffs will be even tougher than the politics of base closures, affecting every single Congressional district in the country. Putting tough decisions about cold, hard realities in the political sphere seems to me less likely to produce needed outcomes, not more.
3. Rate-setting. Putting aside the question of how desirable or feasible it is for a single authority to decide pricing levels and the degree to which competing facilities "deserve" to enjoy pricing differentials (Maryland at least seems to have made this work for the past four decades), there are concerns here. Many single-payer advocates view price-setting authority as a silver bullet for addressing high prices--a surefire way to depress prices and suck money out of a bloated health care system.
   
   The problem is, using newfound pricing authority to deliberately take a wrecking ball to our health sector is a potential economic calamity waiting to happen. Health care is increasingly what we as Americans do. It's where the job growth has been, where it's projected to be, and is now the single largest employment sector. It anchors entire communities, not to mention produces some remarkable innovations. Folks in the political sphere would be constrained in how much they could really use this power to push down spending (see previous bullet on politics--they might well use it to push up spending where it benefits their communities)--but the mere fact that this prospect is even on some people's minds is alarming.

For the most part, I don't think either side is particularly realistic about what single-payer will look like when it comes.

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On the costs in might not ease costs, but we might get more for the money. But I agree that both sides paint the issues inaccurately. All systems have issues. It boils down to what we prioritize.

vegas giants said:

I agree that part of the savings from a single payer system would be in cutting salaries and reducing excess capacity. And politically those things are hard. But personally I have no problem with that

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Salaries to who? Doctors in some single payer systems don't lose in pay. But cutting overhead is quite likely.

vegas giants said:

I agree that part of the savings from a single payer system would be in cutting salaries and reducing excess capacity. And politically those things are hard. But personally I have no problem with that

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Until the economy goes into the toilet and you lose your job.

jaeger19 said:

Until the economy goes into the toilet and you lose your job.

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You mean like happened in all those countries with single payer? LOL

barbarap said:

Green beard, I am typing on an iPhone so it is difficult to respond to every point you made.
I will address just the cost issue... you state that people will lose jobs if we made a switch to single payer. I don’t think so... there will be a shift in jobs that is for sure. But I think most in health care would be able make that shift and still maintain employment.

.

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right.. this magical unicorn where you get something for nothing. So.. we are going to make massive cuts in healthcare spending... and yet no effects on jobs or salaries. Amazing.

And Greenbeard is right.. .there are some small gains to be made in preventative medicine... but they are quite small.. and frankly.. depend on universal healthcare being good at preventative medicine.. which frankly.. if Medicaid and the VA are examples of preventative medicine... ouch.

Medicare has pretty good preventative medicine.. but then you are talking a large expansion of benefits.. way beyond what any countries universal system is like...

There simply is no free lunch here.

vegas giants said:

You mean like happened in all those countries with single payer? LOL

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Actually yes. Greenbeard pointed it out to you . What do you think happens to our economy when you make those cuts? Heck.. we worried about the AUTO? Industry... and now you think we should cut the industry that's 1/3 of our gdp and as Greenbeard stated.. is where a lot of job growth, salary growth and wage pressure is.

jaeger19 said:

Actually yes. Greenbeard pointed it out to you . What do you think happens to our economy when you make those cuts? Heck.. we worried about the AUTO? Industry... and now you think we should cut the industry that's 1/3 of our gdp and as Greenbeard stated.. is where a lot of job growth, salary growth and wage pressure is.

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So Canada fell apart when it happened? Are you kidding? This is just nonsense. We would not be CUTTING one third of our GDP....we are simply making changes to where the money is going

jaeger19 said:

right.. this magical unicorn where you get something for nothing. So.. we are going to make massive cuts in healthcare spending... and yet no effects on jobs or salaries. Amazing.

And Greenbeard is right.. .there are some small gains to be made in preventative medicine... but they are quite small.. and frankly.. depend on universal healthcare being good at preventative medicine.. which frankly.. if Medicaid and the VA are examples of preventative medicine... ouch.

Medicare has pretty good preventative medicine.. but then you are talking a large expansion of benefits.. way beyond what any countries universal system is like...

There simply is no free lunch here.

Click to expand...

Yeah....YOU will take a paycut. Trust me.....you will survive

vegas giants said:

So Canada fell apart when it happened? Are you kidding? This is just nonsense. We would not be CUTTING one third of our GDP....we are simply making changes to where the money is going

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Nope.. greenbeard explained the economics to you.

Greenbeard said:

The problem, I suspect, is that most people don't want to do those things. "Costs" is a nice abstract way to discuss our system. If get down to the level of talking about what those costs are--people, paychecks, places, things--it's a lot harder to jettison them. Hence the challenge.

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To me, the hallmark of 'cost cutting' means 'poor/less quality'.

Just a basic comment and a complaint that I do hear from people in countries with nationalized health care. That, and very long waiting periods.

barbarap said:

Green beard, I have to comment on the “cost” portion of your previous post. While it is true that initially there would be a great cost of shifting to single payer, in the long run, we would see cost savings. Statistics tell us that other countries provide universal health care with less costs and better outcomes.
While the ACA was a small step in the right direction, and needed plenty of shoring up, the one jewel of the act was that it encouraged preventative health care which would reap millions in savings. That, along with the other benefits of single payer, would bring us cost savings in years to come.

Click to expand...

*sigh*

The cost is estimated at 40 trillion over 10 years.
even with the so called cost saving that only amounts to about 5 trillion dollars.
so you are at 35 trillion over ten years.

math is math and the math doesn't add up.

vegas giants said:

Yeah....YOU will take a paycut. Trust me.....you will survive

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Well of course.. I have been taking a paycut since 1999 by the way.. because insurance and the government have been reducing. But..it also means that you are less likely to be seen by a physician. and more likely to be seen by a PA. and you are going to get less time per visit.. and It might mean that I won't accept your insurance as well. it means that when there were 5 facilities providing care.. its now down to three in the area

and with the economy the way it is.. those 3 facilities are a major employer in the area and create positive wage pressure...

I will do fine.. I am independently wealthy and could sell and not work again. The people in the communities that I employ? No so much.

There is no free lunch here.

jaeger19 said:

Nope.. greenbeard explained the economics to you.

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Then both of you are wrong. LOL

jaeger19 said:

Well of course.. I have been taking a paycut since 1999 by the way.. because insurance and the government have been reducing. But..it also means that you are less likely to be seen by a physician. and more likely to be seen by a PA. and you are going to get less time per visit.. and It might mean that I won't accept your insurance as well. it means that when there were 5 facilities providing care.. its now down to three in the area

and with the economy the way it is.. those 3 facilities are a major employer in the area and create positive wage pressure...

I will do fine.. I am independently wealthy and could sell and not work again. The people in the communities that I employ? No so much.

There is no free lunch here.

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This is the same argument for never cutting the military. Oh no you will put all those ship builders out of work. So we just build ships and tanks we don't need. It is the dumbest argument ever

vegas giants said:

Then both of you are wrong. LOL

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When you can provide the evidence to refute Greenbeards evidence.. well then... maybe your opinion may have some credibility...

until then... not so much.

vegas giants said:

This is the same argument for never cutting the military. Oh no you will put all those ship builders out of work. So we just build ships and tanks we don't need. It is the dumbest argument ever

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Well first.. its interesting you mentioned that.. because yes.. we do have trouble cutting the military because of the jobs...

Now.. imaging what happens when you decide to cut 1/3 of GDP that provides the care for the expanding number of elderly in this country...

Or do you think the demand for healthcare is DECREASING?

jaeger19 said:

Well first.. its interesting you mentioned that.. because yes.. we do have trouble cutting the military because of the jobs...

Now.. imaging what happens when you decide to cut 1/3 of GDP that provides the care for the expanding number of elderly in this country...

Or do you think the demand for healthcare is DECREASING?

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It is just total nonsense that we would be cutting one third of the GDP. That is just a flat out lie.