Considering “Single Payer” Proposals in the U.S.: Lessons from Abroad

https://www.commonwealthfund.org/publications/2019/apr/considering-single-payer-proposals-lessons-from-abroad

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ABSTRACT

  • Issue: When discussing universal health insurance coverage in the United States, policymakers often draw a contrast between the U.S. and high-income nations that have achieved universal coverage. Some will refer to these countries having “single payer” systems, often implying they are all alike. Yet such a label can be misleading, as considerable differences exist among universal health care systems.
  • Goal: To compare universal coverage systems across three areas: distribution of responsibilities and resources between levels of government; breadth of benefits covered and extent of cost-sharing in public insurance; and role of private insurance.
  • Methods: Data from the Organisation for Economic Co-operation and Development, the Commonwealth Fund, and other sources are used to compare 12 high-income countries.
  • Key Findings and Conclusion: Countries differ in the extent to which financial and regulatory control over the system rests with the national government or is devolved to regional or local government. They also differ in scope of benefits and degree of cost-sharing required at the point of service. Finally, while virtually all systems incorporate private insurance, its importance varies considerably from country to country. A more nuanced understanding of the variations in other countries’ systems could provide U.S. policymakers with more options for moving forward.

Background

Despite the gains in health insurance coverage made under the Affordable Care Act, the United States remains the only high-income nation without universal health coverage. Coverage is universal, according to the World Health Organization, when “all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship.”1

Several recent legislative attempts have sought to establish a universal health care system in the U.S. At the federal level, the most prominent of these is Senator Bernie Sanders’ (I–Vt.) Medicare for All proposal (S. 1804, 115th Congress, 2017), which would establish a federal single-payer health insurance program. Along similar lines, various proposals, such as the Medicare-X Choice Act from Senators Michael Bennet (D–Colo.) and Tim Kaine (D–Va.), have called for the expansion of existing public programs as a step toward a universal, public insurance program (S. 1970, 115th Congress, 2017).

At the state level, legislators in many states, including Michigan (House Bill 6285),2 Minnesota (Minnesota Health Plan),3 and New York (Bill A04738A)4 have also advanced legislation to move toward a single-payer health care system. Medicare for All, which enjoys majority support in 42 states, is viewed by many as a litmus test for Democratic presidential hopefuls.5 In recent polling, a majority of Americans supported a Medicare for All plan.6

Medicare for All and similar single-payer plans generally share many common features. They envision a system in which the federal government would raise and allocate most of the funding for health care; the scope of benefits would be quite broad; the role of private insurance would be limited and highly regulated; and cost-sharing would be minimal. Proponents of single-payer health reform often point to the lower costs and broader coverage enjoyed by those covered under universal health care systems around the world as evidence that such systems work.

Other countries’ health insurance systems do share the same broad goals as those of single-payer advocates: to achieve universal coverage while improving the quality of care, improving health equity, and lowering overall health system costs. However, there is considerable variation among universal coverage systems around the world, and most differ in important respects from the systems envisioned by U.S. lawmakers who have introduced federal and state single-payer bills. American advocates for single-payer insurance may benefit from considering the wide range of designs other nations use to achieve universal coverage.

This issue brief uses data from the Organisation for Economic Co-operation and Development (OECD), the Commonwealth Fund, and other sources to compare key features of universal health care systems in 12 high-income countries: Australia, Canada, Denmark, England, France, Germany, the Netherlands, Norway, Singapore, Sweden, Switzerland, and Taiwan.

We focus on three major areas of variation between these countries that are relevant to U.S. policymakers: the distribution of responsibilities and resources between various levels of government; the breadth of benefits covered and the degree of cost-sharing under public insurance; and the role of private health insurance. There are many other areas of variation among the health care systems of other high-income countries with universal coverage — such as in hospital ownership, new technology adoption, system financing, and global budgeting — that are beyond the scope of this discussion.

 

 

 

 

 

 

The “Medicare for All” Continuum: A New Comparison Tool for Congressional Health Bills Illustrates the Range of Reform Ideas

https://www.commonwealthfund.org/blog/2019/medicare-all-continuum

Medicare for all paperwork

Several 2020 Democratic presidential candidates have called for “Medicare for All” as a way to expand health coverage and lower U.S. health care costs. Replacing most private insurance with a Medicare-like system for everyone has instilled both hope and fear across the country depending on people’s perspective or financial stake in the current health care system. But a closer look at recent congressional bills introduced by Democrats reveals a set of far more nuanced approaches to improving the nation’s health care system than the term Medicare for All suggests. To highlight these nuances, a new Commonwealth Fund interactive tool launched today illustrates the extent to which each of these reform bills would expand the public dimensions of our health insurance system, or those aspects regulated or run by state and federal government.1

The U.S Health Insurance System Is Both Public and Private

The U.S. health insurance system comprises both private (employer and individual market and marketplace plans) and public (Medicare and Medicaid) coverage sources, as the table below shows. In addition, both coverage sources are paid for by a mix of private and taxpayer-financed public dollars.

Most Americans get their insurance through employers, who either provide coverage through private insurers or self-insure. Employers and employees share the cost through premiums and cost-sharing such as deductibles, copayments, and coinsurance. But the federal government significantly subsidizes employer coverage by excluding employer premium contributions from employees’ taxable income. In 2018 this subsidy amounted to $280 billion, the largest single tax expenditure.

About 27 million people are covered through regulated private plans sold in the individual market, including the Affordable Care Act’s marketplaces. This coverage is financed by premiums and cost-sharing paid by enrollees. The federal government subsidizes these costs for individuals with incomes under $48,560.

For 44 million people, Medicaid or the Children’s Health Insurance Program is their primary source of coverage. These public programs are financed by federal and state governments, and small individual premium payments and cost-sharing in some states. In most states, these benefits are provided through private insurers.

Medicare covers 54 million people over age 65 and people with disabilities. The coverage is financed by the federal government along with individual premiums and significant cost-sharing. About 20 million people get their Medicare benefits through private Medicare Advantage plans and most beneficiaries either buy supplemental private insurance or qualify for additional coverage through Medicaid to help lower out-of-pocket costs and add long-term-care benefits.

Millions Still Uninsured or Underinsured, Health Care Costs High

The coverage expansions of the ACA — new regulation of private insurance such as requirements to cover preexisting conditions, subsidies for private coverage on the individual market, and expanded eligibility for Medicaid — lowered the number of uninsured people and made health coverage more affordable for many. But 28 million people remain uninsured and at least 44 million are underinsured. In addition, overall health care and prescription drug costs are much higher in the United States than in other wealthy countries. U.S. health care expenditures are projected to climb to nearly $6 trillion by 2027.

The Medicare for All Continuum

To address these problems, some Democrats running for president in 2020 are supporting Medicare for All. Meanwhile, in Congress, Democrats have introduced a handful of bills that might be characterized as falling along a continuum, with Medicare for All at one end.

As our new Commonwealth Fund interactive tool illustrates, the bills range from adding somewhat more public sector involvement into the system, to adding substantially more public sector involvement. The bills may be broadly grouped into three categories:

  • Adding public plan features to private insurance. These include increasing regulation of private plans such as requiring private insurers who participate in Medicare and Medicaid to offer health plans in the ACA marketplaces, and enhancing federal subsidies for marketplace coverage.
  • Giving people a choice of public plans alongside private plans. These bills include offering a Medicare-like public plan option through the marketplaces, extending that option to employers to offer to their employees, giving people ages 50 to 64 the option to buy in to Medicare, and giving states the option to allow people to buy in to Medicaid. These bills also bring the federal government’s leverage into provider rate-setting and prescription drug price negotiation.
  • Making public plans the primary source of coverage in the U.S. These are Medicare-for-All bills in which all residents are eligible for a public plan that resembles the current Medicare program, but isn’t necessarily the same Medicare program we have today. The bills vary by whether people would pay premiums and face cost-sharing, the degree to which they end current insurance programs and limit private insurance, how provider rates are set, whether global budgets are used for hospitals and nursing homes, and how long-term care is financed. All of the bills in this category allow people to purchase supplemental coverage for benefits not covered by the plan.

Looking Forward

Many Democratic candidates who have called for Medicare for All are cosponsors of more than one of these bills. The continuum of approaches suggests both the possibility of building toward a Medicare for All system over time, or adopting aspects of Medicare for All without the disruption that a major shift in coverage source might create for Americans. We will continue to update the tool as new bills are introduced or refined. Users also can view a comparison tool of other wealthy countries’ health systems, which shows where select countries fall on a continuum ranging from regulated systems of public and private coverage to national insurance programs.

 

 

Welcome to “The Dose,” a New Health Policy Podcast

https://www.commonwealthfund.org/publications/podcast/2018/oct/doctor-who-prescribed-cooking-classes

 

Today we launch the Commonwealth Fund’s brand-new health policy podcast, The Dose.Every other Friday, host Shanoor Seervai will sit down with a leading expert to break down the latest research, hear personal stories about interactions with health care and the health system, and learn about innovations that could make life easier for patients, families, and caregivers.

In episode 1 of The Dose, Seervai talks to Martin Marshall, a primary care physician in East London. Through the stories of his patients and his own experience, Marshall explores what’s different about delivering primary care in the U.K. versus the United States. You’ll hear how Marshall helps one of his patients manage his diabetes with cooking classes, and how he leans on his intimate knowledge of a client’s family history to arrive at a diagnosis.

Click here to listen, and then subscribe wherever you get your favorite podcasts.

This Tweet Captures the State of Health Care in America Today

Image result for This Tweet Captures the State of Health Care in America Today

A nightmarish accident on a Boston subway platform on Friday — described in gory detail by a local reporter, Maria Cramer, as it unfolded and quickly retweeted by thousands — is one you might expect to see in an impoverished country.

In the face of a grave injury, a series of calculations follow: The clear and urgent need for medical attention is weighed against the uncertain and potentially monumental expense of even basic services, like a bandage or a ride to the hospital, and that cost, in turn, weighed against all the known expenses of living that run through any given head on any given day.

This discord, between agony and arithmetic, has become America’s story, too.

The United States spends vastly more on health care than other industrialized countries, nearly 17 percent of the nation’s gross domestic product in 2014, according to a report by the Commonwealth Fund, compared with just 10 percent of G.D.P. in Canada and Britain. But that disparity is not because Americans use more medical services — it’s because health care is far more expensive here than in other countries. One 2010 study by the Organization for Economic Cooperation and Development found that hospital costs were 60 percent higher in the United States than in 12 other nations.

And that cost is often passed on to patients, either in the form of deductibles and other out-of-pocket expenses or through ever-soaring insurance premiums.

The Affordable Care Act has improved access to health care, especially for lower-income families that now qualify for Medicaid or subsidies to buy private health insurance. Wider access, however, has not come cheaply for most people. As a result, many Americans, including those who are insured, have determined that they must avoid going to the hospital, visiting doctors or filling prescriptions that they need. A 2017 Kaiser Family Foundation survey found that 43 percent of people with insurance said that they struggled affording their deductibles, and 27 percent said that they put off getting care because of cost. Turning to GoFundMe and other crowdsourcing websites has become the norm in medical crises.

Whether the woman on the train platform received the medical attention she needed is unknown. Ms. Cramer said on Monday that she had not been able to get an update on the woman’s condition yet. Ms. Cramer went on to tweet that after several minutes had passed, an ambulance still had not arrived. Instead, fellow passengers tried to help. “One man stood behind her so she could lean against him,” she wrote. “Another pressed cold water bottles to her leg.”

Health care is a complicated problem, one exacerbated by the gridlock in Washington. But the trade-offs that everyday people are being asked to make, the calculations they are being forced to undertake in the scariest of situations, suggest that far too many of America’s politicians have placed too little value on the well-being of its citizens. Nothing will change until their fellow citizens step into the ballot box and insist on something better.

 

Despite Attacks on Obamacare, the Uninsured Rate Held Steady Last Year

The Uninsured Rate Held Steady

Image result for Despite Attacks on Obamacare, the Uninsured Rate Held Steady Last Year

 

The numbers suggest a surprising resilience of the health law.

Last year, Trump administration officials declared Obamacare “dead,” pulled enrollment ads offline, distributed social media videos critical of the law and sent signals that the law’s requirement to buy health insurance was no longer in effect.

But the number of Americans with health insurance stayed largely unchanged. The results of a big, government survey on health insurance status were published Tuesday, and they show that the uninsured rate remained basically flat at 9.1 percent in the first year of the Trump presidency.

The numbers suggest a surprising resilience of the health law, and its expansion of insurance coverage, even in the face of efforts that the law’s defenders call “sabotage.”

The new statistics come from the Centers for Disease Control and Prevention, which monitors the number of Americans with and without health insurance every quarter. Some smaller private surveys, from Gallup and the Commonwealth Fund had shown the uninsured rate rising last year. But the C.D.C. research includes a larger sample size, and is generally regarded as a more definitive study. Tuesday’s study contains data from the entire calendar year of 2017.

Among states that expanded their Medicaid programs under the Affordable Care Act, the uninsured rate actually fell last year. Among states that didn’t expand, it rose a little.

Overall, Obamacare has substantially reduced the number of Americans without insurance. According to the report, 19.3 million fewer people were living without health insurance in 2017 compared with 2010, when the Affordable Care Act passed Congress.

New health insurance options aren’t the only thing that has changed since the passage of the Affordable Care Act. A strengthening economy has nudged more Americans into the work force, increasing people’s access to health insurance at work.

Obamacare has shown other signs of hardiness. This year, the Trump administration slashed the program’s advertising budget by 90 percent, and withdrew key subsidies from insurance companies, leading to premium increases for some customers. But every market had at least one insurer that continued to offer plans on the Obamacare marketplaces, and sign-ups dipped only slightly.

That does not mean that the insurance trends will hold forever. There are several reasons the uninsured rate may rise in the future:

  • In the face of rising premiums, it is likely that some who do not qualify for federal subsidies have dropped coverage this year.

  • Several states are trying to set up work or other “community engagement” requirements for some Medicaid beneficiaries. A few will impose such rules this year. States requesting such changes estimate they will result in a declining number of residents covered by Medicaid.

  • The Trump administration is working on regulations to allow more loosely regulated insurance plans into the market. These plans could prove appealing to some people who are currently uninsured. But they could cause prices to rise for insurance plans with all of the Obamacare consumer protections, prompting other people to drop their coverage. According to an estimate from the Urban Institute, about 2.6 million fewer people may have comprehensive coverage next year.

  • The tax penalty for people who decline to obtain insurance will disappear entirely next year. That change alone is likely to cause several million fewer Americans to have insurance. Early filings by insurance carriers suggest the change will cause another round of big price increases. And economists at the Congressional Budget Office estimate that the policy’s disappearance will also cause fewer people eligible for government help from even investigating such options.

The combination of those changes is likely to mean some backsliding. But last year’s data suggest that Obamacare’s policies have helped create options that are appealing to many Americans who would have gone without insurance in the years before its passage.

 

 

 

 

Evidence keeps mounting that Affordable Care Act’s individual mandate was a success

http://www.healthcarefinancenews.com/news/evidence-keeps-mounting-affordable-care-acts-individual-mandate-was-success?mkt_tok=eyJpIjoiTXpGak1qTmhNbVUxWVRsaSIsInQiOiJwQlwvU1ZxcTU2bExreng4NXpEZ0Q2WkRYeldUbzlNM3kwWlJFeER5WlwvS3NqQ0lvMFwveHVNRExjdmVkdkRNMTBOb3FlZlwvOUJIMTYzR0tVWlNlcDJWMlRkMVM4TzZCK1I3XC9NSkFkc1U5QjhYaTZXKzhaUnY0M2RKNGNubTR5dk84In0%3D

Former HHS Secretary Tom Price. Credit: Alex Wong, Getty Images

Former HHS Secretary Tom Price.

Former HHS Secretary Tom Price’s statements and new research from the Commonwealth Fund suggest the ACA brought more young people to insurance pool.

When the Affordable Care Act was initially passed, some thought that many people, high-income men in good health particularly, would be driven from the insurance market and that would indicate a failure on the part of the ACA’s individual mandate. Instead the opposite appears to be true.

What’s more, former Health and Human Services Secretary Tom Price, MD, said publicly this week that when President Trump’s tax bill, which ends the individual mandate in 2019, kicks in insurance prices are going to rise.

Price’s statement comes after the uninsured rate dropped substantially at least when it comes to one studied demographic during the law’s first few years. Among 26-34-year-old men who earned more than 400 percent of the federal poverty level, the uninsured rate dropped from 11.7 percent in 2013 to 7.2 percent in 2015, according to new research by the Commonwealth Fund.

That’s actually greater than the drop in the uninsured rate of older men. Those between 55-64 also saw a reduction, but only from 3.9 to 2.5 percent.

Before the Affordable Care Act was enacted, young and healthy individuals in many states could purchase limited benefit packages at low premiums. The ACA mandated coverage and charged higher premiums to those not covered by federal subsidies.

Young, healthy males shouldered higher costs due to regulations that shifted the brunt of the cost away from disadvantaged groups, such as the poor and the elderly.

At the time of passage, some states had imposed rating rules for insurance coverage that sought to qualify more people for health subsidies, but the researchers found that when the ACA was passed, the percent of uninsured men that didn’t qualify for subsidies dipped at about the same rate in all states, regardless of whether they had enacted those rules.

The positive impact on young, high-earning men was credited by authors to financial penalties and effective marketing, but the Trump administration has cut the ACA marketing budget by $90 million. Just $10 million is now earmarked for that purpose.

“There are many, and I’m one of them, who believe that [the tax bill] will harm the pool in the exchange market,” Price said at the World Health Care Congress on Tuesday. “Because you’ll likely have individuals who are younger and healthier not participating in that market, and consequently, that drives up the cost for other folks.”

 

U.S. Health Care from a Global Perspective

http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective

Cross-national comparisons allow us to track the performance of the U.S. health care system, highlight areas of strength and weakness, and identify factors that may impede or accelerate improvement. This analysis is the latest in a series of Commonwealth Fund cross-national comparisons that use health data from the Organization for Economic Cooperation and Development (OECD), as well as from other sources, to assess U.S. health care system spending, supply, utilization, and prices relative to other countries, as well as a limited set of health outcomes.1,2 Thirteen high-income countries are included: Australia, Canada, Denmark, France, Germany, Japan, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. On measures where data are widely available, the value for the median OECD country is also shown. Almost all data are for years prior to the major insurance provisions of the Affordable Care Act; most are for 2013.

Health care spending in the U.S. far exceeds that of other high-income countries, though spending growth has slowed in the U.S. and in most other countries in recent years.3 Even though the U.S. is the only country without a publicly financed universal health system, it still spends more public dollars on health care than all but two of the other countries. Americans have relatively few hospital admissions and physician visits, but are greater users of expensive technologies like magnetic resonance imaging (MRI) machines. Available cross-national pricing data suggest that prices for health care are notably higher in the U.S., potentially explaining a large part of the higher health spending. In contrast, the U.S. devotes a relatively small share of its economy to social services, such as housing assistance, employment programs, disability benefits, and food security.4 Finally, despite its heavy investment in health care, the U.S. sees poorer results on several key health outcome measures such as life expectancy and the prevalence of chronic conditions. Mortality rates from cancer are low and have fallen more quickly in the U.S. than in other countries, but the reverse is true for mortality from ischemic heart disease.