Tag Archives: Universal Health System

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

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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.

 

 

 

 

 

 

Incentives Are All Wrong for Single-Payer Health Care

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https://www.bloomberg.com/view/articles/2017-09-12/incentives-are-all-wrong-for-single-payer-health-care

Americans won’t give up their private insurance unless the government option is better. And that won’t be cheap.

The conventional wisdom these days is that the major Democratic presidential candidates for 2020 will end up endorsing some version of single-payer health care. Senator Bernie Sanders is expected to introduce his Medicare for All bill this week, with a considerable number of co-sponsors. This political posturing, however, is far from a practical proposal.

There’s an obvious problem with moving Americans to a single-payer system: Most people with private health insurance are pretty happy with their current arrangements. They are not looking to trade in that coverage for a new government program of uncertain quality, along with unknown higher taxes. When President Barack Obama was selling the Affordable Care Act, he promised Americans that they could keep their health insurance if they wanted to. When this didn’t turn out to be true for everyone, there was a significant backlash.

Progressive analysts thus have turned to how a single-payer system might come about more gradually. But longer transition times don’t solve the core problem.

Let’s say the federal government sets up a “public option,” as it sometimes is called. Individuals would have the opportunity to buy into government insurance at some price. The new government program would be competing with private insurance, but just how good will the new benefits be? If you’re healthy and have other coverage, you probably won’t switch — if you did, that would be a sign that the new government program was of very high quality and probably too expensive for the nation as a whole. Boosting the health care of the best-covered Americans isn’t the policy priority right now.

Instead, the public option might be set up to attract those who don’t already have good coverage. But those are the same people who don’t have the money to pay a fair market price for health insurance now. In essence, the program would come to resemble a Medicaid expansion, whether or not it would fall under the formal rubric of Medicaid.

That’s a plausible option for a marginal change; many states, of course, have already done a Medicaid expansion. The question remains whether such a program can evolve into single-payer health insurance. The answer is probably not. To become a single-payer system, as coverage climbs up the income ladder, the new reform would have to lure Americans out of private health insurance. It either has to make the private alternative worse, say by penalties like a stiff “Cadillac tax” on policies that exceed a certain level, or it has to make the public alternative especially appealing. We are then back to the change either being unpopular or spending too much money on people who already have decent coverage.

You can make a good case for continuing the forthcoming Cadillac tax on private insurance, as is embedded in Obamacare. But the point of that change was to get people to move to less health insurance coverage and to use less health-care resources, not to bounce them into a system with yet lower marginal cost for a doctor’s visit or extra medical procedures.

It’s worth thinking through why some single-payer systems, such as those on the European continent or in Hong Kong and Taiwan, seem to work. Typically those systems were instituted while health-care costs were still fairly low, and then kept down by government fiat. The U.S. is not in that position, and it’s hard to see doctors and hospitals — powerful lobbies — going along with significant cuts to their payments.

Single-payer systems can work for yet another reason: If a citizenry consumes much less health care, and it doesn’t damage patient outcomes so much. Patient queuing isn’t a disaster if people who really need treatment get priority, as is the case in the better-run single-payer systems. In other words, single payer has to be sold as a way of getting us all to cut back on the consumption of medical resources. Unfortunately, the Medicare for All movement is more about easing everyone’s access and boosting the usage of health-care resources, a typically American approach.

When it comes to access, the major problem in the U.S. is distributional: Some of the poor have insufficient access, and arguably some of the well-off receive health care at too low a user price. Given Americans’ love for consumption, it’s probably too late to fix the latter problem. We can, to some extent, improve lower-income access by Medicaid expansions.

The political war along the way to a full single-payer system is unlikely to be rewarding. According to one poll, single payer is supported by only 43 percent of Americans, hardly enough to overcome political gridlock.

Progress will come in bits and pieces. The notion of a universal cure-all is a myth, whether it comes to improving your health or improving America’s health-care system.

 

U.S. Health Care from a Global Perspective

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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.