Beyond Obamacare: How a Single-Payer System Can Save US Health Care

Wednesday, April 24, 2013 by Common Dreams
by Dave Dvorak, MD

As physicians, health care leaders and legislators grapple with the complex changes brought by the Affordable Care Act (ACA), many are concerned that even after the law is fully implemented, hundreds of thousands of people will remain uninsured while health care costs continue to spiral.

What if there were a simple, streamlined solution that would guarantee health coverage while saving billions of dollars? A growing number of physicians are endorsing what they consider to be such a solution: single-payer health care. Weary of having to comply with hundreds of different insurance plans’ administrative requirements while their patients are denied needed tests and treatments, these physicians are drawn to the simplicity, cost-effectiveness and truly universal coverage offered by a single-payer system.

Their views were supported by an independent analysis last year demonstrating that with a state-based single-payer system, every person could have comprehensive coverage while the state would save billions annually.

A deeply flawed system

The desire for meaningful reform comes in the face of the U.S. health care system’s long-recognized dysfunction. Despite health care accounting for 18 percent of the nation’s economy—twice that of other wealthy democracies—48 million Americans lack health coverage. Another 29 million are underinsured, having poor coverage that exposes them to unaffordable out-of-pocket expenses. Health insurance premiums have doubled over the past decade, with the average annual cost for family coverage now exceeding $15,700; and health care costs now account for two-thirds of personal bankruptcy filings in the United States.

At the root of these problems is the fact that we have a fragmented, highly inefficient system. Employed Americans younger than 65 years of age have job- based insurance, if their employer chose to provide it; the elderly and disabled are covered through Medicare; the poor by Medicaid; military veterans through the Veterans Administration; and American Indians through the Indian Health Service. Persons who do not fall into any of those categories must try to purchase individual coverage in the private market, where it is often prohibitively expensive or unobtainable if they have a pre-existing health condition.

Owing largely to this fragmentation and inefficiency, a staggering 31 percent of U.S. health care spending goes toward administrative costs, rather than care itself. Inefficiency exists at both the provider and payer level. To care for their patients and get paid for their work, physicians and hospitals must contend with the intricacies of numerous insurance plans—which tests and procedures they cover, which drugs are on their formularies, which providers are in their network. Meanwhile, private health insurance companies divert a considerable share of the premiums they collect toward advertising and marketing, sales teams, underwriters, lobbyists, executive salaries and shareholder profits. The top five private insurers in the United States paid out $12.2 billion in profits to investors in 2009, a year when nearly 3 million Americans lost their health coverage.

The ACA of 2010, known widely as Obamacare, is expected to extend coverage to 32 million more Americans But it accomplishes this goal primarily by expanding the current fragmented, inefficient system and maintaining the central role of the private insurance industry in providing coverage. As a result, the ACA is expected to do little to rein in health care spending. Furthermore, it will fall far short of achieving universal coverage, as tens of millions of Americans will remain uninsured after its full implementation.

The solution

The central feature of a single-payer health care system would be one health plan that covers all citizens, regardless of their employment status, age, income or health status. Having a public fund that pays for care would slash administrative inefficiencies and eliminate profit-taking by the private insurance industry.

Under a single-payer system, the way society pays for health care would change, but the market-based health care delivery system would remain. Physicians and hospitals would continue to compete with one another based on service, quality of care and reputation. The chief difference is that they would bill a single entity for their services, rather than numerous insurers.

Individuals would benefit immensely by having continuous coverage that is decoupled from their employment. This would alleviate “job lock,” in which people remain in undesirable employment situations in order to maintain coverage. In a single-payer system, individuals could choose to see any provider, in contrast to the current system in which choice is restricted to those who are in-network. Deductibles and copays would be minimal or eliminated, removing cost as a barrier to obtaining needed care.

A single-payer system would be funded through savings on administrative costs, along with modest taxes that would replace the premiums and out-of-pocket expenses currently paid by individuals and businesses. The cost savings to individuals, businesses and government would be considerable. The nonpartisan U.S. General Accounting Office concluded that single- payer health care would save the United States nearly $400 billion per year, enough to cover all of the uninsured.

Physician support for a simplified, universal health care system is robust and growing. A 2008 survey published in Annals of Internal Medicine found that 59 percent of physicians supported a national health insurance system—up from 49 percent in 2002. Physicians for a National Health Program, a national organization advocating for single-payer reform, reports a membership of 18,000. In Minnesota, single payer has been formally endorsed by nearly 800 physicians, other providers and medical students.

Recognizing the implausibility of achieving single-payer reform at the national level in the current political climate, many single-payer advocates have turned their attention to state-level reform. The ACA provides for “state innovation waivers” to be granted beginning in 2017, allowing states to implement creative plans they believe would work best for them. With this in mind, organized single-payer movements have taken root in states as varied as Colorado, Hawaii, Illinois, New York, California, Oregon and Vermont. Vermont’s governor and Legislature passed a law in 2011 setting the path for the state to move toward single payer.

Conclusion

With nearly 50 million uninsured people in the United States and skyrocketing health costs, the need for profound reform of our health system could not be more clear. The ACA is a start, but it will fall far short of achieving universal coverage, and it allows unsustainable spending growth to continue. Single-payer health care would eliminate administrative waste and inefficiency, thereby creating an opportunity to achieve truly universal, cost-effective health care.

The four business gangs that run the US

Ross Gittins
The Sydney Morning Herald's Economics Editor


IF YOU'VE ever suspected politics is increasingly being run in the interests of big business, I have news: Jeffrey Sachs, a highly respected economist from Columbia University, agrees with you - at least in respect of the United States.

In his book, The Price of Civilisation, he says the US economy is caught in a feedback loop. ''Corporate wealth translates into political power through campaign financing, corporate lobbying and the revolving door of jobs between government and industry; and political power translates into further wealth through tax cuts, deregulation and sweetheart contracts between government and industry. Wealth begets power, and power begets wealth,'' he says.

Sachs says four key sectors of US business exemplify this feedback loop and the takeover of political power in America by the ''corporatocracy''.

First is the well-known corporate military-industrial complex. ''As [President] Eisenhower famously warned in his farewell address in January 1961, the linkage of the military and private industry created a political power so pervasive that America has been condemned to militarisation, useless wars and fiscal waste on a scale of many tens of trillions of dollars since then,'' he says.

Second is the Wall Street-Washington complex, which has steered the financial system towards control by a few politically powerful Wall Street firms, notably Goldman Sachs, JPMorgan Chase, Citigroup, Morgan Stanley and a handful of other financial firms.

These days, almost every US Treasury secretary - Republican or Democrat - comes from Wall Street and goes back there when his term ends. The close ties between Wall Street and Washington ''paved the way for the 2008 financial crisis and the mega-bailouts that followed, through reckless deregulation followed by an almost complete lack of oversight by government''.

Third is the Big Oil-transport-military complex, which has put the US on the trajectory of heavy oil-imports dependence and a deepening military trap in the Middle East, he says.

''Since the days of John D. Rockefeller and the Standard Oil Trust a century ago, Big Oil has loomed large in American politics and foreign policy. Big Oil teamed up with the automobile industry to steer America away from mass transit and towards gas-guzzling vehicles driving on a nationally financed highway system.''

Big Oil has consistently and successfully fought the intrusion of competition from non-oil energy sources, including nuclear, wind and solar power.

It has been at the side of the Pentagon in making sure that America defends the sea-lanes to the Persian Gulf, in effect ensuring a $US100 billion-plus annual subsidy for a fuel that is otherwise dangerous for national security, Sachs says.

''And Big Oil has played a notorious role in the fight to keep climate change off the US agenda. Exxon-Mobil, Koch Industries and others in the sector have underwritten a generation of anti-scientific propaganda to confuse the American people.''

Fourth is the healthcare industry, America's largest industry, absorbing no less than 17 per cent of US gross domestic product.

''The key to understanding this sector is to note that the government partners with industry to reimburse costs with little systematic oversight and control,'' Sachs says. ''Pharmaceutical firms set sky-high prices protected by patent rights; Medicare [for the aged] and Medicaid [for the poor] and private insurers reimburse doctors and hospitals on a cost-plus basis; and the American Medical Association restricts the supply of new doctors through the control of placements at medical schools.

''The result of this pseudo-market system is sky-high costs, large profits for the private healthcare sector, and no political will to reform.''

Now do you see why the industry put so much effort into persuading America's punters that Obamacare was rank socialism? They didn't succeed in blocking it, but the compromised program doesn't do enough to stop the US being the last rich country in the world without universal healthcare.

It's worth noting that, despite its front-running cost, America's healthcare system doesn't leave Americans with particularly good health - not as good as ours, for instance. This conundrum is easily explained: America has the highest-paid doctors.

Sachs says the main thing to remember about the corporatocracy is that it looks after its own. ''There is absolutely no economic crisis in corporate America.

''Consider the pulse of the corporate sector as opposed to the pulse of the employees working in it: corporate profits in 2010 were at an all-time high, chief executive salaries in 2010 rebounded strongly from the financial crisis, Wall Street compensation in 2010 was at an all-time high, several Wall Street firms paid civil penalties for financial abuses, but no senior banker faced any criminal charges, and there were no adverse regulatory measures that would lead to a loss of profits in finance, health care, military supplies and energy,'' he says.

The 30-year achievement of the corporatocracy has been the creation of America's rich and super-rich classes, he says. And we can now see their tools of trade.

''It began with globalisation, which pushed up capital income while pushing down wages. These changes were magnified by the tax cuts at the top, which left more take-home pay and the ability to accumulate greater wealth through higher net-of-tax returns to saving.''

Chief executives then helped themselves to their own slice of the corporate sector ownership through outlandish awards of stock options by friendly and often handpicked compensation committees, while the Securities and Exchange Commission looked the other way. It's not all that hard to do when both political parties are standing in line to do your bidding, Sachs concludes.

Fortunately, things aren't nearly so bad in Australia. But it will require vigilance to stop them sliding further in that direction.

A Tale of Two Healthcare Plans

Wednesday, September 12, 2012 by Reuters

by David Cay Johnston

 

 

No issue affecting taxes so clearly divides the two parties in the U.S. election as healthcare. The two parties, in their platforms, describe very different approaches to healthcare economics. Both use political plastic surgery to cover up ugly truths.

The stakes are huge. Americans spend $2.64 per person for healthcare for each purchasing power equivalent dollar spent by the 33 other countries that make up the Organization for Economic Cooperation and Development. The OECD data shows the U.S. spends $8,233 per capita compared with an average of $3,118 in the other 33 countries.

A growing share of federal tax dollars, in direct spending and in tax breaks, is going to U.S. healthcare as the population ages, even though about one in six Americans lacks health insurance.

America‘s healthcare system, more accurately described as a non-system sick care system, totaled 17.6 percent of the economy in 2010, compared to an average of 9.2 percent in the other 33 countries, as the OECD data shows.

In the United States, total public and private cost of healthcare is significantly greater than the total of corporate and individual income taxes, as well as payroll taxes. For each dollar paid in all three of those taxes in 2010, healthcare came to $1.29.

If we just lowered our costs to those of France, which has universal care in what is widely regarded as one of the best systems if not the best, it would save almost as much money as Americans paid in individual income taxes in 2010. The French spend 6 percentage points less of their economy on healthcare. In the United States, the individual income tax in 2010 came to 6.3 percent of the U. S. economy, the lowest since Truman was president.

Take a look at your pay stub to get an idea of the kind of money being spent on a system that fosters bankruptcy, bedevils small business and ranks 31st among the 34 OECD countries in preventing premature death.

REPUBLICAN PLAN
The Republicans say the federal government is “structurally and financially broken” and that “three programs - Medicare, Medicaid, and Social Security – account for over 40 percent of total spending,” which is “harming job creation and growth, (while) projections of future spending growth are nothing short of catastrophic, both economically and socially.”

The Republicans promise to “empower millions of seniors to control their personal healthcare decisions,” a vow immediately followed by a promise to cut federal spending.

The clearest explanation of what that would mean comes from Representative Paul Ryan, the Republican vice presidential nominee. Before he started obfuscating, Ryan laid out his plans in detail. He boasted that by changing Medicare from a plan that provides treatment for every older American into one that gives seniors a fixed sum to buy their own health insurance, taxpayers would save through 2084 the present equivalent of $4.9 trillion.

What Ryan did not mention is that his plan would also mean $8 of increased private spending by seniors and the disabled for each tax dollar saved.

We know how Ryan’s plan would raise total costs because David Rosnick and Dean Baker, economists at the Center for Economic Policy and Research which promotes government policies that it says would benefit workers and the poor, used the same formula that Ryan (or his staff) applied to the same Congressional Budget Office data, but on private medical care spending. Ryan’s spokesman did not respond to requests for comment.

Beyond the fact that it makes no sense to spend $8 to save $1, older people do not have the money. A tenth of Americans age 75 and older live below the official poverty line. Another 24 percent have only saved a tad more.

Every indicator shows that Americans have not enough for their old age and that a shrinking number have pensions while the Republicans now in charge of the party want to cut Social Security benefits, if not kill the program.

So why would any Americans under age 55, whose healthcare benefits Ryan wants to cut when they reach 65, think they can afford to spend $8 to save $1? Recently Ryan has softened his plan to let those who wish stay in traditional Medicare. Since anyone not rich who can count would stick with Medicare, Ryan’s promised taxpayer savings would never materialize.

Alan Grayson, the combative one-term Democratic representative from Florida, got it right when he said on the House floor in 2009: “The Republican plan – don’t get sick and if you do get sick die quickly.”

DEMOCRATS FAVOR UNIVERSAL CARE

 The Democratic platform calls for universal healthcare. “We will end the outrage of unaffordable, unavailable healthcare,” they say, though after six decades that party promise remains unfulfilled.

President Barack Obama‘s Patient Protection and Affordable Care Act will enable those with pre-existing conditions and twenty-somethings without work to get health insurance. But the plan does nothing to address the larger economic problem. American healthcare costs too much and needs replacement, not a nip and tuck.

Portugal, with half the income per person as America, provides universal healthcare. Cuba, the CIA tells us, ranks 40th in infant mortality, while the United States is nine steps lower at 49th, an astonishing fact given U.S. spending compared to the poverty induced by Castro’s collectivist economic policies.

Doing worse than Portugal and Cuba is, in my view, not just costly but immoral.

Just as Republicans are trying to limit the franchise, so are they trying to limit who gets healthcare. The Democrats are better only because they recognize that universal care can be cheaper while removing an annoying and costly distraction from business.

Death and taxes will always be with us. What we need is to spend less on taxes while doing the best we can to stave off death.

Do We Need Health Insurance?

Friday, December 16, 2011 by CommonDreams.org

by Philip Caper, MD

Do Americans need health insurance? The short answer is no — at least not in the form it currently exists in America.

It is true that in many wealthy countries private insurance companies are used in the financing of universal health care systems. But they are nothing like American companies. They are regulated public utilities and are told by their governments who to insure, what to cover and how much and when to pay. Most are prohibited from making a profit and are required to pay any willing provider. Not exactly the American model.

The purpose of health care financing systems should be — and is in all other wealthy countries — to facilitate the delivery of health care services, to protect individuals and families against huge medical care expenses and to avoid breaking the national bank while they do so. But in America, our private insurance system actually interferes with the delivery of health care and is rapidly becoming too expensive.

Last month I argued for adopting a universal health care system on moral, ethical and economic grounds. It is not only more humane but cheaper to cover everybody. We have moved in fits and starts toward that goal since the enactment of Medicare in 1965.

The recent federal health reform law took a few steps forward. But we are now taking a couple steps back, especially in Maine. Last week Gov. Paul LePage proposed disqualifying 65,000 beneficiaries of MaineCare. Earlier this year, the Legislature enacted PL90 that rolls back regulations intended to spread the financial risks of illness and improve access to health care for those most in need of it.

A little history may be informative. Private employment-based health insurance in America was not a planned system, but grew out of World War II wage and price controls. It was one of the few ways employers could attract and retain employees in a tight labor market. The spread of these benefits received a boost when the federal government exempted them from federal taxes.

Private health insurance was dominated by nonprofit Blue Cross and Blue Shield plans until about 1990. That changed when Blue Cross plans across the country began to convert to for-profit status, arguing that it would improve their efficiency. Maine Blue Cross made that transition in 2000 when it changed from a company whose mission was facilitating health care to one whose mission was maximizing shareholder wealth.

The business model of for-profit insurance companies is pretty simple. The creation of wealth for shareholders, including many of their executives, depends upon profitability. To maximize profitability they must charge premiums as high as the market will bear, offer skimpy policies that limit coverage, impose high deductibles and minimize what they must pay out for the services they do cover.

Maximizing premiums, imposing high deductibles and limiting the scope of coverage are pretty straightforward. Minimizing payouts for services they do cover is a little more complicated. Four techniques are used.

First companies try to avoid insuring people likely to require health care, such as those with a history of illness or who are elderly or in dangerous occupations.

Second, they dispute the need for health care that is recommended or has already been provided to their customers by micromanaging the decisions of doctors and patients and denying as many claims as they can. This is a very expensive and contentious process that often damages the quality of care.

Third, they bargain down the prices health care providers charge as much as possible, shifting costs to other payers. This has created the curious and uniquely American situation where uninsured people pay the highest prices for health care products and services.

Fourth, many companies try to find a reason to retroactively dump sick customers who have filed claims by asserting that they have failed to accurately state their health care history, therefore defrauding the insurance company.

These people end up on public insurance or on the roles of the uninsured. This practice, called “rescission,” is particularly unfair but nevertheless appears to have become widespread. It has been banned by the new federal health care reform act.

What is the problem with this picture? It is not that for-profit insurance companies are failing in their mission. In fact, they are doing a very good job of exactly what their mission demands, maximizing the wealth of shareholders. The problem is that their mission fundamentally conflicts with the mission of a decent health care system.

What can we do to fix this problem? The obvious first step — but not the last — is to replace for-profit insurance companies. They are like a camel entered into the Kentucky Derby. No matter how much it is trained, how hard it tries, how hard it is whipped or who the jockey is, it never wins. It just wasn’t designed for the job.

Although insurance companies could play a role in a redesigned system by becoming public utilities, that is not the most efficient way to finance a system that includes everybody. For example, private insurance companies are currently fighting the new federal health care law’s requirement that they keep their overhead below 20 percent. Medicare, financed through publicly mandated premiums and taxes, spends less than 5 percent on overhead and interferes with health care decisions much less than private carriers.

Maybe it’s time to replace that camel with a racehorse. While we’re at it, why not go for a thoroughbred? An improved Medicare-like system for all could provide better coverage while spending less. What’s not to like about that?