Single-Payer Reform: The Only Way to Fulfill the President's Pledge of More Coverage, Better Benefits, and Lower Costs

I am an internist and worked in the US for 30 years and New Zealand for 9 years, 8 of which as a full-time employee in a public hospital. As a provider I never had a job or life better than that which I've had in Australia. All hospital based care is free to patients here. The purpose of public health care is provide medical care not to make money. There is a health care budget and not everything is available for everyone yet we have better OECD outcomes than the US for many measures at a fraction of the per capita cost. There are no uninsured and no one goes into debt or shoulders huge bills in the public sector. I am very well compensated, worked under a wonderful national physcians contract (I am working part-time now as a locum) with very generous benefits. Should also mention little to no indemnity concers - i am free to practice medicine and my patients are free to access it without financial concern. It's far from perfect but it's pretty good and I am delighted to be a part of it.

I was an internist. I am now a full time Parkinson's patient. I want to keep the traditional "original" Medicare coverage I have. I have practiced capitated medicine and want no part of it as a patient. Single payer can only exist in Canada with the relief valve of US hospitals so close. If we adopt the same system, the sick in both countries will need to flee as medical tourists to another continent. ObamaCare was set to self-destruct regardless of the election results. I was tired of paying a sneaky tax of a six thousand dollar deductible, triple what I had before with lower premiums. Medicare is the only medical coverage I have ever loved. Medicare for everyone! We can pay for it by not interfering in any more foreign civil wars.

Despite Drs. Woolhandler and Himmelstein’s claim that “Single-Payer Reform: The Only Way to Fulfill the President's Pledge of More Coverage, Better Benefits, and Lower Costs,”(1)  there is another, better option.
 
EMBRACE (2)  Single-System reform would not only accomplish these goals, but also create an infrastructure that would allow the American healthcare system to seamlessly integrate twenty-first century technologies like electronic health information platforms and evidence based practice guidelines.(3)  And, it would accomplish this by including a robust participation of affordable private insurance. Since most countries that have established a single-payer system (SPS) eventually allow private insurance participation,(4)  the EMBRACE system is a more realistic, real-world version of SPS. 


Briefly, EMBRACE has three innovations that are designed to work together: An evidence-based 3-tiered benefits system; a web based, nation-wide Health Information Platform (HIP); and an independent Nationals Medical Board (NMB) that oversees the nation’s entire unified healthcare system- thereby creating a “Single System."
The NMB will be an independent non-governmental body that will oversee the entire healthcare system. This separation from direct government oversight is yet another important difference from most SPS proposals and overcomes the objection to government run healthcare that has been the major obstacle to healthcare reform for the past 60 years. 


The Tiered Benefits System is comprised of three levels:  The basic tier (Tier 1) that covers all life-threatening conditions and all life extending or preventive services; while Tier 2 will cover conditions that affect quality of life; and Tier 3 would cover “luxury” services. 


The benefit tiers are separated in this manner to determine coverage. Because Tier 1 conditions are the most serious in terms of both personal and public health, they are covered by a form of public insurance that is managed by the NMB. This coverage is automatic (thus eliminating the individual and business mandates of the Affordable Care Act-ACA) and universal and does not depend on age, gender, employment status, preexisting conditions, or military service; it covers the entire population from cradle to grave. Tier 2 is covered by private insurance or paid out of pocket and Tier 3 services would generally be out-of-pocket.
 
EMBRACE Single System reform would not only fulfill the President’s pledges about healthcare, it would also help Congress reach its goals of limiting government oversight over healthcare, eliminating the individual and business mandates, increasing personal responsibility, reducing public healthcare expenditures and repealing the ACA.  


  1.Woolhandler S, Himmelstein DU. Single-Payer Reform: The Only Way to Fulfill the President's Pledge of More Coverage, Better Benefits, and Lower Costs. Ann Intern Med. 2017;166:587-588.


  2.Lancaster GI, O'Connell R, Katz DL, Manson JE, Hutchison WR, Landau C, et al. The Expanding Medical and Behavioral Resources with Access to Care for Everyone Health Plan. Ann Intern Med. 2009;150:490-492. 


  3.Lancaster GI, Drozda J. EMBRACE single system healthcare reform- How Congress can repeal Obamacare while creating a more perfect healthcare system. The Hill. Accessed at   www.thehill.com/blogs/congress-blog/healthcare/321284-embrace-single-system-healthcare-reform on May 2, 2017


 4. Colombo F, Tapay N. Private Health Insurance in OECD Countries: The Benefits and Costs for Individuals and Health Systems. OECD HEALTH WORKING PAPERS. Accessed at www.oecd.org/els/health-systems/33698043.pdf on May 2, 2017. 

Dr. Silverman aptly describes the advantages of practice in Australia's single payer system, where patients’ face few financial barriers, and physicians are spared much of the billing and administrative hassle that plagues our profession in the U.S. Recent studies document what every doctor knows: we waste countless hours on useless bureaucratic tasks, which doubtless contributes to soaring burnout rates.

Drs. Lancaster and Drozda view their proposed reform as more realistic than single payer. While several nations offer examples of highly functional single payer systems, their proposal rests on several speculative assumptions.

Their claims for a new Health Information Platform recall similar forecasts, dating back five decades, that a rosy computer-driven future is just around the corner . Moreover, they don't say how payers far from the bedside can delineate life-extending interventions covered for all under "Tier 1", from those in "Tier 2" that merely improve quality-of-life and would be reserved for those who can pay? In which Tier are treatments for addictions, mild depression - or even many drugs for type II diabetes? What of patients seeking care for chest pain or pigmented lesions, which turn out to be indigestion (Tier 2) or freckles (a Tier 3 luxury)?

Their proposed system would perpetuate administrative complexity and expense. They'd retain multiple private insurers, whose high overhead drains funds from care. Hospitals would still bill per-patient, rather receiving global, lump-sum budgets (as in Canada and Scotland), a payment strategy that halves hospital overhead . The current obsession with coding would persist, since billing codes would, presumably, determine the coverage tier. Without single payer's proven administrative savings, expanding coverage is unaffordable.

Policy debate now centers on Republicans' efforts to replace the Affordable Care Act. According to the official Congressional Budget Office, the House bill passed in May would add 23 million to the ranks of the uninsured, and deprive millions more of essential benefits . Coverage losses would be concentrated among vulnerable patients - the near-elderly, the poor and persons with pre-existing conditions.

The Republican alternative would be a backward step, but the health care status quo is also unacceptable. Twenty-eight million remain uninsured, and millions more have insurance they can't afford to use because of copayments, deductibles, and uncovered or out-of-network services. Single payer reform wouldn't fix all of health care's problems. But it could affordably cover everyone, and alleviate doctors' bureaucracy-induced malaise.

References
Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, Westbrook J, Tutty M, Blike G. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016 Dec 6;165(11):753-60.
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Himmelstein DU, Jun M, Busse R, Chevreul K, Geissler A, Jeurissen P, Thomson S, Vinet M-A, Woolhandler S. A Comparison Of Hospital Administrative Costs In Eight Nations: US Costs Exceed All Others By Far. Health Aff September 2014 33:1586-1594.
Congressional Budget Office. H.R. 1628 American Health Care Act of 2017: As passed by the House of Representatives on May 4, 2017. Washington, DC: May 24, 2017. Available at: https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1628aspassed.pdf (accessed May 27, 2017).

In reply:

Some health care reforms cost more than expected, others less. Dr. Grey cites the early underestimation of Medicare's costs, but omits cases where costs were overestimated. For instance, the Congressional Budget Office initially projected that the Affordable Care Act's coverage expansion provisions would cost $187 billion in 2017 , its latest estimate is $66 billion lower . Similarly, Medicare's drug benefit has cost 35% less than predicted .

Experience in nations with national health insurance (NHI) also indicates that universal, comprehensive coverage need not break the bank. All spend far less than we do, yet avoid the narrow networks and surprise bills that bedevil many patients. Almost all enjoy better health outcomes, and in the ten other countries included in recent surveys, even poor residents reported better access than the average American ; only Germany's primary care doctors were less satisfied than those in the U.S.

Nonetheless, Grey is correct that single-payer reform would require tradeoffs. We cannot afford private insurers, who add nothing of value while charging overhead four-fold greater than Medicare's, or the complex payment systems that impose $200 billion in unnecessary paperwork on hospitals and doctors. Nor can we sustain drug firms' exorbitant prices and profits.

Our current payment strategies also encourage providers to inflate their billings. Hospitals, HMOs and ACOs live or die based on their bottom line - their profit (or, for non-profits, "surplus"). Profitable institutions can expand and modernize, while unprofitable ones shrivel, even if they're providing excellent and much-needed care. The profit imperative - under both capitated and fee-for-service payment - drives providers to seek out lucrative patients and services, avoid unprofitable ones and portray all patients as sicker than they really are, boosting administrative and total costs..

Payment strategies that decouple care from the prospect of profit have proven far less inflationary, and better at matching resources to community need. For instance, Canada and Scotland pay hospitals global operating budgets - like schools or fire departments - obviating the need for per-patient billing. There's little incentive to upcode or cherry-pick, since hospitals can't keep surplus operating funds; new investments are instead funded through separate government grants.

Market-driven care is the root cause of America's health care dilemma. No law of nature decrees that costs must soar or patients must suffer; that MBAs should supervise MDs; or that the our nation can't match or exceed others' health care successes.

Steffie Woolhandler, M.D., M.P.H
David U. Himmelstein, M.D.

References

Congressional Budget Office. Letter to Nancy Pelosi. March 20, 2010. Available at: https://www.cbo.gov/sites/default/files/111th-congress-2009-2010/costestimate/amendreconprop.pdf (accessed 10/29/2017).
Congressional Budget Office. Federal subsidies under the Affordable Care Act for health insurance coverage related to the expansion of Medicaid and nongroup health insurance: Tables from CBO's January 2017 baseline. Available at: https://www.cbo.gov/sites/default/files/recurringdata/51298-2017-01-healthinsurance.pdf (accessed 10/29/2017).
Elmendorf, D. The Accuracy of CBO’s Budget Projections. March 25, 2013. available at: https://www.cbo.gov/publication/44017 (accessed 10/29/2017)
Osborn R, Squires D, Doty MM, Sarnak DO, Schneider DC. In new survey of eleven countries, US adults still struggle with access to and affordability of health care. Health Aff (Milwood) 2016; 35:2327 -2336,
The Commonwealth Fund. 2015 International survey of primary care doctors TOPLINE. available at: http://www.commonwealthfund.org/~/media/files/surveys/2015/2015-ihp-survey_topline_11-20-15.pdf (accessed 10/29/2017)).

Disclosures: We founded Physicians for a National Health Program and have served as unpaid advisors to Senator Bernie Sanders