'Single-Payer': the Wrong Debate

"Single-pricing" is the real issue. In other words, we're having the wrong debate, creating a huge distraction.

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Once again, our healthcare reform is mired in muck. That means we’re knee-deep and grinding away at our circular healthcare debate, but it’s really a big distraction. It’s the wrong debate. We keep debating the math of coverage and cost as if they’re independent of system design — and they aren’t. As Senate Majority Leader Mitch McConnell is finding out, there’s no solution to the Rubik’s Cube he’s playing with, because it’s the same one we’ve been fiddling with for decades: tiered coverage to support tiered pricing. The only way to lower the cost is to end coverage (“how” and “for whom” are just the dials). The good news is that “single-payer” healthcare isn’t necessary to solve our healthcare cost crisis. The bad news is that single pricing is, and that will require systemic change. Lost in our debates (often intentionally) is a critical design component called universal health coverage. Here, the landscape is littered with artifacts and variations of the term, but they’re often used in a way to disguise, confuse or obfuscate the core principle of universal coverage. There are many good definitions, but this one from the World Health Organization captures the general intent well:
“Universal health coverage is defined as ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services. Universal health coverage has therefore become a major goal for health reform in many countries and a priority objective of WHO.”
Terms like “universal healthcare,” “Medicare for All,” and “single-payer” are typically substituted for universal coverage as if they all mean the same thing and everyone understands the reference. They don’t, and the big distinctions are critical for any debate. Payment and coverage are definitely connected, but that connection can (and should) be simple and transparent, not complex and opaque. Universal coverage is that simplicity and transparency. What we have is tiered coverage designed to support tiered pricing. It's not just complex for everyone, it's totally opaque. Medicare, Medicaid, VA, Indian Health Services, employer-sponsored insurance, Obamacare and the uninsured are all different tiers of coverage — all with different pricing. That works well to maximize revenue and profits, but the enormous sacrifice to this design is safety, quality and equality. A big myth surrounding the debate is that our system is just broken. It’s not. It’s working exactly as designed, and we need a different system design based on the core principle of universal coverage. See also: Healthcare Needs a Data Checkup   Obviously, how universal coverage is paid for (either single- or multi-payer, delivered through government or privately owned industries) is a critical debate, but who qualifies for coverage (and under what terms) shouldn’t be. There are only three big arguments against universal coverage — clinical, fiscal and moral — and they all fail. The clinical evidence alone isn’t dazzling, but it is compelling. As MedPage Today noted last week:
“There are a lot more studies covered in Woolhandler and Himmelstein's paper, but they all suggest roughly the same thing–that insurance has a modest, but real, effect on all-cause mortality. Something to the tune of a 20% relative reduction in death compared to being uninsured.”
That’s just the clinical evidence, but healthcare is really expensive, so health coverage is inseparable from payment — which, of course, is the fiscal or economic argument. As a country, we've been arguing, fussing and fighting over the economics of healthcare for decades — and we're likely to continue for years to come — but the following chart is the only proof we need that we're not just on the wrong clinical trajectory, we're on the wrong fiscal one, as well. [caption id="attachment_26817" align="alignnone" width="570"] Creative Commons License by author Max Roser[/caption] Our system design is the death spiral — not Obamacare. Of course, policy wonks and politicians love to confuse the debate with a heavy focus on the y-axis of life expectancy. The general argument here is that the data around life expectancy is too variable around the world, so it’s all wrong. By extension, the argument goes, the whole chart must be wrong, but I’ve seen no dispute with the x-axis because the math is bone simple. Take our (estimated) National Health Expenditure for 2017 ($3.539 trillion, from CMS) and divide that by our current population (325,355,000, from the Census Bureau). The result is a whopping $10,877 per capita spending just on healthcare this year (the chart only goes to $9,000 in 2014). The argument that universal coverage is just too expensive for Team USA also fails with this chart because all of those other countries have some variant of it. Our debate swirls endlessly around economic options of tiered group (and now individual) coverage, but it’s all the science of actuarial math. The largest single group is always an entire country, and that’s also where the actuarial math is fully leveraged. As we can see from the chart, our decades-long battle with actuarial math has been epic, but the battle using tiered coverage (or some variant) is un-winnable. All of which brings us to the final argument: the moral one. Germany was among the first to recognize the moral imperative of universal coverage with its Health Insurance Bill of 1883. We’ve argued this imperative as well–perhaps none so eloquently or succinctly as Dr. Martin Luther King, Jr. in 1966:
“Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death.”
He’s right, and we know it. The clinical, fiscal and moral arguments against universal coverage all fail, so what’s left? All we really need now is the logic behind our obvious and longstanding political intransigence against it. Why don’t we just implement universal coverage? Here’s the simplest and best answer I’ve seen from the legal mind of Harvard Law Professor Lawrence Lessig:
“You know, when Bernie (Sanders) was talking about single-payer healthcare people rolled their eyes. Not because it was a bad idea, but because there’s no chance to get single-payer healthcare in a world where money dominates the influence of how politicians think about these issues.”
He’s right, too, and we know it. Much of our "healthcare debate" isn't really a debate at all. It’s a huge distraction from our fatally flawed system: the status quo. We’re just grinding away at the math hoping for an undiscovered calculation to solve our Rubik’s Cube. Politicians and heavily entrenched incumbents love to debate the variants of tiered coverage (and opaque pricing) because it continues to support the enormous revenue and profits for the healthcare industry. At almost $11,000 per capita per year, our healthcare system is a gigantic monument to the priorities of “shareholder value,” inequality and injustice (at scale). No one group is to blame for our healthcare cost crisis because each segment of the industry is complicit, and they each have a fiduciary obligation to their shareholders. Payers, providers, pharma, suppliers, educators, software vendors and medical device manufacturers are all harvesting enormous profits from our $3.4 trillion “medical industrial complex.” Naturally, they also lobby heavily for legislation to support those profits, and they have the war chests to do that effectively. See also: A Way to Reduce Healthcare Costs   Again, a payment mechanism for universal coverage is the only real debate, because there are many options and enormous ancillary benefits as well. Two of the biggest are single pricing (versus the opaque, tiered pricing of our current system) and the elimination of annual enrollment. I’ve never seen a clinical or economic argument supporting annual enrollment in health insurance because there aren’t any. That’s just not how healthcare works. It's just another artifact (like employer-sponsored insurance) in a system that's been optimized for billable episodes of care — not health — all marching to the drumbeat of an annual tax calendar. Single-payer is certainly one payment option, but it’s not the only one, and it’s easy to argue that it's not a good cultural fit for Team USA. That’s OK, because we don’t need single payer to get to single pricing. As one of the wealthiest countries on the planet, we can easily afford any healthcare system we choose — except one. The one we have. The future of Obamacare or Trumpcare isn’t the real debate, because it’s not as much a clinical or financial debate as it is a civil rights one. That will take time, but the result is inevitable. Universal health coverage isn’t a matter of if, only when, and not just because it’s the right thing to do but because it’s in our collective economic and clinical interest to end tiered pricing as the way to maximize revenue instead of optimizing for health. Obamacare was a step closer to universal coverage, but as Obama (and others) have suggested, progress isn’t always linear. My book Casino Healthcare is now available. You can also follow me on twitter @danmunro.


Dan Munro

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Dan Munro

Dan Munro is a writer and speaker on the topic of healthcare. First appearing in <a href="http://www.forbes.com/sites/danmunro/#594d92fb73f5">Forbes</a&gt; as a contributor in 2012, Munro has written for a wide range of global brands and print publications. His first book – <a href="http://dan-munro.com/"><em>Casino Healthcare</em></a> – was just published, and he is a <a href="https://www.quora.com/profile/Dan-Munro">"Top Writer"</a> (four consecutive years) on the globally popular Q&amp;A site known as Quora.

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