Should the US adopt a single-payer health care system?

[Deus Naturae]

A public option and ACA-style markets with a mandate along with the repeal of tax benefits for company insurance would probably work better with less effort.

As awesome as the end result of single-payer would be, it would be a nightmare to implement.

We already have single-payer in the form of Medicare and Medicaid, but politicians in both parties restrict access so only 1/3 of the population receive the benefits. Republicans are terrified of the political implications derived from creating single-payer insurance for catastrophic medicine, though, it would be a huge boon to the economy. Democrats are terrified of the political fallout and ideological compromise associated with swapping pork-dispensaries for entitlements that actually work.

I heard of such a scheme in the Atlantic but what would be catastrophic and when would end of life termination of care be determined or how?

I'm guessing that anything short of catastrophic care could then be taken care of in Walmart or Walgreens or something like that?

Doctor's offices are also a thing...

[Person Man]

A public option and ACA-style markets with a mandate along with the repeal of tax benefits for company insurance would probably work better with less effort.

As awesome as the end result of single-payer would be, it would be a nightmare to implement.

We already have single-payer in the form of Medicare and Medicaid, but politicians in both parties restrict access so only 1/3 of the population receive the benefits. Republicans are terrified of the political implications derived from creating single-payer insurance for catastrophic medicine, though, it would be a huge boon to the economy. Democrats are terrified of the political fallout and ideological compromise associated with swapping pork-dispensaries for entitlements that actually work.

I heard of such a scheme in the Atlantic but what would be catastrophic and when would end of life termination of care be determined or how?

I'm guessing that anything short of catastrophic care could then be taken care of in Walmart or Walgreens or something like that?

Doctor's offices are also a thing...

The gist is that routine care could possibly becoming inexpensive or easy to finance if insurance companies are no longer providing care.

Another issue though would be specialists. Would some of their care like blood tests and what not be pushed onto general practitioners while things like MRIs, tissue/cell grafts, gene therapy, radiation and chemo   be handled by catastrophic insurance?

[AggregateDemand]

I heard of such a scheme in the Atlantic but what would be catastrophic and when would end of life termination of care be determined or how?
I'm guessing that anything short of catastrophic care could then be taken care of in Walmart or Walgreens or something like that?

Non-catastrophic coverage would be provided by private insurers. The reason for the catastrophic/non-catastrophic distinction is that catastrophic care doesn't function as a marketplace.

I'm not sure of the exact services or end-of-life limitations because I'm not a government healthcare actuary, but we have about $200B in failed end-of-life services so we have a place to start making reforms.

[Replicator]

Ah so many people on this site want a single payer system yet so few American voters actually support it. Good luck taking down the American Electorate.

[andrew_c]

The US is the only developed country in the world without universal health care.  It's time for them to catch up to the rest of the developed world.

[anvi]

The US is the only developed country in the world without universal health care.  It's time for them to catch up to the rest of the developed world.

The U.S. doesn't want any of them foreign ideas.  And I'm with them all the way.  Foreign ideas should be banned.  Take the Ten Commandments, for example. They came from someplace in the Middle East. And so did the gospels. And that there US constitution was based on a bunch of ideas by Scottish, English, French and Dutch eggheads.  Foreign ideas ain't welcome here. 

[Person Man]

Like I said, the ACA should be as "universal" as some of the "conservative" European models are with about an insurance rate of 93-95%. If the ACA doesn't hold up because its repealed or overruled, then we really have no alternative to single -payer except for maybe targeted expansions of Medicaid and Medicare using targeted tax increases. 

[Frodo]

Something to bear in mind.

[Representative MJM]

The United States needs a single-payer system more than anything else. Health care is a basic human necessity, and the U.S. government should not stand by and allow its citizens to go into ridiculous amounts of debt just to pay for necessary procedures (or, on the other hand, have its citizens never go for procedures because they don't think that they can afford it). Free services are a must, yet even Medicare as it exists today does not cover all medical costs for seniors. We need to improve the system and let it cover all people. Obamacare was a mess from the start which could never work on the level of a single-payer system. Why are we the only advanced economy without any form of universal healthcare? It is embarrassing, frankly. Regarding the loss of jobs, the government will have to try its best to employ the people who lost their jobs. Unfortunately, this is an effect of its implementation, but it is a short-term problem compared to the long-term problem of healthcare costs.

[AggregateDemand]

Something to bear in mind.

Nader is so lost I doubt he'll ever find his way back.

Corporate America is not behind the current healthcare system. In fact, an overwhelming majority of employers would prefer to get out of the healthcare industry completely, and focus on their core competence, which is not healthcare management.

We've created a trillion dollar entitlement industry that powers NGOs, like AARP. Furthermore, the industry is politically protected by both Republicans and Democrats. The former support Medicare/Medicaid because their voters abuse it, and the latter lend support because it's their political turf.

We can only dream of a day when corporate America turns on the government-funded healthcare industrial complex, and they force through reform or they make Medicare and Medicaid available to everyone, without raising taxes.

[Person Man]

Something to bear in mind.

Nader is so lost I doubt he'll ever find his way back.

Corporate America is not behind the current healthcare system. In fact, an overwhelming majority of employers would prefer to get out of the healthcare industry completely, and focus on their core competence, which is not healthcare management.

We've created a trillion dollar entitlement industry that powers NGOs, like AARP. Furthermore, the industry is politically protected by both Republicans and Democrats. The former support Medicare/Medicaid because their voters abuse it, and the latter lend support because it's their political turf.

We can only dream of a day when corporate America turns on the government-funded healthcare industrial complex, and they force through reform or they make Medicare and Medicaid available to everyone, without raising taxes.

The United States needs a single-payer system more than anything else. Health care is a basic human necessity, and the U.S. government should not stand by and allow its citizens to go into ridiculous amounts of debt just to pay for necessary procedures (or, on the other hand, have its citizens never go for procedures because they don't think that they can afford it). Free services are a must, yet even Medicare as it exists today does not cover all medical costs for seniors. We need to improve the system and let it cover all people. Obamacare was a mess from the start which could never work on the level of a single-payer system. Why are we the only advanced economy without any form of universal healthcare? It is embarrassing, frankly. Regarding the loss of jobs, the government will have to try its best to employ the people who lost their jobs. Unfortunately, this is an effect of its implementation, but it is a short-term problem compared to the long-term problem of healthcare costs.

Just keep in mind that there will not be major change until unsustainable becomes unviable.

[politicallefty]

Something to bear in mind.

That only shows how the framing of various healthcare questions affects polling. It's the same way the ACA has majority disapproval, despite the vast majority of its provisions being very popular. If you frame single-payer as "government-run" or a "government takeover", the polling will probably be problematic. If it's placed under the "Medicare for All" banner, the polling is much more favourable. Medicare is wildly popular, especially among beneficiaries. I think the biggest disappointment of the ACA was the failure to include the 55+ Medicare buy-in option (and we have Joe Lieberman to thank for that).

[Frodo]

The brief window of opportunity we had of having a single-payer system on par with the National Health Service in Great Britain was in the immediate post-war years.  We missed it.  And there is nothing to suggest that such a window will open again in the immediate future, not with the suspicious -almost paranoid- attitude of the American people toward their government (if you were a census worker or with the civil service, you'd know), which hasn't improved after six years of this administration.  

Considering how painful and difficult it was to pass Obamacare, not to mention its lingering unpopularity, introducing single-payer would meet an even worse reception from the American people, already suspicious of government overreach with Obamacare.  

Single-Payer is dead on arrival.  Count on it.  

[AggregateDemand]

The brief window of opportunity we had of having a single-payer system on par with the National Health Service in Great Britain was in the immediate post-war years.  We missed it.  And there is nothing to suggest that such a window will open again in the immediate future, not with the suspicious -almost paranoid- attitude of the American people toward their government (if you were a census worker or with the civil service, you'd know), which hasn't improved after six years of this administration.  

Considering how painful and difficult it was to pass Obamacare, not to mention its lingering unpopularity, introducing single-payer would meet an even worse reception from the American people, already suspicious of government overreach with Obamacare.  

Single-Payer is dead on arrival.  Count on it.  

Single-payer and nationalized healthcare are not similar concepts. I'm not particularly keen on single-payer health insurance, but we've never been closer to having it than now. Medicare and Medicaid didn't exist immediately following the post-war era so the government had no experience administering healthcare. Furthermore, the programs have been abused to such an extent that they cost as much as single payer.

We could have single-payer tomorrow but for all of the people who refuse to reform Medicaid and Medicare.

[politicallefty]

The brief window of opportunity we had of having a single-payer system on par with the National Health Service in Great Britain was in the immediate post-war years.  We missed it.  And there is nothing to suggest that such a window will open again in the immediate future, not with the suspicious -almost paranoid- attitude of the American people toward their government (if you were a census worker or with the civil service, you'd know), which hasn't improved after six years of this administration.  

Considering how painful and difficult it was to pass Obamacare, not to mention its lingering unpopularity, introducing single-payer would meet an even worse reception from the American people, already suspicious of government overreach with Obamacare.  

Single-Payer is dead on arrival.  Count on it.

I can't say I entirely disagree with you. Wholesale transformation of the American healthcare system in one bill is virtually impossible. I was never someone that ever believed we could get single-payer passed in 2009 or 2010. However, I am one that believes it can be accomplished piecemeal. As I said above, lowering the age of Medicare eligibility to 55 would have been a huge accomplishment. I was also one that was strongly supportive of a public option. Our main problem was Joe Lieberman (and Ben Nelson, to a lesser extent). And, if it weren't for SCOTUS, a lot more people would be on Medicaid (even more if we had passed the House bill instead of the Senate bill).

As for the past, there were far too many missed opportunities. I would have happily taken Nixon's proposal. It wasn't perfect, but it would've been a huge foundation to build upon.

[Frodo]

Any criticism of the ACA needs to acknowledge that it improved a system that was and still is in a state of prolonged collapse under the weight of an aging population, technological improvements, and increasingly unmanageable hospitals.

That said, American health care remains a byzantine, inhumane, unsustainable, and expensive mess. It's even more byzantine now, but the ACA addresses the rest of those nasty adjectives to varying degrees.

Single payer would have been more difficult - i.e. impossible - to pass. But it would be easier to defend. The chief problem with the ACA is that only a handful of people understand the law, and that was before the Supreme Court and the Obama administration decided that they would be amending it on the fly. Accordingly, people have a poor sense of how they've benefited and intense anxiety about what they might lose. The law has also become a convenient excuse for doctors, employers, and insurance companies. Patients rarely know any better when whatever human jackal they're dealing with tells them that Obamacare is why their deductible is going up, why they'll have to wait months for knee surgery, or why they are losing their coverage.

The great political tragedy that underlies this dispute is that we are unwilling to trade a system that offers great care for a few, good care for most of the rest of us (albeit accompanied by uncertainty, financial headaches, and stress), and little or no care for the rest for a system that would guarantee good care for everyone.

There are alternative health care models that offer universal coverage, you know.  This isn't an either/or situation.  It just so happens single-payer has that sex appeal among progressives (especially here) that Bismarck apparently doesn't.

[anvi]

It is a shame Bismarck just hasn't entered the Progressive political consciousness in the U.S. yet.  It has much of the efficiency and private centers of care delivery and insurance that "Single Payer" largely lacks, but includes the benefits of universal coverage and effective cost containment. 

[Frodo]

"Bismarck" style health care is essentially what the ACA gives us, with subsidized, heavily regulated, for-profit insurance companies in the place of not-for-profit sickness funds.

What you described in your first post here is most certainly not Bismarck, because if Obamacare was truly based on the Bismarck model, it wouldn't have the problems you mentioned.  Unless you are suggesting that citizens in Germany and Switzerland are suffering for lack of a single-payer system.

  

[they don't love you like i love you]

I think it was accurately said that the Bismarck model is what Obamacare is designed to eventually become. Obviously it's a bit away from that now with its launch.

[Frodo]

Voted Yes because I think it's the most straight-forward way to deal with the problem, I think healthcare access is a right, and I don't think it should be the responsibility of an employer to provide healthcare access, or the responsibility of the person to go buy it at this point.

If single-payer is so wonderful, then why are countries like Sweden moving away from it?

"Bismarck" style health care is essentially what the ACA gives us, with subsidized, heavily regulated, for-profit insurance companies in the place of not-for-profit sickness funds.

What you described in your first post here is most certainly not Bismarck, because if Obamacare was truly based on the Bismarck model, it wouldn't have the problems you mentioned.  Unless you are suggesting that citizens in Germany and Switzerland are suffering for lack of a single-payer system.

What are the chief differences, other than what I've already specified?

Unlike those two countries, we don't set prices for health care services and products (i.e. prescription drugs), and let drug companies and hospitals decide whether or not they want to participate.  Instead, we let insurers do the negotiating.  And since they are so weak (because they are so fragmented), they use the benchmark set by whatever Medicare is paying, and add a percentage on top because they lack the power to strike similar deals.  

[anvi]

In Bismarck systems, you have mostly privatized delivery and insurance systems.  Insurance companies are mostly mandated to be non-profit entities and must cover the conditions of those they insure, which is a big difference already.  Insurance is offered through employers, but municipalities, generally, cover those who are unemployed or too poor to purchase insurance themselves.  Opt-outs are often available for the top 10% of income earners so they can purchase plans with wider coverage than standard sickness funds but which are more expensive.  Benchmarks on prices for procedures and medicines are negotiated between government, industry and insurers on a mostly annual basis, but those benchmarks apply, with regard to medicines, to the least expensive but most generally effective medications on the market.  Prices then are not fixed; pharma companies are allowed to charge whatever they want for their meds, but patients are informed by physicians about what sorts of meds are available, and best or adequate, for their conditions and they make choices on what to buy.  The fact that care delivery comes through private hospitals and clinics means wait times and quality of care are generally better than in "national insurance" systems.  Physicians receive their medical educations largely free and don't acquire massive amounts of debt getting their degrees, and tort laws give them broad protections from lawsuits--but these advantages also generally translate into lower earnings for physicians, though their livelihoods are still quite good compared to the average income-earner.  There are therefore mechanisms built into the system for efficient care delivery, multiple mechanisms for cost control, both through negotiation and consumer choice, and also mandates for universal coverage.  Obviously, the system is not perfect--nothing human is--and it requires a broader tax base than exists in the U.S. to support it.  But, given my experiences living in countries with both Bismarck and national insurance models, I think Bismarck works far, far better.  The differences between Bismarck and ACA are fairly dramatic, though.  ACA leaves for-profit insurance in place, it has far fewer mechanisms for cost containment--though it has some--and the insurance system it envisions is still far more fragmented than in Bismarck systems, which leads to dramatically persistent cost-shifting.  On top of that, the "mandate" of ACA is not really a mandate at all, and in the long run will prove completely ineffective in financing health care delivery on the whole.  Don't get my wrong; I'd rather have ACA than not have it--but it is light years away from what can be most effective.

[anvi]

Coverage in Bismarck systems is portable between jobs, as the sickness funds are nationally valid.  Coverage is available to full and part-time workers as well as to guest workers.  Unemployed worker coverage does not change, their premium contributions are paid by federally administered statutory unemployment insurance during the term of unemployment.

[anvi]

Sure, they drive up costs.  Lots of things do.  But countries with Bismarck systems spend between 10-12% of their GDP on health care costs as opposed to the current 17% of the U.S, the the cost increases of the former rise at slower rates on top of it.  I doubt the ACA will hold down health care expenditures in the short or long terms as effectively as Bismarck systems, particularly given the fact that the quantity and quality of cost control mechanisms in Bismarck systems are better than ACA.  Very generic similarities between these two kinds of systems, in my view, don't matter too much when the specifics of each translate into such glaring cost differentials.

The problem is that Bismarck is probably not politically feasible in the U.S. anyway.  Once you decide to make the health care industry a for-profit one, both on the delivery and provider ends, there are too many interests that will fight against fundamental change.  So, something like ACA, but better crafted, and with a less fragmented but still universal coverage system, might be the best we can do here.

[Filuwaúrdjan]

The so-called Bismarck model does not actually exist; it is a fiction largely created by American policy wonks who want to imagine that the world was (and is) created by people like them (thankfully this is not the case). The system of social insurance introduced by Bismarck was certainly highly influential and can be seen as foundational in terms of German social policy (which, by the way, is insanely complex and reflects well over a century of constant tinkering by governments red, blue, black and brown. As regards healthcare, some particularly important changes - aimed at greater uniformity - were introduced by the SPD-led coalition in the 1970s), but it was not a universal service and nor was it ever envisioned as one; it only covered manual workers in industry and lower grade public servants. These groups were chosen for blatantly political reasons as they were most likely to vote for the SPD, an organisation then regarded as subversive and dangerous. Subsequent expansions of coverage (and changes to regulation, to administration, to the nature of coverage and so on) have also tended to be inspired by short term political calculations, as is often the way with incremental reform. The resulting system might look to be the creation of a singular vision, but this is basically an illusion.

[Lief 🗽]

I don't think anyone is implying that the German system was the result of a singular system. "Bismarck model" is just a convenient and abstracted shorthand for the system in place in Germany, the Netherlands, Japan, etc.