What would a single payer system look like?

[Xlorgguss]

So as we enter 2016 we have a democratic candidate opting for a single payer system or rather "Medicare for all". Now whether something like this could or should pass, what would the healthcare system look like with this in place. Please note that this is not a political argument as far as democrat vs republican or anything like that. I am simply curious to see how the system would change and if the change would be better, worse, or the same. Please feel free to post your thoughts!

[MunoRN, RN]

MunoRN mentioned BC sending patients to California for cardiac surgery. Not true. They send their complex cases to Alberta. The Mazankowski Alberta Heart Institute provides cutting-edge cardiac surgical care to thousands of patients of all ages every year, as does the KC Hui Centre at the Royal Alexandra Hospital. The pediatric cardiac ICU at the Stollery Children's Hospital in Edmonton has the best outcomes in North America for pediatric cardiac surgeries over several metrics. None of those families receives a bill for this high-quality care. Patients from all over Canada have their surgeries at the Stollery and the cost of their care is billed to their province of origin.

I think you may have misunderstood my post, another poster claimed that Canada sends it's open heart patients to the US for surgery which I pointed out wasn't actually true.

[DoGoodThenGo]

There are several ways of going about single payer health schemes. But regardless of at what level or who does it there are and will be methods of containing costs, and that does often translate into someone somewhere making certain decisions.

Take France for instance, a country whose health care model many seem to want the US to emulate. Everything from number of medical students, to hospitals and so forth is controlled by the government. Wages for physicians who along with nurses and most everyone else involved are also set by the French government because they are basically all employees.

French socialized medicine vs U.S. health care: Having a baby in Paris is much less costly than it would be in the States.

The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States

Even with the above the French health care system perhaps may be on balance better than the current USA methods; it does come at a cost; France devotes a very large share of GDP recourses to social spending. Funding for such spending comes from a bewildering and vast array of taxes, fees and surcharges including something we do not have in the States; the VAT.

Mr. Sanders has been talking a lot about SPP on the campaign trial; but when you look at his numbers they don't add up. The False Lure of the Sanders Single-Payer Plan

The only way for the USA to fully implement and pay for a single payer plan would be to find huge savings elsewhere *and* dedicated new revenue sources. Those savings would have to be real and concrete as well, not the budget gimmicks Congress often plays that merely kick a can down the road.

Finally in order for a single payer system to work in the USA it would involve treading deeply into state's sovereign rights, more so than it does now via Medicare and Medicaid.

Federal government cannot force states to overhaul their malpractice statues. For instance here in NYS a physician, hospital or health care provider can be sued for injuries caused attending a child's birth until (IIRC) the kid reaches age of 21.

[NotReady4PrimeTime, RN]

I think you may have misunderstood my post, another poster claimed that Canada sends it's open heart patients to the US for surgery which I pointed out wasn't actually true.

I stand corrected. My apologies!

[pmabraham, BSN, RN]

Since insurance doesn't guarantee access as providers don't have to accept insurance, single payer doesn't increase access. What research has been doing into looking at HSA's as a means of increasing access to healthcare by bypassing insurance so that patients and providers have a complete relationship (no insurance providers involved)?

[elkpark]

A recent (16 May) Gallup poll found that 58% of the respondents favor replacing the Affordable Care Act with a federally funded healthcare system that would cover all Americans (i.e., single payer system).

Majority in U.S. Support Idea of Fed-Funded Healthcare System

[DoGoodThenGo]

Since insurance doesn't guarantee access as providers don't have to accept insurance, single payer doesn't increase access. What research has been doing into looking at HSA's as a means of increasing access to healthcare by bypassing insurance so that patients and providers have a complete relationship (no insurance providers involved)?

New York Times did a piece on just this a few weeks ago: http://www.cnbc.com/2016/05/14/

Basically yes, in theory persons now do have insurance coverage, but finding providers who will accept can be a challenge. You might as well have Medicaid coverage for all the good many exchange plans are doing for what they cost.

This probably explains why in many areas you are still seeing very high ER utilization rates. Despite having health care coverage people still do not have access to primary care physicians and or specialists. So they just go where care is mandated to be offered.

[DoGoodThenGo]

A recent (16 May) Gallup poll found that 58% of the respondents favor replacing the Affordable Care Act with a federally funded healthcare system that would cover all Americans (i.e., single payer system).

Majority in U.S. Support Idea of Fed-Funded Healthcare System

Quoted from above:

The current survey used shorthand descriptions to describe the alternatives for dealing with the ACA, and it's possible that not everyone understands the implications of each approach. Instituting a universal healthcare system, in particular, would be one of the most significant overhauls of a major part of American life in modern U.S. history, and would create huge consequences and challenges. Additionally, other research shows that when given a choice, Americans are philosophically more inclined to favor a private healthcare system than one run by the government. Americans are generally satisfied with their personal healthcare, something that also could slow down the process of adopting a major overhaul of the healthcare system.

End of quote

Wherein lies the rub... Anyone who has taken an introduction to marketing, statistics or behavioral course knows how easy it is to influence certain responses to a survey. Fun starts when the devil that is the details is let loose. A majority of Americans may be in favor of a federally funded healthcare system in theory, however when the reality of what it looks like unfolds you may hear another story.

It could be argued the USA already has a federally funded health scheme; Medicare and Medicaid. Each on balance serves their purposes well enough and at less cost than private insurers. That being said both also impose strains on the health care system.

New York City just lost our 21st (or 20th? I've stopped counting) full service hospital (Beth Israel) in about 20 years, and odds are that won't be the last. Several places in Brooklyn are really only being kept alive via state money which sooner or later must end.

When you look at the places that have closed while there are/were many other issues one common thread remains; they rely heavily upon Medicare and or Medicaid patients; neither of which come remotely close to reimbursing even fifty percent of actual costs. There is no reason to believe any fully federally funded health care scheme would be any different.

[pmabraham, BSN, RN]

Doctor Stops Taking Insurance, Cuts Prices in Half – Political Outcast -- for me, that's what it would look like with insurance companies (including single payer -- i.e. all insurance) out of the picture. HSA's ;-)

[MunoRN, RN]

Since insurance doesn't guarantee access as providers don't have to accept insurance, single payer doesn't increase access. What research has been doing into looking at HSA's as a means of increasing access to healthcare by bypassing insurance so that patients and providers have a complete relationship (no insurance providers involved)?

I'm not sure how you're claiming that not having insurance results in the same access as having insurance. The ability to pay for services greatly increases your ability to obtain those services, and conversely the inability to pay for services makes it harder to obtain those services. Having insurance doesn't mean there aren't limitations on what that access is, but there's not really any arguing that it reduces one of the biggest hurdles in accessing care (ability to pay for that care). Increased access that increased to the point of being unlimited access is still increased access.

HSA's are actually a really good way to manage the funds used for the patient's direct contribution to various services, and the number of people who use HSA's has increased dramatically under the ACA. There's not really any potential for it to be the only way we pay for healthcare services however. It's relatively easy to rack up a 6 figure hospital bill out of the blue, and it's those acute care episodes that make up the majority of our healthcare spending. It doesn't make much sense, and would be economically disastrous, to put enough money in everyone's HSA to cover any potential healthcare costs, which would have to be a $million plus per person. How exactly do you see that working?

[pmabraham, BSN, RN]

My argument is that insurance never guarantees access as long as providers have a choice to say no to the insurance. If you look at how much money was sunk into the ACA from inception until the present, had the money been put into HSA's each legal American citizen would have 1 or more million in their HSA. Get rid of the insurance companies (that were somehow evil before ACA was implemented as if the ACA changed that now that healthcare insurance is required), and you have more patient to provider connections than ever before (insurance shouldn't be in the middle).

[Eru Ilúvatar]

NurseFifty made a statement that access to health care is tied to a Social Security number, but Canada doesn't have those, we have Social Insurance numbers; And it's not true that access to health care is tied to them; it IS tied to a provincial health care number, in Alberta we call them Universal Lifetime Identifiers. Newborns who haven't had their births registered are still able to access required care... I'm sitting next to one of them as I type.

MunoRN mentioned BC sending patients to California for cardiac surgery. Not true. They send their complex cases to Alberta. The Mazankowski Alberta Heart Institute provides cutting-edge cardiac surgical care to thousands of patients of all ages every year, as does the KC Hui Centre at the Royal Alexandra Hospital. The pediatric cardiac ICU at the Stollery Children's Hospital in Edmonton has the best outcomes in North America for pediatric cardiac surgeries over several metrics. None of those families receives a bill for this high-quality care. Patients from all over Canada have their surgeries at the Stollery and the cost of their care is billed to their province of origin.

There definitely IS less "business" involved here in Canada. Most physicians however do have private practices that require administrative supports and someone to keep track of billing. It's illegal to advertise pharmaceuticals direct-to-consumer and physicians are not really allowed to advertise their services either unless they're providing purely elective treatment (think Botox for wrinkles - Botox for spasticity is covered).

While we want to be seen as meeting patients' satisfaction it's not the driver of our work. The best outcome for the patient is.

There was a time when some of the provinces would send out statements of health care expenditures to patients, partly to show what health care actually costs and partly to ensure the care billed for was actually delivered. The administrative costs of this program were determined to be poor value so they stopped doing it. Occasionally the topic comes up but typically dies on the vine.

Supplemental insurance, as stated above, is to cover the things the province doesn't. Most employers provide this coverage at low cost. It pays for vision care, dental care, prescription drugs administered at home, semi- or private hospital accommodations (although many hospitals only have at most 2 patients per room except when on over-capacity protocol), ambulance charges, durable aids like crutches ad wheelchairs and so on.

Not so. I've had several hospitalizations in the past several years, surgeries, diagnostic imaging and many, many labs. I've never been asked to fill out a satisfaction survey. Hospitals have capital budgets that cover the day-to-day costs of running the facility; physicians bill on a fee-for-service basis, labs bill the province based on volumes of tests - a fee schedule is readily available on request. The care I receive is no better or worse than any other person with my health issues.

When more than 30% of all dollars spent on "health care" goes to administration - insurance companies, billing offices, pushing paper around ad infinitum - how can the cost of implementing a single payer, which would eliminate most of that waste, be more expensive than what you're doing?

I'd also like to clear up the piece of misinformation that keeps popping up when universal access and single-payer systems are discussed. The government DOES NOT DECIDE WHO GETS CARE, OR WHAT CARE THEY GET. The government also does not dictate who provides your care. If I don't like my family doctor, I can pick someone else. If I see a surgeon for a consult and decide I don't like his or her bedside manner, I can ask for a referral to someone else. And I will. My husband and son also have chronic health issues - my son's from birth -that are very well looked after. There are worse things than a single-payer, universal access health care system.

My statement is on reference to the US Medicare system.

[MunoRN, RN]

My argument is that insurance never guarantees access as long as providers have a choice to say no to the insurance. If you look at how much money was sunk into the ACA from inception until the present, had the money been put into HSA's each legal American citizen would have 1 or more million in their HSA. Get rid of the insurance companies (that were somehow evil before ACA was implemented as if the ACA changed that now that healthcare insurance is required), and you have more patient to provider connections than ever before (insurance shouldn't be in the middle).

The overall effect of the ACA is actually a net reduction in cost compared to no ACA, the money the ACA has us paying in a different (more equitable) way for care is money we would have to pay either way, but even if we count that as "new" costs, it's still not anywhere near $1 million per person that could just be put into HSA's.

Over the first 10 years of Obamacare, we'll spend about $1.2 trillion in subsidies for coverage and other costs, that works out to $3,783 per person, not a $million or more. There are many people for whom that might actually cover their healthcare costs over a 10 year period, but for many it won't. How does somebody who ends up with bypass surgery pay that $250,000 bill with the $3,783 in their HSA?