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!

[DoGoodThenGo]

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).

Yes, but does everyone *need* a million dollars or some such number just sitting in a HSA basically doing nothing, and what is the lost opportunity costs for federal government.

If you give persons money they have basically two choices; spend or save. Funds locked into a HSA can only be consumed for that purpose. If you don't have a legitimate need then the money simply sits there. Human nature being what it is persons will find something to consume that qualifies regardless of actual need; that is they *want* or have been lead to believe must have. Either way you end up with more spending than required which simply adds to the wasteful health care spending in this country.

[pmabraham, BSN, RN]

Yes, but does everyone *need* a million dollars or some such number just sitting in a HSA basically doing nothing, and what is the lost opportunity costs for federal government.

1. It would earn interest.

2. It would promote access to healthcare.

3. It would remove the insurance companies that were so evil before ACA (as if ACA changed anything in that department).

4. It would promote lower healthcare costs.

What matters most? "opportunity costs for federal government" or more access to affordable healthcare? Do you believe anything that creates and sustains a larger government is beneficial?

[DoGoodThenGo]

Why should the federal government give persons money just to "earn interest" when they could keep those funds and get a far higher return themselves. Even a million dollars in savings held in individual accounts wouldn't pay the same rates as billions in a single federal.

Again reinventing the wheel is not necessary; countries like France already provide universal health coverage at less cost and without giving away millions per person to sit in bank accounts. Problem is how to pay for and make it work in the United States.

[pmabraham, BSN, RN]

The problem with using insurance as a vehicle to increase the size of the federal government, and provide the government with any opportunities is that in America a provider (hospital, doctor, pharmacist, etc.) does not have to accept the insurance. This decreases access to healthcare rather than increasing access. Furthermore, even when accepted it puts control over what the patient really needs in the hands of whomever is highest on the string pulling chain; i.e. the government has ultimate control followed by insurance companies with the healthcare providers and patients having the least control. The list goes on.

[DoGoodThenGo]

The problem with using insurance as a vehicle to increase the size of the federal government, and provide the government with any opportunities is that in America a provider (hospital, doctor, pharmacist, etc.) does not have to accept the insurance. This decreases access to healthcare rather than increasing access. Furthermore, even when accepted it puts control over what the patient really needs in the hands of whomever is highest on the string pulling chain; i.e. the government has ultimate control followed by insurance companies with the healthcare providers and patients having the least control. The list goes on.

Actually not really.

Again using France as an example that country's national health scheme relies upon private insurance to implement much if not all and it does so for less cost than USA. It simply is a matter of how things are set up.

Only thing preventing the United States from going with such a model is the powerful vested interests on both sides of the political aisle. Just as with Medicare, Medicaid and under Obamacare insurers can be made to toe whatever line government wishes if they accept federal funding.

Employers use insurance companies to provide health care and they can and often do exert great pressure on same to keep costs down.

Play with the thought for a moment if the US government threatened to repeal the McCarran–Ferguson Act: McCarran–Ferguson Act - Wikipedia, the free encyclopedia

Think further if the federal government actively promoted and or created a nationwide health insurance scheme laying down parameters and so forth. Trust me when I say there would be panic in the boardrooms and on golf courses.

Or better yet, just open up Medicare at a lower age (subject to perhaps paying higher premiums that would decrease until reaching FRA), again the result would be almost the same.

On another note lone among developed western nations the US government does not set/bargain with drug companies for prices charged to "pension" health care plans (Medicare) or that of the indigent (Medicaid). I can walk into Duane Reade and purchase a bottle of acetaminophen at roughly 50 tablets for about $4 USD. However if that same generic Tylenol is given in hospital it costs about $10 per pill *and* there is a 25% surcharge for "administering".

Main reason we don't have universal health insurance here is that fear mongering and falsehoods are allowed to cloud judgment and or shut down the debate. It is odd that persons have no problem with the vast control federal government already has over healthcare via Medicare and Medicaid (and it is VAST), but object to the government "taking over" health insurance.

Of course sitting on the other side of that proverbial desk are those on forums such as this; providers of health care. If Europe is any example things would change including compensation and or perhaps working conditions. That would be a worthy debate to have since changes are coming down the pike anyway.

[pmabraham, BSN, RN]

It still doesn't change healthcare access as providers don't have to accept insurance. In so long as America is a free country, providers have the right to state they only accept cash or very specific insurances et al.

[MunoRN, RN]

1. It would earn interest.

2. It would promote access to healthcare.

3. It would remove the insurance companies that were so evil before ACA (as if ACA changed anything in that department).

4. It would promote lower healthcare costs.

What matters most? "opportunity costs for federal government" or more access to affordable healthcare? Do you believe anything that creates and sustains a larger government is beneficial?

If you're having to ignore that an HSA only system wouldn't be able to pay for the majority of healthcare services then there may be a problem with your plan, but as to your points:

"1. It would earn interest"

HSA's do earn interest but at a much lower rate than healthcare cost inflation, so money put into an HSA now will have less ability to pay for healthcare costs in the future. And that doesn't take into account how getting rid of the ability of consumers to negotiate as a group would further increase healthcare inflation.

"2. It would promote access to healthcare". Being unable to pay for larger costs, such as the majority of hospitalizations, would eventually make those services unavailable, which would drastically decrease access to healthcare.

"3. It would remove insurance companies.." I'm all for getting rid of insurance companies in their current form, but some way of paying for services that exceed what an HSA system can support would still need to exist, in which case I support whomever can provide that service at the lowest cost, which currently is the federal government. What do you suggest we do instead of hospitalizing patients? Should someone who's HSA can't cover the potential costs of their chest pain complaint just be put on comfort care? Should most of the things we currently hospitalize people for be replaced with comfort care?

"4. It would lower healthcare costs". We already know that individual consumerism can reduce costs but only for a relatively small portion of healthcare spending. For the types of services for we already generally pay for independently individual consumerism can help competition and avoid wasted spending, for everything else however it results in higher costs. This is why for those services, negotiating and paying as a group has already been shown to be cheaper, plus there are many situations where you just aren't in a good position to get a better deal, an unconscious patients who rolls into an ED after cardiac arrest doesn't have much ability to negotiate or shop around. Although under your proposal I'm still not sure if that patient would receive any treatment at all.

[pmabraham, BSN, RN]

Doctor Stops Taking Insurance, Cuts Prices in Half – Political Outcast -- treatment at half the price, no insurance.

[DoGoodThenGo]

It still doesn't change healthcare access as providers don't have to accept insurance. In so long as America is a free country, providers have the right to state they only accept cash or very specific insurances et al.

Fair enough I suppose; but acceptance of Medicare and Medicaid is "optional" and yet nearly every single hospital in the USA does so.

If the federal government (ok, basically the POTUS) can pretty much force states to accept gay marriage, universal heath care isn't that difficult an assignment. You are looking at the glass from an half empty point of view instead of the opposite.

Providers only opt out of accepting this or that insurance coverage where they have other options.

What do you think would happen if fifty, sixty or even 70 percent of a given health care demographic were insured by a single payer insurance scheme?

Do you know of the Commerce Clause of the USC? Do you know that Congress has vast leeway in placing conditions upon acceptance of federal dollars, and by doing so can put the "screws" to local governments, institutions and or persons. Do you know how many billions from various sources the federal government doles out in health care spending? Everything from research grants to equipment funding and so forth.

Again this whole line of thinking is moot as the thing has already been done. Here in NYC and elsewhere heath care networks have grown larger to deal with insurance companies, and the latter in return have sought to grow as well to counter. Neither of them has the unlimited spending power nor size of the federal government. If Congress established a national nationwide health care system that covered *ALL* states it would be too large a market for many providers to ignore.

I'll give you a final example; for decades physicians, hospitals and other health care providers have largely ignored and or avoided anything to do with transgender. Fast forward to now between Obama ordering Medicaid, Medicare and ACA to cover and several governors issuing the same for Medicaid in their state along with mandating insurers operating in; now things are quite different. Hospitals are falling over themselves to put in place LGBT (emphasis on the "T") care including gender reassignment. Mount Sinai Beth Israel in NYC is on that list.

This brings up a final point; in many markets individual practices are going away in favor of hospitalist and or physicians employed by health care networks/systems. Such doctors will do as they are told if you pardon the words. Since payment is handled by the parent system it doesn't matter to them who or how the bills are paid; they get their paycheck regardless

[heron, ASN, 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)?

Unless there's some sort of means-tested subsidy or price controls, an HSA would seem to be ineffective in creating better access, since it depends on the income of the person doing the saving.

Lantus insulin is going for nearly $300 for a 10ml vial. CBG test strips run about $1 per strip. My late partner's prn generic neurontin script cost over $200 for 120 caps. Rather hard for a diabetic earning, say, minimum wage to save that much on top of paying the basic bills of daily living. The fact is, all vendors - not just insurance companies - have consumers over a barrel.

For most low or middle income people, dependence on HSAs without both strict price controls and subsidies primarily provides the opportunity to die young.

[pmabraham, BSN, RN]

Fair enough I suppose; but acceptance of Medicare and Medicaid is "optional" and yet nearly every single hospital in the USA does so.

If the federal government (ok, basically the POTUS) can pretty much force states to accept gay marriage, universal heath care isn't that difficult an assignment. You are looking at the glass from an half empty point of view instead of the opposite.

Are you stating that one day, there will be no such thing as individual freedom in the United States and providers will be forced to accept specific means of payment whether they want to do so or not?

[MunoRN, RN]

It still doesn't change healthcare access as providers don't have to accept insurance. In so long as America is a free country, providers have the right to state they only accept cash or very specific insurances et al.

Are you saying you think they should be required to accept any amount or form of payment? In general, being able to pay for a service greatly increases your chance of being able to obtain that service, you seem to disagree with that.