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Learning from Other Countries

An excellent op-ed in the New York Times properly highlights lessons from other wealthy nations. Diving deeper into those examples reveals that single payer is the only plausible path to achieving efficient and equitable health care financing in the US.

June 15, 2023

I Studied Five Countries’ Health Care Systems. We Need to Get More Creative With Ours.
New York Times
June 14, 2023
By Aaron E. Carroll

[H]ealth care reform doesn’t seem to be a top political issue in the United States right now. That’s a mistake. The American health care system is broken. We are one of the few developed countries that does not have universal coverage. We spend an extraordinary amount on health care, far more than anyone else. And our broad outcomes are middling at best.

When we do pay attention to this issue, our debates are profoundly unproductive. Discussions of reform here in the United States seem to focus on two options: Either we maintain the status quo of what we consider a private system or we move toward a single-payer system like Canada’s. That’s always been an odd choice to me because true single-payer systems like that one are relatively rare in the world, and Canada performs almost as poorly as we do in many international rankings.

In the first half of the year, I was privileged to visit five other countries and learn about their health care systems. In February I traveled to Britain and France with Indiana University’s Kelley School of Business and, more recently, with the Commonwealth Fund and AcademyHealth to New Zealand, Australia and Singapore.…

America could learn a thing or two from these other countries. We could take inspiration from them and potentially improve access, quality and cost. However, it’s important to frame our examination correctly. Focusing on these countries’ differences misses the point. It’s what they have in common — and what we lack — that likely explains why they often achieve better outcomes than we do. …

Universal coverage matters. What doesn’t is how you provide that coverage, whether it’s a fully socialized National Health Service, modified single-payer schemes, regulated nonprofit insurance or private health savings accounts. All of the countries I visited have some sort of mechanism that provides everyone coverage in an easily explained and uniform way. That allows them to focus on other, more important aspects of health care.

But the United States can’t decide on a universal coverage scheme, and not only does it leave too many people uninsured and underinsured; it also distracts us from doing anything else. We have all types of coverage schemes, from Veterans Affairs to Medicare, the Obamacare exchanges and employer-based health insurance, and when put together, they don’t work well. They are all too complicated and too inefficient, and they fail to achieve the goal of universal coverage. Our complexity, and the administrative inefficiency that comes with it, is holding us back.

When I was younger, I was more of a single-payer advocate, until I realized how many systems perform better than Canada’s. More recently, I favored the tightly regulated, entirely private insurance system of Switzerland because it performs exceptionally well using a private scheme I thought would be more palatable to many Americans. Today, though, I really don’t care how we get to universal coverage.

If we could agree on a simpler scheme — any one of them — we could start to focus on what matters: the delivery of health services. …

What separates the countries I traveled to from the United States is that they largely depend on public delivery systems. Most people get their hospital care from a government-run facility. However, each country also has a private system that serves as a release valve. If people don’t like the public system, they can choose to pay more, either directly or indirectly, through voluntary private health insurance, to get care in a different system. …

In fact, explicit tiering is a feature, not a bug, of all of these other systems. Those who want more can get more, even in Singapore’s public system. But more isn’t better care; it’s more choice in terms of physicians, private rooms, fancier food and even air conditioning. (While many Americans see the latter as a necessity, most people in Singapore — where it’s much hotter — don’t agree.)

In the United States, on the other hand, most care is provided by private hospitals, either for-profit or nonprofit. Even nonprofit systems compete for revenue, and they do so by providing more amenity-laden care. This competition for more patient volume leads to higher prices, and while we don’t explicitly ration care, we do so indirectly by requiring deductibles and co-pays, forcing many to avoid care because of cost. …

I’m convinced that the ability to get good, if not great, care in facilities that aren’t competing with one another is the main way that other countries obtain great outcomes for much less money. It also allows for more regulation and control to keep a lid on prices.

I’m not arguing it would be easy to expand the number of public hospitals in the United States. It would be politically difficult to expand the government’s role in delivering health care, directly or indirectly. But allowing people to choose whether to accept cheaper care delivered by a public system or to pay more for care in a private system might make this much more palatable. By doing so, we could make sure that good care is available to all, even if better care is available to some.

Comment by: Jim Kahn

Dr. Carroll offers many cogent observations: the failure of our health system, the paramount importance of universal coverage, the valuable role of public providers, and the wisdom of investing in non-medical social welfare programs. He appropriately highlights admirable examples of universal coverage in other wealthy countries. I even accept his observation that the Canadian single payer system isn’t the most popular among single payer approaches.

What he fails to do is note the critical features of successful national insurance systems. Here they are:

  1. Universal coverage with an identical broad benefit package. That is, everyone has the same excellent coverage, and the same payment rates. This is a far cry from universal coverage as defined in the US. It is essential for both equity and efficiency.
  2. This universal coverage is provided by the government or not-for-profit insurers. Even in Switzerland and the Netherlands, cited as examples for feasibility of a private insurance model, these insurers provide standard comprehensive benefits without taking profit. He alludes to the not-for-profit highly regulated use of insurers. But he fails to point out that this model has nothing to do with how US private insurers operate.
  3. Additional private insurance, such as for access to more providers or to cover cost-sharing, is a very small portion of total health spending, typically just a few percent. It’s the exception, not the system; the frill, not the core.
  4. Cost-sharing is low, maximum hundreds of dollars instead of thousands or tens of thousands in the US. That’s critical for access to care, with nearly half of adults delaying or skipping care for financial reasons.
  5. Providers deal with only one payer, instead of dozens here. This allows them to focus on clinical care instead of payment activities, which currently consume about 15% of US health care costs.
  6. Drug prices and provider payment rates are regulated and negotiated centrally. This assures reasonable prices, not the outlandish levels so often seen in the US.

So … if the US is to learn from foreign experience, as it should, it’s not just about universal coverage. It’s about excellent identical insurance, with no profit motive, no or little cost-sharing for patients, simplicity for providers, and negotiated uniform prices. Our private insurers don’t and can’t align with these essential conditions. Ergo, single payer.

About the Commentator, Jim Kahn

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Jim (James G.) Kahn, MD, MPH (editor) is an Emeritus Professor of Health Policy, Epidemiology, and Global Health at the University of California, San Francisco. His work focuses on the cost and effectiveness of prevention and treatment interventions in low and middle income countries, and on single payer economics in the U.S. He has studied, advocated, and educated on single payer since the 1994 campaign for Prop 186 in California, including two years as chair of Physicians for a National Health Program California.

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