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NY Times Tantalizingly Close On Health Care Financing Issues

July 20, 2023

Summary: This week, a profile of challenges facing the UK NHS and an op-ed proposing universal coverage in the US got so many issues right. But they critically missed on pivotal pillars of successful health care financing: adequate funding and comprehensiveness of coverage.

A National Treasure, Tarnished: Can Britain Fix Its Health Service?
New York Times
July 16, 2023
By Mark Landler

As it turns 75 this month, the N.H.S., a proud symbol of Britain’s welfare state, is in the deepest crisis of its history: flooded by aging, enfeebled patients; starved of investment in equipment and facilities; and understaffed by doctors and nurses, many of whom are so burned out that they are either joining strikes or leaving for jobs abroad.

Health care spending rose by an average of less than 2 percent a year from 2010 to 2019, compared with 5.1 percent from 1998 to 2008. Britain spent less a year per person on health care than the wealthiest European Union countries during the decade of austerity, and now has fewer doctors and hospital beds per capita than its European neighbors. Its capital investment lagged the bloc’s average by $41 billion, according to the Health Foundation, which tracks the industry.

We’re Already Paying for Universal Health Care. Why Don’t We Have It?
New York Times
July 18, 2023
By Liran Einav and Amy Finkelstein

There is no shortage of proposals for health insurance reform, and they all miss the point. They invariably focus on the nearly 30 million Americans who lack insurance at any given time. But the coverage for the many more Americans who are fortunate enough to have insurance is deeply flawed.

Health insurance is supposed to provide financial protection against the medical costs of poor health. Yet many insured people still face the risk of enormous medical bills for their “covered” care. A team of researchers estimated that as of mid-2020, collections agencies held $140 billion in unpaid medical bills, reflecting care delivered before the Covid-19 pandemic. To put that number in perspective, that’s more than the amount held by collection agencies for all other consumer debt from nonmedical sources combined. As economists who study health insurance, what we found really shocking was our calculation that three-fifths of that debt was incurred by households with health insurance.

What’s more, in any given month, about 11 percent of Americans younger than 65 are uninsured. But more than twice that number — one in four — will be uninsured for at least some time over a two-year period. Many more face the constant danger of losing their coverage. Perversely, health insurance — the very purpose of which is to provide a measure of stability in an uncertain world — is itself highly uncertain. And while the Affordable Care Act substantially reduced the share of Americans who are uninsured at a given time, we found that it did little to reduce the risk of insurance loss among the currently insured.

It’s tempting to think that incremental reforms could address these problems. For example, extend coverage to those who lack formal insurance. Make sure all insurance plans meet some minimum standards. Change the laws so that people don’t face the risk of losing their health insurance coverage when they get sick, when they get well (yes, that can happen) or when they change jobs, give birth or move.

But those incremental reforms won’t work. Over a half-century of such well-intentioned, piecemeal policies has made clear that continuing this approach represents the triumph of hope over experience, to borrow a description of second marriages commonly attributed to Oscar Wilde.

Coverage needs to be free at the point of care — no co-pays or deductibles — because leaving patients on the hook for large medical costs is contrary to the purpose of insurance. A natural rejoinder is to go for small co-pays — a $5 co-pay for prescription drugs or $20 for a doctor visit — so that patients make more judicious choices about when to see a health care professional. Economists have preached the virtues of this approach for generations.

But it turns out there’s an important practical wrinkle with asking patients to pay even a very small amount for some of their universally covered care: There will always be people who can’t manage even modest co-pays. …

Finally, coverage must be basic because we are bound by the social contract to provide essential medical care, not a high-end experience. Those who can afford and want to can purchase supplemental coverage in a well-functioning market.

Keeping universal coverage basic will keep the cost to the taxpayer down as well. It’s true that as a share of its economy, the United States spends about twice as much on health care as other high-income countries. But in most other wealthy countries, this care is primarily financed by taxes, whereas only about half of U.S. health care spending is financed by taxes. For those of you following the math, half of twice as much is … well, the same amount of taxpayer-financed spending on health care as a share of the economy. In other words, U.S. taxes are already paying for the cost of universal basic coverage. Americans are just not getting it. They could be.

We … were struck — and humbled — to realize that at a high level, the key elements of our proposal are ones that every high-income country (and all but a few Canadian provinces) has embraced: guaranteed basic coverage and the option for people to purchase upgrades.

Comment by: Jim Kahn & Don McCanne

The profile of UK NHS challenges is vivid and compelling in portraying the financial and associated operational and clinical problems plaguing that system. And, buried deep into the article, they do mention, in passing, the reason: “Health care spending rose by an average of less than 2 percent a year from 2010 to 2019, compared with 5.1 percent from 1998 to 2008.”

Let’s be appropriately blunt about this: The Conservative Party (the Tories) are intentionally bleeding the system, since 2010 putting the NHS on austerity footing. See HJM discussion here. Privatization is driving up family financial burdens and increasing mortality.

Thus, the crisis is intentional, policy- and politics-driven. The good news is that there is a good chance that the Tories will pay a steep political price for this evisceration of the popular NHS.

Turning to the US: Wow, Einav and Finkelstein got so much right. The health insurance system is fundamentally broken, unfixable. We need free, universal coverage. Just what we in the single payer movement have been saying for decades. Just what all other wealthy nations do.

But wait, “basic”? What does that mean? The article doesn’t elaborate (their book, to be released later this month, lays out some principles if not a definitive definition …).

We don’t like the sound of it. If “basic” means “access to under-funded and over-stretched providers,” that’s a recipe for a two-tiered system with divergent political interests, like we have for schools. If basic means excluding a subset of medical services, what would we comfortably omit? Not a good solution.

On the other hand, if “basic” means “everything necessary for quality medical care, and no fluff” that could be fine. As long as “medical care” includes inpatient, outpatient, drugs, mental health, dental, vision, medical equipment … everything medically indicated. That’s what other countries do: supplemental insurance is typically just a few percent of total health spending, for example providing access to private hospitals or specialists in a system with excellent public care. Long-term care should be in the “basic” category too.

We think it will be impossible to define “basic” narrowly in a way that is medically sound and doesn’t lead to operational and political fractures. The good news is, we don’t need to be stingy. Analyses of single payer demonstrate that we can provide standardized, comprehensive coverage and still save money for the system and for households.

Our colleague Ed Weisbart put it very well: “Two-tiered systems become as underfunded as the UK’s National Health Service, and outcomes degrade. We’re either all in this together, as a society that looks out for each other, or it’s Game of Thrones for us all.”

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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