Cost of Single-Payer Healthcare in the US: A Systematic Review

Cost of Single-Payer Healthcare in the US: A Systematic Review


we’re about to start everybody in the
physical room and those of you who are joining us remotely we’re about to start fantastic good afternoon my name is
Ninez Ponce and I am the Director here at the UCLA Center for Health
Policy Research based here in Los Angeles welcome to today’s seminar, “The
Cost of Single-Payer Health Care in the US: a Systematic Review. We welcome our
guests Dr. James Jim Kahn who came all the way from San Francisco or Oakland or
Berkeley but from UCSF and one of our Center faculty associates and great
allies and collaborator Dr. Michael Rodriguez for this timely discussion. Health care reform and how to best approach it have consistently been at
the center of the US political discussion not just today or last month,
but for the past few decades. From fights over preserving or building on the
Affordable Care Act, to talks about implementing what is known as medicare
for all single-payer system all sites have been weighing in on how to resolve
the nation’s health care delivery and ultimately perhaps a spending crisis.
This talk will highlight findings from a recent study by researchers at UCLA, UCSF,
and UC Berkeley which shows that this healthcare system could save e US money over time the single-payer
system this findings may shed valuable insight in informing healthcare planning
in California and serve as a model for universal health care in the nation and
importantly this talk is part of our ER Brown Symposium series named after our
founding director Rick Brown this started in February of last year where
state and international experts such as Jim Kahn, Michael Rodriguez, Jerry
Kaminski, Tom Rice, here in the room presented data on lessons in the United
States and in other countries on financing approaches to get us to
universal care if you’re interested in today’s slides you can request them from
our communications department at the email address shown on your screen and
please stay tuned for announcements on our upcoming seminar on Wednesday
February 19th on addressing the aging population and the needs of older adults
with Dr. Ritu Sadana, Senior Health Advisor at the World Health Organization
Ritu is based in Geneva self-proclaimed
double Bruin and is a big supporter of the UCLA Center for Health Policy
Research so let’s begin today’s discussion with Dr. Khan. Jim. Thank you,
Ninez and thank you for inviting me thank you to the Center for inviting me as well it’s
great to have the opportunity to talk about this research and to hear some
feedback. Let’s start with the situation in the United States
this shows the percentage of US adults without health insurance from 2008 to
2018 back way back in 2008 about 15% of adults were uninsured that increased
steadily to a peak of about 18% and then the Affordable Care Act began that
dropped this number down to about 11 percent in 2016 and then it started
to rise and it’s currently at about 14% the reason for this coming back up is
the way the Trump administration has dealt with the ACA there was an initial
attempt to repeal the ACA entirely this failed by one vote how many of you
remember john mccain sticking out his hand and pointing down at 1:00 in the
morning I haven’t always been a great John McCain fan but in that moment I
certainly was. John McCain felt that the process was irresponsible by failing to
think about what would come next unable to repeal the Trump
administration has pushed for retrenchment on multiple fronts, the
individual mandate was repealed as part of the 2017 tax cut and then the Trump
administration fostered non-compliant health plans. So the ACA is a private
plan enhancement is built around defining what is a plan that that
protects consumers that is compliant and requires all ACA plans to meet that they
had one narrow exception a 30-day temporary plan that didn’t have to
comply the Trump administration has taken that 30-day exception and extended
it up to 364 days essentially offering a year-long alternative to the compliant
plans this has not been taken up widely but it could be and would undermine
patient protections. The Trump administration has also attempted to try
to restrict subsidies for the near poor to get insurance many states including
California have worked around that and restructured the subsidies to keep them
in place and finally not on this live there is a case working its way through
the courts which attempts to declare the entire ACA unconstitutional we’ll see
how that comes out aside from the issue of how many people are uninsured there’s
the issue of under insurance this slide shows the makeup of employment based
insurance it’s work that’s done annually by the Kaiser Family Foundation the very
dark bar at the right shows the percent of plans that are high deductible plans and starting in 2008 you began to see this in employment based
insurance and now we’re up to about one third of people who have insurance
through work have high deductible plans it’s becoming much more common and the
level of the deductible is also becoming more significant this shows on the on
the right the two bars on the right what percent of these deductibles are more
than a thousand or more than two thousand dollars way back in 2007
seventeen percent were a thousand or more over time this has grown so that as
you can see as of 2018 of those with a high deductible plan 35 percent have a
deductible between a thousand and two thousand and an additional 19 percent
have a deductible of more than $2,000 why do we care about this because it
matters to access to care. This graph shows that more than 2 of 5 adults who
are underinsured report problems getting needed care because of cost so the blue
bars are the people who are insured Oh II here and not under insured you can
see their current but it’s fairly low the big brown bar is for people who are
uninsured the middle bar which is a sort of I guess of an orange color is people
who are insured all year but who are underinsured and you can see that being
unable to get care due to financial barriers is quite common in that group
and not getting care may mean of course increased morbidity and perhaps
mortality let’s take another look at the US healthcare system how do we finance
it, our system is financed 43% through official public programs this includes
Medicare for the elderly and long-term disabled Medicaid for the poor the
Veterans Administration military health Indian Health Service and many many
state and local safety net. This 43 percent is primarily federal with
substantial state and local contributions. 34% of healthcare is paid for
through private insurance employers contribute about two-thirds of those
premiums employees about one-third and in addition family spend about 12%
out-of-pocket but there’s an important footnote, the public share of spending is
actually about two-thirds that’s because some of the private insurance that you
see listed there is actually paid for by government employers so when the federal
government state and local governments hire someone using public money and buy
private insurance for that individual that really is public money an
additional addition there are substantial tax subsidies for companies
to provide insurance for workers when you add this all up two thirds of the
spending is actually public. So we have thousands of insurance plans, these leads
in many cases to poor access to care partly because of financial barriers
partly because of highly restrictive networks and also a poor choice of
providers. The billing is burdensome is this an area that’s a special interest
of mine if anyone wants to talk more about it I’d love to and our systems
for price negotiation are fragmented and imbalanced in other words there are many
many insurers and many many providers and as a result these negotiations are
not very effective particularly because some of the providers like hospitals are
getting bigger and bigger and able to demand higher and higher payments so we
have no effective cost controls so taking all of this into consideration
how does the US do against other wealthy countries how many of you can
find the US on this graph this is a wonderful graph I didn’t invent this but
I love it it starts at the lower left in 1974 the vertical axis is life
expectancy the horizontal axis is health expenditure per capita per year as you
can see the vast majority of countries have this sort of slightly tilting
bouquet to the right where life expectancy has risen
durably since 1974 and prices have also gone up the US by comparison has a
much lower increase in longevity and a much higher rise in prices in my work in
decision analysis and cost-effectiveness analysis that’s called a dominated
solution it’s worse and more expensive so the question is how could we do
better so some of us myself included have a vision for a single-payer
approach to paying for health care that involves universal high-quality coverage
which eliminates the financial barriers that I mentioned and uses simplicity and
price negotiations to reduce costs while also removing the role of profit from
the system. By universal high quality coverage I mean everyone is covered
cradle to grave with broad benefits and wide choice of provider eliminating
financial barriers means no deductibles at all and low or no co-pays a topic of
discussion with progressive financing meaning the rich pay a higher percent of
income to finances and using simplicity and price negotiation means you have one
payment system you negotiate fair prices for providers and similarly fair prices
for drug costs to bring them more in line with what’s available in the other
wealthy countries the question then arises can we afford this? Can we pay for
this expansion of coverage and so on and so we decided to look at all of the
existing economic models of the cost of single-payer and we did a systematic
review this is the team Kris Chi was the lead author and Chris not here today but
when I call out the incredible work that he did and also want to call out the
fine collaboration over our to UCLA colleagues who are sitting right here
thank you. This is how we approached it we searched of course we searched in
PubMed but actually where we got the most yield
was in Google why because very little of this literature is in the peer review
journals almost all of it is grey literature we also reviewed past lists
of single payer studies we looked at all the references in the studies we found
and we sent out an email inquiry to experts we included studies that were
about single-payer and had adequate technical information to assess input
values and results of there were some studies that didn’t just have that much
information so we excluded studies that were economic studies but weren’t about
cost maybe they were about how to finance or other issues and we excluded
studies who are not really single payer even though they might say they were for
example if they anticipated a role for private insurance a central role for
private insurance that was outside of our working definition of single-payer
and again if the reporting was inadequate we also made a practical
decision not to include studies from the same analysts on similar plans and we
went in and check that method and you’ll see in the appendix that we saw there’s
little difference between the excluded and the included studies. Our final sample was 18 studies with 22 analyses several of the studies had multiple
analyses for variants of single payer we included both national and state studies
in the analysis we extracted the input values and the results and we
transformed everything to percent of current spending just to facilitate
comparison it’s very hard to compare Vermont and the United States if you’re
using the raw numbers. We then did a qualitative portrayal and did some
statistical analyses this slide is organized the 22 analyses are
organized from the far left is the one the studies that have the highest net
costs and the far right is the highest net savings the red bars show the
increase in costs because utilization increased because people have better insurance when you insure people or you remove under insurance you get more
utilization and that increases costs the green bars captures the savings I’ll
show you the detail in a moment but this is the total savings from administrative
costs and other things and you can see on the far left the red bar is bigger
than the green bar so for that study there was a net cost and you can see the
blue line that runs through the middle you can see that that that blue line
angles down to the right that’s how we organized this graphic. Our main finding
was that 19 of the 22 analyses found net savings in year one so right out of the
box year won 19 out of 22 found net savings with a median net saving of 3.5%
all of the studies suggested net savings over time because of controls on the
rate of ink the rate of growth in health spending this graph is organized by year
so the oldest study is on the left the newest study is on the right the red
bars again represent the increasing cost due to utilization rises the black bars
which you can see start always at the beginning of all of these studies
represent savings from administrative simplification and you’ll see black bars
in all of these studies the green bars represent savings from negotiating
prices for drugs and also medical equipment and you can see the green bars
show up in about 2000 and they’re in most of the studies subsequently in
other words most studies assume that we could decrease the cost of drugs through
negotiation done in in various ways the orange light orange bars appear at
the very end in some recent studies included shift over to Medicare payment
rates that’s something that not all of us agree it has has a role but it was
modeled in these studies and this is where we compared the
features of the analysis to the results again this one is organized from the net
highest net cost on the left to the highest net savings on the right so the
studies on the right are most optimistic about what we would find with
single-payer down below is a table which I’m sure you cannot read and so to
address that problem two things feel free to look at the article that’s
sitting in front of you or downloaded from the web but I also took a snapshot
and move it up a little bit so we can talk about one part of if you look at
the bottom of this table where it says savings the first line says simpler
payment administration you can see that all of the studies had some component of
simpler administration so they’re all yeses with two of them in yellow being
low and then drugs and equipment this is negotiating prices for drugs and medical
equipment you can see just kind of lean back a little I’m leaning back because
I’m close to the screen but you can see that the left side these studies that
showed higher net costs or limited savings did not include the drug price
reductions and on the right almost all of those cells are green and they did
include so there seems to be qualitatively some kind of connection
there but we took it to the next step with some statistical analyses and we
started with bivariate regression so your predictor is yes/no on various
questions and your outcome is the net cost or net savings we found that
co-payments for these studies did not have a significant effect on the results
including the undocumented on the results however meds and equipment
savings did have a significant effect I’m not sure you can see the line there
but the the point estimate shows that the net savings are greater and it’s
statistically different than the null so met medical and equipment savings are
important efficacy in fraud reduction not significant in Medicare
payment rates it’s also not significant that these are just bivariate I’ll come to
multivariate in a moment we also look as a suggestion of a determined reviewer at
funder type and announce analyst type so what we found is in these bivariate
regression, left-leaning funders as we could best categorize were
associated with higher net savings not entirely surprising I guess analyst type
academic studies found higher net costs I don’t know if that’s surprising or not
but the people in this room maybe or I don’t know let’s let that less
optimistic and sound higher net cost still net savings but not as not as high
we then did some regressions using continuous predictors that on the upper
left what you see is we compared the rate of increase in utilization so the
the estimated magnitude of the increase in utilization associated with going
from uninsured to insured and what we found is that the studies that had a
bigger jump in utilization had a lower net savings or a higher net cost in
other words if your utilization goes up more in your assumptions then your net
savings will be reduced not surprising the upper right administrative savings
also not surprising the bigger the administrative savings in terms of
quantitative magnitude the greater the net savings overall more administrative
savings means the system saves more overall similarly on bottom left graphs
see medical and equipment savings the bigger the magnitude of those savings
the more likely to have large net savings overall and then last one we
looked at which was efficiency in fraud reduction we didn’t find a relationship
there we then did do a multivariate regression but we had fairly low power
due to a relatively limited number of studies and quite a few variables that
we were including in the model what we found is
that net costs are associated with medical and equipment savings so more of
those than costs go down we found that administrative savings were not
significantly associated with net savings we were surprised I remained
surprised for someone who’s you know better statistician than me can explain
but that’s what we found again with a limited ability to do a multivariate
regression all of the other factors that we had looked at including a funder an
analyst type were not significant in the multivariate regression so the
conclusions from this review that we did were first that there is a broad
consensus in economic models that is among economic modelers that single
payer is likely to save money in year one and that these savings are likely to
increase over time that might well I’ll leave the next day’s to Michael and that
I will just say one last thing there’s some very new data that came out this
year about how much utilization changes in historic coverage expansions and what
these studies found is empirically is that utilization doesn’t go up it goes
up for the newly insured but it goes down for those who were already insured
in on balance it doesn’t go up that might suggest that if these models
included a much smaller utilization increase that the net savings might go
up now in terms of talking about the implications and limitations and global
context for all of this I turn it over to my colleague Michael. Thank you so
much Jim for that excellent presentation queuing me up to underscore one of the
main implications of this study being that that in spite of the concerns that
many people and organizations may have about the potential costs of
single-payer this study underscores that as opposed
to increasing costs all the evidence supports savings most significantly
associated with medical medications savings but also we saw that
administration even though it’s not significant in the studies is also as an
important factor this is important not only because of the cost factor but in
fact we would be able to cover the 27 plus million people who currently are
uninsured that’s important agreement from the future yes as we say out of the
mouth we love that as in all studies there are limitations
and so this slide mentions the major limitations that that to be found in the
study including the variety a range of methodological rigor the fact that
quality rating scores this was brought up by one of the reviewers were not
applied although we could not find any quality rating systems in order to to do
that there’s no domestic empirical example that is there is no single payer
here in the US that we could use to test these economic models the study was
focused and limited to proposals of single-payer as was mentioned it’s time
limited this search period ending in December of 2018 and and what was not
taken into account was the one-time transition costs which are estimated to
be about 18% which is much much smaller than the overall costs of
the system and and so all of these suggests that one direction for us to go
is to do some state experiments or demonstrations to help us get some
better information now for the global context when we think about this from a
bigger the bigger picture we really go back to just after World War two when we
when the world had recognized the atrocious ways that different people are
being were being treated not only because of the war but for other reasons
and the 1948 Universal Declaration of Human Rights was passed it was passed to
set the bar for all peoples and nations so that we could have some decent
standard of living for everybody and that included medical care the right
also to healthcare is embedded in many national constitutions so that coverage
for everybody is a right and it’s not simply focused as a benefit that
employees receive when we think I’m glad to hear that support for that and also
when we’re looking currently more and more support globally is for universal
health coverage to be the global health priority in fact the United
Nations has agreed to try to achieve universal health care by 2030 to
underscore the importance of that as we drive forward for development globally the reality here in the US is that the
US is the only one of 33 developed countries without a universal health
care system that’s the bad news the good news is that it provides us
with opportunities to learn from all those other countries and and we can
learn about how to reduce fragmentation how to implement payment procedures as
simple as in other countries – two methods to reduce drug prices
from our current very high levels and also how to use data-driven and dynamic
clinical data to reduce inappropriate care. Just a note about single payer and
terminology you know it is a one of the most prominent types of universal health
care models the the single payer a there’s there so the type that is where
the government provides free health care paid with revenue from income taxes this
is frequently referred to as the national program that comes out of came
out of the United Kingdom but it’s also used by Spain New Zealand and Cuba. The US
currently offers the type of that to military personnel the other version of
single parasol’s is the national health insurance also known as a single-payer
type uses public insurance to pay for private practice every citizen pays into
the national insurance plan and Canada, Taiwan,South Korea, use this model
and then there’s that mandatory or social health insurance model where
countries use social health insurance that that requires this model requires
every person to buy the same type of insurance and with the same type of
it’s countries that use this include Germany France Belgium Netherlands Japan
and Switzerland and so why single-payer well many of us feel that it provides
greater efficiency due to the administration less lower administration
and purchasing costs as well as drug costs and the other ones that were
mentioned in by Jim the greater equity everybody gets the same
in contrast US. costs are currently impossible to sustain all countries
agree on equal affordable access to healthcare. Health is a human right
everyone should be able to access good quality health care services when they
need it wherever they need it without fear of
the financial consequences for themselves their families their
businesses and their jobs thank you why’d you come on up so we can address
any questions might that might come up my audience here as well as our audience
that’s out there virtually. complex health care delivery system
insurance companies there is industries and lots of lots of people working in
that and then switching from that current to the proposed single-payer has
consequences potentially costs I’m not sure can you expand a little bit about
how we might get there sure so the transition is is really important if you
look at past instances for example Taiwan the
transition was made in Taiwan after a period of planning the transition was
made in 9 months so quite quickly if you look at
implementation of Medicare the United States also almost instantaneous you
have to remember that the transition we’re talking about is a different way
to pay for healthcare we’re not changing the healthcare delivery system that
would be a far greater undertaking so the question is you know do you want to
do it that way there are others who argue that we should have some interim
steps and in fact Elizabeth Warren proposed recently that before even
trying to pass single-payer we should fix the gaps in Medicare and expand the
age range they down to 55 and all children so that people can you know
really get a sense for what it would look like and then two or three years
down the line make the final jump to single-payer so there are various ways
to do it the only method that I hesitate about is if we say well why don’t we you
know want to do a public option that’ll be on the way there and I’m worried
because doing something like a public option is plenty of legislative and
regulatory work and you know we’ll only add to the complexity of the current
system and I wonder I would worry that we would get stuck but this is all
crystal ball stuff exactly how to get there no one really agrees on I think I
hope that the kind of evidence it’s accumulating such as we summarized will
help convince people that we need to move to that planning step thank you
both for this great presentation I’m wondering in the data collection process
did the issue of campaign financing come up and the reason I’m asking is this in
this country the wealthy have a great influence as donors on elected officials
who vote and make decisions on policy and as you stated the wealthy would be
taxed at a greater rate to finance this system arguably wouldn’t
the wealthy influencers if they’re going to have to pay more rather keep a system
in place where they can pay more and private pay and not worry about changing
the status quo how do you did you look at this and what influence might this
have in extrapolating the experiences of other countries to say this would be our
experience a political feasibility and political strategy Michael I think
that’s going to be in your camp right well I mean I can say a few points I do
want to acknowledge that there’s a wealth of experience and expertise in
this audience itself that could sort of fill the rest of our time discussing
that easily but Sir I agree yes issues of wealth and influence over politics is
extremely important which is why the sort of health sort of finance reform is
one that has been proposed many times it’s challenging because those people
who are benefitting from it are asked to vote against it right and so so that has
been a major challenge in getting that passed regardless it is extremely
important why people such as yourselves should be engaged and why there’s
several movements underfoot organizations efforts around the US and
elsewhere in the world as I mentioned for single-payer and for universal
health coverage in the US we have organizations such as the physicians for
national health program we also have organizations in California such as
California one care these are organizations that can help to bring the
voice of people and data such as when Dr. Kahn was presenting to put that in
to serve the policy that we need thanks I enjoyed the presentation very much I
was curious about the whole profit thing so you put in the beginning that the
idea to take profits out of the system then you had a examples of
single-payer you came as an example where there wasn’t really for-profit
organizations Canada as an example of national health insurance where a care
was provided private privately what would you say I get that there wouldn’t
be profits there wouldn’t be a for-profit insurance sector under the
proposal what happens to the other for-profit entities which are rife in
the United States under the proposal so this is a point of discussion among
people who study and think about an advocate for single-payer many argue
that at a minimum we need to remove absentee stock shareholders so if you
have a you know a capitated health system which is permitted under most
versions of single-payer that I’ve seen it can’t be owned by in a for-profit way
by absentee shareholders there needs to be a structure that doesn’t allow anyone
to profit by say suppressing utilization I’m not as comfortable
talking about the the ins and outs of what constitutes acceptable profit
clearly there going to be some situations where you know the owner
might be a physician owner of a practice it’s going to make a profit is going to
make more money that’s fine but it’s it’s avoiding a corporate structure
where where I think that it it bears more strict rules and careful scrutiny have any of your team or others are
aware of thought about the constant if there are any constitutional issues
involved in saying that there can’t be us a for-profit company involved in say
medical imaging not that I’m aware of although one of my
colleagues has estimated how much money would be required to buy out the
existing floor profits so that it wouldn’t be any unconstitutional taking
of of that so so a little bit but I’m not sure that anyone’s had done a full
exploration of that I wanted to follow up on something Jim you just alluded to
with regard to the role of capitated plans in a single-payer system so one of
the questions that I get asked most frequently and I’m always a little
puzzled because it’s not clear to me in some of the proposals that are currently
out there is how’s kaiser fit into a single-payer system what are your
thoughts and because I’ve never really I’ve looked at at senator Sanders
proposal quite thoroughly I can’t really discern a definitive answer to that
question from the existing proposal beyond intense ongoing debate among
single payer advocates about you know whether to allow for kaisers in the
short hand and my feeling is that we live in California we know that Kaiser
is very popular among many people who choose to be in Kaiser and among many
providers and many I won’t say most cuz I haven’t counted but many single-payer
airplanes do allow for capitation and therefore would allow for salaried
physicians collecting under an umbrella such as Kaiser to continue to do what
the Medical Group at Kaiser and the hospital does at Kaiser the Kaiser
insurance plan part would go away but Kaiser would would continue to exist and
would prosper and if and if we could convince Kaiser of that fact and we get
their support on single payer so far we haven’t. That last question was from Dr. Jerry
Kominski the senior researcher here at this Center and
senior fellow and also the former director of the UCLA Center for Health
Policy Research so I’m going to switch to the online questions okay if that’s
okay so one question is a tweet a this is you tweaked and improved
healthcare for all okay so the whole point is we want to get it to universal
coverage but it will create significant efficiencies in a delivery of health
care in America has a likely overall reduction with healthcare for all and
the current resource intensive environment environmental carbon
footprint of the for-profit US healthcare system transportation
materials etc has happened researched and estimated. Climate change issue, if I
understand the question properly. I want to try but you can jump in I know
very little about this and I’ve been working on single payer systems for a long
time and this is the first climate change question I would I would say
that there is some potential for a mild mitigation you’re talking about saving
money money is resources resources resource use in various ways as what
causes climate change we’re not burning coal in the hospitals but you know
people work they drive to work you have to have buildings and and so on the
other thing that is interesting to me how many of you are health services
researchers who have used claims data bet datasets for something so yeah quite
a few people in the room it seems to me that the claims data that we could get
from single payer will be a significantly more useful quicker more
consistent more complete and if that helps us find wasteful practices and
even fraud that we might further reduce costs and with that perhaps help the
climate I don’t think we’re going to solve the climate crisis by single payer
I don’t want to over claim today just to add that there are potential
benefits certainly of having one system and and and that’s such a system guided
by wise people could incorporate practices and policies
that helped to reduce the sort of the inefficiencies and be conscious about
the environment and so those things could happen they are happening right
now amongst many different companies and they actually need to continue to expand
as such practices need to happen throughout the rest of the system and
the world you know I just want to answer a question you didn’t ask am i allowed
to do that relates to climate change I have a colleague who said I like
single-payer but I think it’s a huge mistake to invest political capital in
single-payer when we have a much more existential threat in front of us
climate change and I was surprised to hear that objection and I thought about
it for a while I talked to some colleagues and I and I ended up with
this formulation we need to do both obviously if we can get our acting gear
to deal with climate change many people will still argue that it was
always a false alarm anyway and all the things we did really didn’t make a
difference it would have gone away anyway if we get people health care it
will be clear that we’re getting them health care and it will build social
solidarity which may be the critical piece to get the to responding to
climate change so that’s my formulations thank you that was not my question
that was one of the questions and so the audience but there are a number of
questions so let me start with continued choice opponents are already using this
I promise you can keep your plan and your doctor to raise fears about single
payer can you address access and choice as a factor in your single-payer
analysis did you assume MD and Hospital reimbursement would stay the same? So
first of all in terms of MD and Hospital reimbursement aside from the few plans
which I showed you that included a reduction to Medicare payment rates
otherwise the the analyses assume a blended payment rate of current payment
rates which I think is right now there would be some reduction to capture the
administrative savings but that’s because there are savings to to to
capture and now I forgot what question was, I’m sorry. choice the
other choice was another part of it so and there’s a wonderful op-ed in The New
York Times a few weeks ago by a gentleman by the name Wendell Potter
Wendell was a very high-level health insurance official to about ten years
ago when he decided to decamp to the single-payer community and
advocate for getting rid of it insurance companies why he did that you can read
about and see a movie about but his piece in The New York Times reviewed
this whole notion of taking over the idea of choice that’s been attempted by
the insurance companies and they make it trying to make it about choice of
insurance plans as an American right and who wants choice of insurance plan no
one really does they want choice of doctor and that’s preserved through the
single-payer system under this most single-payer plans of support long-term
care both institutional and home based or community based care we just had a
conference if anyone’s interested as of this morning our conference videos are
almost up on YouTube we just have to do some tweaks and if you want to hear a
twenty minute no forty minute discussion of long-term
care and its role under single-pair that’s one of the videos it’s from my
chair Jack Needleman Department of Health
Policy and management it sounds like one of the reviewers your use of single
payer is not standard most discussions of single-payer are Medicare for all
single insurer a private delivery system what you have called single appear is
usually characterized as a national health plan or system like that in the
UK or Sweden. Luckily he’s not my chair and I can say that’s not correct what we
looked for is is a single-payer literally a single-payer with with the
services provided by both public and private providers but he knows how to
find me, I am happy to dhat right well anyone here in the room while
I scroll through the rest thank you I have two questions one is so
I did my my masters in Canada so the first time I got here what I what I
heard was so you’re so lucky that you were here now because you have more
choices and you have you know there’s amazing novel system and so I feel that
there is this perception of entitlement to have all possible types of care and
when we consider when we compare what we have in the US with other systems we
have a much shorter list of procedures that are paid by the state so for
example I don’t know like imaging testing for low back pain so in the
British in British Columbia for example now they’re not paying for this so and
this can create like a huge backlash to move towards a single-payer system in
the sense that now all the pressure of course contain payment will be on a
single actor the government so how do you see this pressure and another
question is when we see the uniqueness of the US we talk about universal
health care coverage and the ACA correct me if I’m wrong with it it was like a
movement toward a national insurance social science model in trying to get
closer to that idea so do you to use think that going for a
single-payer system is an abandonment of the ACA idea or it’s a more actually
progressive and shocking proposal so two questions one is about cost control and
the other is about what the ACA was leading us towards I would I would not
agree that the ACA push the sort of social insurance model it added some
elements of that there also greatly strengthened the hand or the private
insurers so it was taking us further on the mixed model in fact obama explicitly
said that if he was starting over he would probably
favor single-payer but given where we were that the path was leading there was
path dependence and then we should sort of continue on that path so I think it’s
pursued a mixed model including you know government social component in terms of
cost control this is not this is actually nice that we’ve looked at the
evidence I showed you some of it from other countries clearly we failed at
profit cost control compared to all of the countries that have either
single-payer or a single mandated plan that and then with the government acting
as the as the negotiator monopsony single buyer sure it could be that the
experience of 35 other countries doesn’t apply in the United States we are
special after all but in my business and it’s evidence-based medicine I think
it’s not a terrible assumption that this tells us a way to go. Jim would you mind
talking a little bit about the administrative cost savings of this
change and comment further on the results of the multivariate analysis but with the easy part the multivariate
analysis again we had you know limited sample size and quite a few predictors
and my colleague Justin, who’s a co-author and a fine economy attrition
you know did those analyses and you know they they are what they are a lot of
things were not significant and at least one of them an administrative
association between administrative savings and overall costs not
significant I don’t understand why but but we you know if someone’s a better
statistician the me can help answer my medical school colleagues question
Jonathan the the second was about administrative cost I’ve done work which
suggests that that we’re wasting about four hundred billion dollars a year that
was quite a few years ago so it’s going up some colleagues just published a
paper that they estimate six hundred billion dollars a year in unnecessary
paperwork in the United States and that’s the basis for great
administrative savings and and that work is done by comparing what happens here
for administrative costs to what happens in other countries the fraud reduction
sort of group together not a big one I actually I think and if others with with
experience in this area wanna chime in I encourage it what I gather from when the
Institute of Medicine looked at fraud and waste is number one it’s huge
could be twenty percent or more of our system number two it’s really hard to
get rid of which is why it’s 20 to 40 percent of our system it’s really hard
to define what constitutes a wasteful duplicated practice what’s fraud part of
that is because our data systems currently are so fragmented and so if
someone’s billing three different insurers each of them for 90 percent of
a full clinical practice none of the insurers can look at the other insurers
data and say how can you be working two hundred seventy percent so under
single-payer there may be opportunities to reduce that somewhat but my my
understanding as an outside observer is it’s really hard to identify waste and
fraud to the point where you can actually get rid of it significantly
thank you what about salaries I’m gonna combine two questions one is the cost
and pain of transition was one question and and then what will happen to two
salaries so the unintended constant transition from current system to single
payer and then question position costs and salaries my short-term memory is so
the biggest transition cost I mean there obviously would be IT costs so we need
to create that single billing system it’s gonna be orders of magnitude less
complex and what we have now but it’s it still needs to be created the other one
that people talk about a lot appropriately is what about the people
who lose their jobs because they’re currently doing the administrative work
that’s costing an extra half a trillion dollars a year and so a colleague of
mine Bob Pollin at UMass Amherst who also did a couple of the studies on this
list he looked at what it would take to retrain those people to help them retire
early etc etc and estimated that it would cost about 1% of healthcare
spending for each of three years so three percent of one year’s health
spending in order to properly cushion that transition you know it’s going to
be disruptive for those people I think many of us have experienced job changes
job loss career changes it’s not fun but with the right support the transition
can can happen in terms of I think physician salaries was another what do
you expect the impacts of a single-payer system beyond salaries and wages and
providers and health center well if we in fact use blended rates and in other
words we look at the the average payment for services now and just only for
administrate savings then people should continue to
get pay the same there are some specialists I am told who earn a lot of
money some surgeons who earn millions of dollars and if that were capped I
personally wouldn’t object but I also wouldn’t insist on it because that’s not
where the real savings are real savings are in getting rid of administrative
waste and the and what we pay for drugs and medical equipment has anyone looked
at the larger impact of bringing equal health care dollars per capita on the
economy of communities currently suffering as healthcare deserts seem to
me there’s a broader issue of economic greening of impoverished areas. Economic greening I’m not sure what’s
referred to as economic greening, yeah I think that the one of the major issues of the
United States is the inequity that we have kind of goes back to the comment
that was made earlier there’s a perception that in in a reality that
there’s enormous wealth in this country and that enormous wealth isn’t that
distributed equally and there are those folks who receive less services across
the board including healthcare and so certainly those those populations have a
potential to benefit from having more equal access to healthcare related
services than those who already are receiving it and and so from that
perspective it certainly would help to not only provide greater access to
healthcare but also greater access to potentially other related factors that
not only promote health but also promote the ability for them to perhaps perform
better in school work more productively and overall be able to be more
productive people to a society and to the economy okay this is gonna be the
last question that I think helps tie the two and still may leave us all with
questions after this provocative discussion, how do you propose to
guarantee a right right as you said Michael to health care when it must be
funded which conflicts with the definition of a right and what happens
when funding is not sufficient to pay for that right which has happened and is
happening in countries with single-payer systems so maybe that’s I think there’s
more but maybe sure I mean I’ll start and we can add others so on one level we
do that already we do that for public schools we do that for our protection
for the police departments we do that for our fire departments we do that for
the essential factors that we feel communities need to be able to sustain
and protect their people who are living there so certainly healthcare should be
included in that mix that have lost funding or you know what’s happening
with other countries there are always tough choices in many of these countries
there are political debates there are funding levels that some people think
are not enough but overall because everyone in the population is in the
same system and has therefore an interest in seeing the system work
adequately and fairly that that’s all worked out and as you saw in my graph
the costs are controlled and I didn’t show you all the the performance data
comparing countries but all of those other countries have essentially 100%
coverage much better access to providers and you know and as I noted better
better health outcomes so sure it’s a challenge but our system is a complete
fragmented chaotic mess and it’s not working so maybe we would do better to
have something that’s simpler and to make those challenges visible and
explicit and resolve them as best we can while being reasonably efficient at
transferring those dollars into health care thank you and let’s give our
speakers a hand today for providing us with resources on informative caught
this conversation on single-payer health care thank you

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