A sizable, but likely still a minority, of the population seems to think that the federal government should have sole responsibility for the funding and delivery of medical care in the US – ie, a single payer system. Many, if not, most people make up their minds about the provision of both medical care and politics on the basis of emotions rather than analysis. Nevertheless, it is useful to look how a single payer system is working elsewhere.
The National Health Service was established in the United Kingdom shortly after the end of WW II. It provides medical care for at least 90% of the British population. The remaining 10%, the most affluent citizens, pay the taxes that support the system, but go to private practitioners and hospitals for their medical care. To understand how the public and private medical systems in the UK operate go here.
The NHS has been popular since its inception both with patients and doctors. The latter have been very well paid since the beginning of the system. Recently, however, junior physicians (the equivalent of US resident physicians) have threatened to strike over low pay and long hours.
The NHS has struggled with increasing costs for decades as has virtually every medical system in the developed world. A system funded entirely by the government has only two ways to react to increasing costs. It can get more money from the government or limit the services it provides – ie, rationing. The former requires more taxes or diversion of money from other services. The latter means some patients will not get prompt treatment. Either eventuality is hated by the public. In a democracy, the result is flight from reality. All sides of the political spectrum will have their catchwords and slogans. But the basic support of the welfare state, of which medical care is the major component, will not be fixed until after it collapses. No other solution is politically possible. We’d rather have a lot of pain later than a moderate amount now.
Consider the recent response of parts of the NHS to rising costs and the subsequent reaction. The NHS (or a component thereof) will ban overweight patients and those who smoke from elective surgery until they lose weight or stop smoking. The clinical commissioning groups of of East and North Hertfordshire are under financial duress and are seeking to save £68 million during this fiscal year. Whether they can save the whole amount by denying care to those whose behavior they find objectionable is uncertain. But it’s easy to see where they’re headed.
You could expand the list of miscreants who do things that are felt to worsen their health to people with more than 1 or 2 traffic violations or to those who drink too many sugary drinks even if their BMI is less than 30. Thirty is the cutoff that the CCGs find actionable.
Of course the Royal College of Surgeons is outraged as they should be. But the basic problem remains. How to pay for ever increasing portions of medical care that are the inevitable consequence of an aging population and a delivery system that operates outside the border of a free market. Here’s the explanation for this rationing:
The CCGs already delay surgery for up to nine months for those with a high BMI, telling them to lose at least 10 per cent of their weight.
The new rules increase the amount of weight the heaviest patients must lose – and crucially, they mean those who fail to lose weight or give up smoking could wait indefinitely.
The restrictions mean those with a Body Mass Index of 30 or more will be set targets to reduce their weight by 10 per cent over nine months, with those with a BMI over 40 will be told to cut their weight by 15 per cent.
At the end of the nine months, any patient who failed to lose enough weight will have their circumstances “considered by a clinical panel” a spokeswoman said.
Those who have not lost enough weight could be left waiting indefinitely, she confirmed.
The CCG’s executives said they face a shortfall of £550 million by 2021 if they don’t ration care. They didn’t use the word ration. Do I have a solution that would work? Of course not. Once the government gives a benefit that its recipient thinks someone else is paying for, it’s forever – or at least to the death.
Most people think that medical care is a right. How much? Does one have a right to something that someone else is forced to pay for? Life liberty, and the pursuit of happiness do not require additional taxes or an increase in the public debt. But I’m making a losing argument. The best I can offer is – don’t put your faith in politicians. We’re in a medical mess and no one is going to fix it.
A couple of Shakespeare quotations come to mind:
Kill me tomorrow—let me live tonight! Othello Act 5, scene 2
Lord, what fools these mortals be! A Midsummer Night’s Dream Act 3, scene 2
Does not subsidizing self-destructive behaviour encourage more of it??? Eat, smoke, drink all you want as NHS takes care of the consequences. Incidentally, my English father-in-law had private insurance.
“A sizable, but likely still a minority, of the population seems to think that the federal government should have sole responsibility for the funding and delivery of medical care in the US – ie, a single payer system.”
This is an extraordinarily misleading and disingenuous statement. Virtually no advocates for a single payer health insurance program have proposed that the federal government take over “sole responsibility for the funding and delivery of medical care” in this country. It’s frankly such a fallacious assertion that it diminishes good faith in the reason and intent of any argument that follows.
First, administering an insurance program is not the same as funding medical care. With any kind of insurance, the premiums of those who pay into the program fund the expenditures, while some third party typically administers the bookkeeping. Currently, for-profit corporations administer most health insurance programs in this country, and their 30-35% cut is part of the cost of American health care. Advocates of single payer believe that not-for-profit insurance administration through the federal government lowers health care costs by eliminating the for-profit middle man. This is how Medicare for seniors works now (which is why single payer is often called “Medicare For All”).
Second, there is virtually no one proposing that our health care delivery system be taken over, in whole or in part, by the federal government. That all hospitals and health care facilities be run by the government? That all medical professionals and staff be federal employees? That our health care be delivered as a government service? It’s simply false to imply this is what single payer means. That the NHS functions that way in the U.K. has no practical application nor bearing on the debate about how to reform health insurance administration in the United States. (The only analogous program here is the Veteran’s Administration, and nobody’s calling for “VA For All”…..)
I expect your long experience as a physician has given you many interesting insights into health care administration. That alone gives your perspective weight and validity. There’s no need to erect straw men arguments, or misrepresent those you disagree with, to make your points.
I thought a long time about the phrase you find objectionable. It wasn’t in the first draft of the article. The reason I included it was that while the physicians and administrators who run our current system, are not employees of the government, they operate under so many rules and regulations that they are fast becoming de facto employees of the government. Under a single payer system autonomy would be completely lost and while the fiction of independence might be preserved, every hospital and practice would become an arm of the government.
Under the current system (50% government funded) a physician cannot write a prescription at a dose some low level administrator finds inappropriate. This is just one example of a system that has diverted the attention of the physician from the patient to the computer. It is wishful thinking to believe that the government can run any system for less cost than the private sector. Medicare boasts that its administrative costs are 2-5% compared to 20% for the insurance companies. In truth, Medicare has no idea what its administrative costs are as it passes almost all of them to providers as unfunded mandates. Can you really believe that a government will pay for a multi trillion dollar system without controlling how it operates while lowering its cost? Every medical system in the developed world is under intense financial pressure. Even the Swiss who have a relatively unobtrusive system have started to ration care. They have limited the frequency of screening mammograms as a cost saving measure.
I spent years working at a VA hospital (for free) and have a pretty good idea how they work and have even more experience with Medicare. This is just an opinion, but one based on a lot of experience – Medicare for all will be no different from the VA. Affluent seniors are already buying their way out of Medicare. See the growth of concierge medicine. Unless we go the Canadian way – mandatory Medicare for all – a single payer system will result in a two tiered system. One for the top 10% and another for the rest.