So why does it seem to me like it's so unlikely to happen in the near term? I've been thinking about the stakeholders in the issue and who among those stakeholders has the power. And my initial thinking has been that the power in the equation is stacked up against us. But that's based on my gut feelings, and the decade old experience I had working in for a Congressman involved in the health care reform debacle of 1993-94. It's time to think more critically about these assumptions, so I'd do a little thought exercise here today, sort of an informal stakeholder analysis. (Doesn't that sound like fun? C'mon, you know you love wonky exercises.) The key stakeholders I want to look at are consumers, providers, industry (insurers and pharma), and lawmakers.
More on the flip.
So who has the largest interest in this? We do. Consumers and, by extension, our employers who struggle to keep up with rising costs. Here's a good little assessment for 2004 from the Kaiser Family Foundation:
So why aren't consumers and businesses clammering for a single payer system? Right now they're at the mercy of the market manipulations of the pharmaceutical industry, medical equipment industry, and certainly the insurance industry. And here's the thing: we've been indoctrinated to believe that market forces will always result in healthy competition which will always result in the best price for the consumer. Unfortunately, the fact that this industry just doesn't fit that model hasn't seemed to sink in. People are still very wedded to the idea that a single payer system is tantamount to socialism, as well as to the notion that health care is inexoriably tied to employment. The other barrier as far as the consumer is concerned is how the system would be financed--or rather, what we call the system for financing--taxes. Never mind that the payroll tax for consumers and businesses would probably be a fraction of what they are currently paying in premiums, it's a tax. It's sending more of our hard-earned dollars to the government to mess up with. Which leads to the final big concern for the consumer. There is an inherent distrust of government in this populace. I think convincing them that a government agency is capable of effectively administering their health insurance is probably the most significant challenge. Even if you do get the majority of the people there, though, what about business? The Chamber of Commerce and National Federation of Independent Businesses seem pretty unlikely to embrace the idea. However, and this is a big however, a few more years of annual double digit cost increases for them might be enough to get them warmed up to the idea a bit.
Okay, now to providers, defined for my purposes as physicians (as a loose term for all health care professionals). Here's where the stakes get pretty high, particularly for physicians. In a single payer model, fees are generally predetermined, and in fact physicians' salaries determined by the government. That thought has to be pretty terrifying to someone coming out of medical school--particularly in one of the specialities. I'm not saying that doctors are in it only for the money, but because of their many, many years of highly specialized and difficult education and training, they expect to be able to earn. There is a definite potential disincentive for people to go into medicine if there is a limit to what they can earn. Certainly not for all physicians, but undoubtedly for some.
On the other hand, the bureaucracy and the overhead for operating an office would decrease substantially. Imagine what it's like for your run of the mill doctor's office today. They probably deal with at least a half-dozen different insurance companies a day, not to mention Medicare and maybe Medicaid. Every company has different forms. Every company has different levels of payment for different treatments. Sorting all of that out takes time and takes human resources. Dealing with just one agency would certainly make life simpler for providers at that level. Does it outweigh the "self-determination" factor I pondered above? Probably yes, for some doctors.
Now we get to the real crux of the problem: the health care industry and the folks feeding at their trough--our lawmakers. It's a sick, symbiotic relationship that will be very hard to sever. Opensecrets.org provides a little bit of perspective here. The pharmaceutical and health products industry spent $14.5 million this election cycle (2/3 went to Republicans). The insurance industry spent $30.7 million (more than 2/3 to Republicans). These two industries spent more money when combined than any other sector in both the House Energy and Commerce Committee and the Senate Health, Education, and Labor Committee. A single payer health care system would effectively end the way these industries have been doing business all these years. Which would in turn dry up a significant source of income for many of our most prominent Members of Congress. Call me a cynic, but in my opinion, this is the singlemost significant force working against the adoption of a single payer health care system in the United States.
I do think there is probably some potential for a strong grassroots movement, particularly if it could be combined with the weight of business, to move the ball forward on this issue. But I also think that it's going to take a concerted public education effort to get that movement off the ground, and I think it's going to be a long, slow process. How we get started is a question for all you organizers out there. I'm certainly open to suggestions!