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Last week I wrote about health care priorities, and it ended up that a lot of people wanted to talk about health insurance, or the lack thereof. In that discussion I said that from my perspective, and looking at the survey results, we're a long way from getting anything like a single payer system in this country.

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.

First, let's establish what it is precisely we're talking about when we say "single payer." Here's a pretty good FAQ from the  American Medical Students Association. A basic definition: "the financing of health care expenditures for a nation's entire population through a single source, presumably the government, with funds collected through progressive taxation of citizens and businesses." Well that doesn't sound so bad, particularly when you read a little further to learn that "the United States in the only nation in both NATO and the twenty-four nation Organization for Economic Cooperation and Development (OECD) that does not extend medical coverage to all of its citizens." (But you already knew that, didn't you?)

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:

Employer-sponsored health insurance premiums increased an average of 11.2% in 2004--less than last year's 13.9% increase, but still the fourth consecutive year of double-digit growth, according to the 2004 Annual Employer Health Benefits Survey released by the Kaiser Family Foundation and Health Research and Educational Trust (HRET). Premiums for employer-sponsored health insurance rose at about five times the rate of inflation (2.3%) and workers' earnings (2.2%).

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. 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!

Originally posted to Joan McCarter on Fri Jan 21, 2005 at 07:23 PM PST.

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Comment Preferences

  •  Whooo hooooo!!! (4.00)
    Health care reform on a Friday night!!! Do we know how to have a good time, or what?
    •  Frame/Tipping Point? (none)
      "There is an inherent distrust of government in this populace."

      I think this statement lies at (or near) the heart of the problem.  If we can't trust the government to solve the healthcare problem, it can't be solved.  All the players are part of the problem, and it will take someone from outside who is big enough to be able to make the changes, to step in.  The only thing big enough is the government.

      This distrust of the government took root under Reagan - it was a major campaign theme of his.  And it is near and dear to the heart of the conservative movement.  Indeed, I would call it the basis of their ideology.  If we can get the population to reject this mindset, then the rest of the battles become easier.

      In fact, the populace already believes that government can solve their problems.  They've just been conditioned to forget it.  Every single citizen of the last 70 years has direct proof of the ability of government programs to solve serious problems - Social Security.  

      George Bush has handed us a golden opportunity.  If we can win the Social Security battle he has begun, and I think it's possible, then we can use that sea change to break the back of the conservative effort to convince people that government is the problem.  If we can show people just how successful SS has been, how low the administrative cost load is, that they get a very high value for the money that they spend on it, that their parents-grandparents-greatgrandparents live without fear of destitution because of it, then we have shown them that big government programs can be a good thing.

      I'm not saying it would be easy, and there are many ways that it could go wrong, but this battle has the potential to reward huge dividends.  The specifics of how to go about it I think is a topic unto itself, and I would love to discuss it further.  But I think this has possibilities.


  •  This issue, mcjoan,... (none)
    will take a tipping point.  The question is really, what is that point and, secondarily, when will it happen?

    Then, and only then, will we have a single payer system.


    This is a joke...right?

    by NYBri on Fri Jan 21, 2005 at 07:38:34 PM PST

    •  A much larger crisis (none)
      than we currently have. How much worse can it get?
      •  Where are the tipping points? (none)
        I keep asking myself, "How much worse can it get?" about everything this administration does...and the tipping point keeps getting farther and farther away.

        We need a "Mr. Bush, have you no shame?" moment, but I guess the answer has already been offered, and it's a resounding "No."

        Maybe the tipping point concept is wrong in this case.

        This is a joke...right?

        by NYBri on Fri Jan 21, 2005 at 07:59:22 PM PST

        [ Parent ]

      •  When it makes the wealthy worried (none)
        Seriously.  Hear about the mutation of the bird flu  that spreads person to person?  Modern medicine makes the wealthy think that they are immune from communicable diseases.  Public health, is likely to be a much more palatable justification for universal healthcare access, than recognition of human life and digniy as inviolable.  The emergence of communicable diseases that are easily transmitted by person to person contact, could convince the wealthy that allowing poor people to get sick means that they might be exposed to communicable disease.  Ask yourself, If Detroit rather than Toronto had been struck by SARS, would our half ass healthcare system have been able to contain it?  If it had Sars had spread amongst the working poor of Detroit, some of whom make fast food for surburbanties, would there have been an uncontrolled epidemic?
    •  tipping point (4.00)
      mcjoan mentions precisely in her post what the tipping point will be: high cost to employers.

      Frankly, I am shocked that corporations (large and small) haven't been screaming about rising health care costs over the past few years.  Health care costs cut significantly into profits and a government based "single payer" system was help the bottom line.  Besides costs, just think of all those trees we would save because of the reduction in paperwork!

      The odd thing that mcjoan mentions is how we have been trained to believe that if something is administered by the government that it is inherently bad (or socialists).  

      I used to be paranoid until I lost my self-esteem. Who is going to waste their time following me?

      by Mote Dai on Fri Jan 21, 2005 at 08:16:10 PM PST

      [ Parent ]

      •  aoeu (none)
        Some of the car manufactorers have been making noise about it recently.
        •  UAW (none)
          After you mentioned that, I remembered something that my dad just told me over the holidays while home.

          My dad works for Delphi, which used to be part of General Motors, so he still has health insurance that was part of a UAW agreement.  This used to be some of the best insurance in the country a union worker could get.  He used to be able to get any prescription, but now he is required to get a generic if it exists.  I know this doesn't sound like a big deal to most people, but it was a huge deal for him.  He said there have been grumblings in the company about the costs of health care.

          I used to be paranoid until I lost my self-esteem. Who is going to waste their time following me?

          by Mote Dai on Fri Jan 21, 2005 at 09:12:57 PM PST

          [ Parent ]

    •  I Question if this is a tipping point situation (none)
      I think this is something that our system has somehow been set up against.  IMHO, I think its going to require a lot of work on our part to push it through, and that of course means winning back the country.  Should be fun. :)

      To his virtues be very kind, to his vices, very blind.

      by Descrates on Fri Jan 21, 2005 at 10:24:09 PM PST

      [ Parent ]

      •  I agree (none)
        I don't think you can wait for a tipping point. This must be a strong grassroots effort as it was in my country, Canada. It was started by people like farmers, civic leaders, union workers, church goers, and others interested in fair health care for all.

        The father of Medicare, Tommy Douglas, was a man with a cause and he pushed hard. I think it's worth taking a look at the history of Medicare in Canada and how it came about along with our very simple principles outlined in the Canada Health Act.

        These are the 5 principles:

        The five criteria of the  Canada Health Act  are:

        • public administration: the administration of the health care insurance plan of a province or territory must be carried out on a non-profit basis by a public authority;
        • comprehensiveness: all medically necessary services provided by hospitals and doctors must be insured;
        • universality: all insured persons in the province or territory must be entitled to public health insurance coverage on uniform terms and conditions;
        • portability: coverage for insured services must be maintained when an insured person moves or travels within Canada or travels outside the country; and
        • accessibility: reasonable access by insured persons to medically necessary hospital and physician services must be unimpeded by financial or other barriers.

      We also have dispute resolution measures. Public health care is an organic issue in that it is ever evolving and growing in scope. It also comes with problems and constant pushes from the Conservatives for privitization - an effort rejected by the majority of Canadians.

      The US and its government are huge in comparison to Canada but, I believe if you fight for very simply identified principles, such as those defined by our Health Act, many Americans who might write off a health care solution as too complex, will actually be able to go along with these clearly stated goals.

      The US must look to other countries with public health care in order to form a successful movement. There is absolutely no need to reinvent the wheel and the public must be convinced that it's not too late to change the system.

      Sidenote: our physicians are paid according to a fee schedule but that doesn't mean we don't have wealthy doctors here. You can research that issue for more details. Also, some provinces like mine (Alberta), charge health care premiums in addition to the taxes pooled by governments for health care. These premiums are much, much less than what Americans pay and are waived for the poor.

      This issue is extensive, but it's not a hopeless goal. In my opinion, Democrats could move successfully to a single payer system but, as you stated, they must be willing to cut their ties with the industry lobbyists. I agree that this is probably your biggest stumbling block but they need to understand that being in the pocket of industry is not a liberal value.

  •  Some thoughts from a provider (4.00)
    Hey, we DO know how to have fun on a Friday night, don't we?

    I'm a general internal medicine doc, spent quite a few years working as medical director of a small, hand-to-mouth community health center, and lately have been working at VA facilities.  I've watched my peers in private practice struggle and lose control of the profession as it has been transformed into an "industry", and have tried to focus on giving quality care for all without regard to ability to pay.

    Almost all providers--a few wingnut ideologues aside--believe in universal access to health care. Most don't really know how to get there, though many do a fair amount of free care as their personal contribution.  I've had to study the system a little more closely as a result of my work experiences, and have some observations to make on this subject.

    1. Administrative costs are killing health care.  Numbers for administrative costs as a proportion of total costs in most private health care systems run in the 15-18% range.  Compare this with the 3-4% figure usually cited in the VA system, the largest single-payer (or "socialized medicine") system in the country.  In a $1.5 trillion sector, you can see that this adds up.  The vast majority of administrative costs consist of insurance companies trying to avoid paying money, and providers trying to get paid.

    2. Drug costs are skyrocketing.  We are prescribing more and more medications for more and more people. Drug costs are going up every year, and efforts to restrain drug spending are miserably ineffective.  Again, the VA is an exception.  THEY negotiate prices--hard--and consequently pay the lowest prices in the country, almost at Canadian levels.  They also limit which drugs can be prescribed (to enforce the cost savings), but provide a good representative sample from all necessary categories.

    3. Medical reimbursement is extremely uneven.  The huge costs of surgical procedures compared with primary care (where most truly effective health care is delivered) are an ongoing scandal.  I make maybe $100 for a 45-minute physical exam; an ophthalmologist makes $2000-2500 for a 10-minute cataract operation.  But the physical exam is where most of the important stuff happens: diet and exercise counseling, treating blood pressure and cholesterol and diabetes, screening for cancer, coordinating specialty care, and counseling on the fly.  

    4. Health care coverage is feast or famine.  Many people in this country have excellent coverage.  Many have little or none.  It's as if you have a choice between a Cadillac and walking.  The VA, on the other hand, gives almost all vets a perfectly serviceable Chevy.  Community health centers give out a fine vehicle for people who can barely afford to fill the tank.  Even the Cadillacs are having quality problems these days, of course, and we need to focus on reliability more.

    Single payer systems as proposed tend to equalize health care access and spending.  They (can) shift the focus to basic primary care.  They offer the opportunity to control drug costs.  They dramatically decrease the huge, wasted administrative costs.  They relieve businesses of a huge and growing burden, as mcjoan points out.  That's why almost every country has adopted them.

    They're not perfect, of large bureaucratic enterprise can be.  But what we have now is a damn sight less perfect.  It's the obvious, correct solution to the growing crisis in health care.

    Democrats, if they're smart, will seize the opportunity to be bold in proposing a broad single-payer health care reform, with a fair and equitable financing structure.  Some preliminary framing of Republicans as big-business whores and corrupt liars would help deflect the inevitable Harry-and-Louise propaganda attacks, but things are reaching the point where people will no longer be fooled by the lies in any case.  Make health care reform one of the 3 or 4 central planks of a new Democratic agenda, and you'll be on to a winner.

    Don't ask a question unless you want to hear the answer.

    by Dallasdoc on Fri Jan 21, 2005 at 08:00:14 PM PST

  •  nothing sexier (4.00)
    than a wonk on a Friday night ...

    ""All things entail rising and falling timing. You must be able to discern this." - Miyamoto Musashi

    by Madman in the marketplace on Fri Jan 21, 2005 at 08:28:39 PM PST

  •  It's (relatively) easy to sum up what's wrong (none)
    ... and why any of several SP systems would be better. But that's not the problem. You can repeat this analysis over and over, and you'll get the same solution: single payer.

    The trick is finding a political trajectory that results in implementing the right solution ... or even a better solution.

    One step in this direction is stakeholder analysis, especially in conjunction with a candid look at history: why do the wheels come off every time we try to move this reform wagon?

    Here's a clue. At any given time, the collective health care finance crisis has only a very small number of us (on the order of 1%) in conditions of intense disadvantage. [To make matters worse, a substantial fraction of these individuals won't live to see the next election.]

    Meanwhile, the rest of us (on the order of 100% of likely voters) experience only diffuse disadvantage -- elevated costs, inconvenience, competitive disadvantage, elevated risk of crisis (but not crisis itself).

    At the same time, we're all subject to realistic suspicion that the next grand scheme might not work out so well, or might not work out so well for us. And that's enough to keep us from jumping into the unknown.

    This is aggravated by general American faith in markets and distrust in government.

    It's also aggravated by the fact that about half of us have bargained -- explicitly or implicitly -- for health care as a benefit ... and the next grand scheme would void this bargain without giving us back any of what we traded away (direct compensation, job satisfaction, etc).

    Cranking up the volume of argument for single payer will not get us over or around any of these frictional impediments.

    You are asking parts of the right questions ... but you might not like the answers well enough to accept them.

  •  Can Single Payer be achieved w/o Feds? (none)
    Do you think multiple manufacturing states could join in a regional single payer system for competitive purposes?

    The news from GM the other day that healthcare costs were hurting profits got me thinking about manufacturing and healthcare. If you look at this map of manufacturing peaks the entire rust belt (PA, OH, IN, MI, IL, MO) had a peak of manufacturing jobs in over 30 years ago. So what? Union health insurance was pretty good compared to what people have today. More than most Americans these states see the effects of the current broken system.

    I wonder if a summit of State Governors and a campaign using the state referendum process could get Michigan, Illinois, and say, Ohio to pool costs and systems into one big single payer unit (with the supplemental private coverage the wise Docs mention upthread)? I'm guessing 85% of healthcare and wellcare costs could be achieved with about 2/3 of the current expenditures if the profits of Big Pharma and administration costs are reduced.

    CAW, the northern equivalent of UAW, is a huge supporter of public health in partnership with the Canadian versions of GM, Ford and Daimler-Chrysler. They estimate is $4 per labor hour is saved versus American competitors. What happens when the remaining choice manufacturing jobs head North? I think savvy politicians have an opportunity to act now on something like a regional single payer system, for all the usual reasons of good health and for the financial and political reasons of maintaining economic advantage.  

  •  a possible intermediate step or two? (none)
    I will skipp over Dean's proposal to do something modelled on what the Federal government gives its employees.  That is in effect a single payer, with lots of options, and avoids the problem of laying off lots of people who work for insurance companies.   But it still does not address one of the real problems, which is the administrative costs.

    So, as someone who worked in data processing for 20+ years b efore becoming a teacher, including a brief stint working on a system for U of Penna Hospital, let me offer a transitional suggestion.

    Find a wsay [I'm not yet saying how] to require all health care providers to use the same codes, the same accounting package, etc.  This would in all likelilhood more than halve the adminstrative costs expereinced by single physician and small group practices.    I know doctors who refuse to accept certain health care plans because they don't want to deal with so many different sayw of reporting.

    I used to joke, 15-20 years ago, that I cut cut health care costs by giving every doctor in America a laptop computer loaded with the same reporting forms, and requiring all the third party payers to accept it.  If anything the problem is now worse.

    BTW, I like the idea of approaching this as a public health issue.  If anyone does not have access to regular preventivie mdeical care, then we are all at risk at seeral levels.  First, the chance of infectious diseases spreading is greatly increased.  Second, those people without access to regular medical care are far more likely to wind up in emergency rooms, where the cost of treatment tghis astronomically higher, and which cost is foten passed on to tghe rest of us in the insurance premiums and hospital fees paid on our behalf.  

    One other thought   ---  this could be included as part of a larger campaignthat educates Americans to realize that in many ways we are not the richest or best-off nation.  We may hae a higher per capita consumption than just about any other nation.  But on other measures  -- life expectancy, infant mortality, level of education, overall public health  ---  we rank pretty far down when compared to our industrial competitors.   We can also make this an issue of economic competitiveness, and get the backing of many corporate interests.  They realize that a healthy workforce is a more productive workforce, and that concerns about family health issues also decreases productivity.  But the way things are now, there is a race to the bottom when it comes to corporation's willingness to provide adquate and affordab le access to health care, because that additional cost makes their products and services less competitive when other profviders do not provide health care or provide it, as does Wal mart, at a level that costs the company very little.

    Were this built into a national policy which also reduced the adminstratitive costs and the costs of necessary prescription drugs, we would then be competing among ourselves [American corporations] and with economic competitotrs on a far more level playin field.

    IANAE  [that means I am not an economist], but it seems to me that this issue is addressible on economic grounds, and is one that has real biting power politically, although Americans are fairly discouraged that our political elite will ever address the issue.  Remember, part of why Clinton won in 1992 was health care, which his administration then promptly messed up as an issue and as a policy.  Still, it is, along with education, one of the two almost universal issues in domestic policy.  

    Those that can, do. Those that can do more, TEACH!

    by teacherken on Sat Jan 22, 2005 at 05:07:58 AM PST

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