21 August 2007

Single-Payer: a Clarification

In response to my last post, The House Whisperer asks:
How do you reconcile this with your enthusiasm for single payer?

I am glad you asked. I would not, in fact, characterize myself as a single-payer enthusiast. This touches on a pet peeve of mine; in the medical blogosphere, there is this false dichotomy presented when health finance reform is discussed: either you are for single-payer, or you are against reform. There are literally dozens of proposals out there, none of which ential centralized planning or government-provided healthcare, and only one, "Medicare for all" is single payer. Medicare for all, championed by Democratic Congressman John Conyers, is not endorsed by any of the leading democratic presidential contenders. Yet there is this reactionary tendency of many in medicine and the med-bloggers to equate any fundamental health finance reform with their bete noir, socialized medicine. It's just not so.

I am an advocate for reform, and a passionate advocate for universal coverage. I am not exactly opposed to single-payer, but I am wary of it and think there are better possibilities.

So, to answer your question a little more directly, this move by Medicare to unilaterally impose "quality" rules/cost containment is a perfect example of the danger of a single-payer system. Where there is only one buyer of services, a monopsony (the inverse of monopoly), there will inevitably be downward pressure on the price of such services. As a provider (and consumer) of health care, that worries me. Medicare currently does not reimburse adequately for services provided to beneficiaries; further cuts will threaten the industry's ability to recruit talented providers and to invest in the technological infrastructure required to deliver high-quality health care.

As I have written before, a single-payer system like Medicare for all has a significant up-side. It would be more efficient in reducing administrative overhead (on both the payer and provider sides) and that efficiency would, at least temporarily, mitigate the escalation in health care costs. It would be universal, funded by premiums, and means-tested to allow coverage for the indigent and low-income classes. It would replace the god-awful patchwork of horribly underfunded programs for the poor that we currently have. It would still rely on private delivery of care by independent providers in a fee-for-service model. And it would de-burden American businesses from the cost of provideing healthcare. As a policy maker and a taxpayer, there's a lot to like there. If there were some way to insulate it from budgetary pressures, and if reimbursement were not guaranteed to go down, I could see physicians getting on board with it. But as it is, that's not likely.

I still remain enamoured with Wyden's Healthy Americans Act.

1 comment:

JimII said...

So what you are saying is that we can be smart about this. We don't have to do things in a bad way.

I think the desire to start using our government to come to sensible solutions is at the heart of the third-party craze, or the non-partisanship rhetoric. A sort of enough with ideology mood.