To my fellow progressives: Single-payer is good, but unnecessary
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I’m as left-wing as the next guy. When it comes to single-payer, sign me up. Among my progressive brothers and sisters, it is fast becoming an article of faith that single-payer is the goal. ObamaCare, at best, is a way station on the way to something like Medicare for all. I try to maintain a data driven, evidence based approach to public policy, and when I look at the top healthcare systems, I see a hodgepodge.

Single-payer is not universal among universal healthcare systems.

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What is universal is finding the U.S. well back in the pack on all objective rankings, usually last among first-world countries — on both cost and health outcomes. The U.S. spends the most per capita on healthcare, around $9,000, about a third more than Switzerland, the second highest spending nation.

 

For that expenditure, according to the Commonwealth Fund, “The U.S. ranks last overall with poor scores on all three indicators of healthy lives — mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60.” In second most expensive Switzerland, at least you get what you pay for. It’s ranked number three on the healthy lives scale. France, which spends a relative pittance of $4,000 per capita, ranks number one.

But even though all of our peer nations have universal coverage, single-payer is far from universal. Among the countries in the Commonwealth comparison, only three of the eleven have a single-payer system — Canada, Australia, and the UK.

The others are a mixed bag.

Norway is a hybrid system, with national funds being administered through regional authorities. France is a multi-payer systems, with several rather than one tax-funded payer funding care. In Germany, two-hundred non-profit insurers cover 90 percent of the population, although 10 percent of people above a certain income level can opt for private for-profit coverage. The Netherlands has private insurers competing for premium dollars (with public insurance covering long-term nursing home care), but signing up for insurance is mandatory, and the insurers have to provide an essential benefit for all at the same price.

The common thread is mandatory coverage — whether by taxation or individual mandate. Implement mandatory coverage and the universal outcome is lower costs and better outcomes. (Most, although not all, are also run on a not for profit basis).

American exceptionalism aside, there is a virtually universal acceptance that healthcare is not a commodity that can be efficiently peddled in a market based system.

If there’s only one drug that will cure you, where is the competitive market? Maybe there will be competition down the road after the patent expires, and you are, unfortunately, dead. And if you live in a rural community with one doctor or hospital, where’s the competition for your healthcare dollar? Not in the hospital a couple of hundred miles up the road.

Which brings us to the Swiss system, which I like to call ObamaCare the way it’s supposed to be.

The Swiss have a rigorously enforced individual mandate. If you don’t sign up for insurance, the government can impose penalties of 30 to 50 percent above the premium and garnish your paycheck to cover any arrears. In the U.S., in 2016, the 7.1 million people who opt to pay the ACA non-enrollment penalty will fork over a paltry $969 per household, according to estimates by the the Kaiser Family Foundation.

In Switzerland, there is nothing like single-payer or socialized medicine. It’s all paid for by private insurers, who, as is the requirement with the ACA, have to provide an essential healthcare benefit. But the big difference is that the essential benefit has to be provided on a non-profit basis. Insurers still can make money.

They can sell you coverage for benefits such as private room, orthodonture, or alternative medicine. In effect, the essential benefit, non-profit plan is a loss leader — that cheap gallon of milk in the back of the supermarket that gets you to walk past the steaks. And that “gallon of milk” is indeed very affordable. For an adult, premiums average around $465 a month, with low-income people receiving a subsidized premium reduction.

The conclusions of this brief comparative analysis are obvious.

To my friends on the left, single-payer is fine, but not necessary. What is key is that everyone jumps in the pool. As conservative economist, Stuart Butler, put it, in unveiling the Heritage Foundation plan in 1989 (before the Heritage Foundation forgot about it), “each household has the obligation, to the extent it is able, to avoid placing demands on society by protecting itself.”

It’s easy to reform ObamaCare if we have the will: Enforce the individual mandate with the penalty being the cost of the lowest priced Bronze Plan. If there’s no advantage to paying the penalty, everyone will sign up, and the rest of the problems will work themselves out.

To my adversaries, on the right. I can respect your intellectual honesty if you don’t believe in universal healthcare, just don’t pretend that access equals coverage. To say that I have the freedom to buy a policy I can’t afford is like saying I have the freedom to buy a Rolls Silver Phantom.

That’s a phantom, too.

Ira Rosofsky is a psychologist who has worked for years providing services in eldercare facilities. He is the author of Nasty, Brutish, and Long: Adventures in Eldercare, a memoir of his professional life, and the story of caregiving to his own frail, elderly parents. His writing on healthcare policy has appeared in the New York Times, the Los Angeles Times, and Salon, among other outlets. He holds a PhD from the University of Chicago.


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