Current Major Reform Proposals and the Single Payer Advocate

What, if anything, is there to recommend current health reform efforts to an advocate of universal, single-payer coverage? Assume, for the moment, that you support the adoption of universal, single-payer coverage in the United States. Let us say that you believe that everyone has a right to a decent and equitable minimum of health care, and that we as a society have a moral duty to ensure that everyone has financial and other access to such services. Under these circumstances, to what extent, if at all, can you reasonably support the current major congressional efforts to reform health coverage, and at what point if at all – and why – ought one to withdraw support?

Single Payer

Single-payer advocates in the U.S., such as Physicians for a National Health Plan, to take just one example, argue that present health reform efforts ought not even to be considered “reform.” Steffie Woolhandler of PNHP, for example, testified at a hearing at the President’s Council on Bioethics in 2008 that most of the health reform proposals being floated during the 2008 elections constituted “placebo” reform. For PNHP, the issue is that we’ve got nearly 50 million Americans who are uninsured, and who disproportionately suffer and die because they’re uninsured, in this country. Yet others get far more care than they need, and in fact more care than can do them any good. Coverage is not stable for most Americans. Private individuals and companies profit off the illness of others. As a result, we spend far more on health care than any other developed nation, yet fail to profit from it sufficiently, and in fact do much worse in many basic measures of public health than most other wealthy nations. Dr. Woolhandler believes that all necessary and effective health care should be free for everyone who needs it, and that it should be paid for via a nonprofit, national health plan.

Single-payer health care can look different depending on its foundational principles and how it’s instantiated. PNHP, for example, advocates universal access to comprehensive, publicly funded health care, free of additional charge to the public, provided by one’s own choice of providers, with policies set through democratic means. Many of its goals are similar to the goals of Canada’s Medicare program, which are public administration, comprehensiveness, universality, portability, and accessibility. PNHP, focusing on its American audience, pays particular attention to emphasizing free choice of private providers – a feature which, in this land that otherwise emphasizes choice, most insured Americans don’t currently enjoy through their coverage.

Incongruous Values

If you believe that everyone ought to have access to health care, that everyone will benefit by having universal access, and that we have a duty to ensure such access by stewarding dollars in the most effective and efficient means possible, then single payer looks like a pretty reasonable way to go. Indeed, it – or, perhaps, another form of universal coverage, such as one that uses a heavily-regulated system of nonprofit insurers who set provider payment rates through all-payer negotiation and who accordingly also do not restrict their beneficiaries’ choices of providers – would be just about the only reasonable way to go. As Joseph White and others have detailed, we have little evidence that the private market has improved health care costs and delivery in this country in recent decades.

But, if you do not assume everyone has an equal right to health care, regardless of ability to pay, and if you give less priority to the role of social solidarity, and perhaps also regard health care primarily as a consumer good, then single payer can start to look rather problematic. This is where we find ourselves in this country, where a distinct subsection of the population believes that justice, or at least distributive justice, in the case of health care among other items, entails allowing each person to keep the fruits of his or her own labor and accomplishments, without redistribution of the wealth.

In the United States, the values that we tend to prize are not ones that would at first glance favor a single-payer, Canadian-style system, but rather something far more like what we’re presently seeing going through Congress – an at-times incongruous amalgam of conflicting values and ends. Distributive justice in health care in the United States is a curious notion. On the one hand, most would agree in principle that health care should be equally available to all, and that we should strive to make it so. We do provide a substantial amount of care through public means or charity, and most of our coverage is tax-subsidized or -advantaged. Yet few of us have guaranteed coverage, and if we go without, the public often considers this to be our own fault. The substantial role of the government in the provision, financing and regulation of coverage tends to be obscure to most casual observers. Additionally, most of us obtain our health insurance through work, which appeals to our notion, whether real or fictional, of equality of opportunity and meritocracy in action. According to these notions, those of us who have coverage through employment do so by dint of hard work, intelligence, perseverance or other traits, and many of those who lack it do so because of a failure of effort, will, or other issue.

This becomes clearer through an examination of polls asking the public about health coverage. A recent Gallup poll, for example, found that 61% of Americans believed that individuals, rather than the government, should be primarily responsible for ensuring that they and their families have health coverage. And while a plurality or majority of Americans, when polled, support national, tax-financed health insurance, the number drops substantially – to about 40% – when asked whether their support would continue if this entailed that all Americans would get their coverage from a single government plan.

These incongruous values and beliefs pose a problem in implementing any health coverage system with a relatively homogeneous set of underlying values. We can’t simply decide that a given form of coverage is abstractly best suited to accomplish certain policy and ethical goals, and then implement it accordingly. Rather, like Daniel Callahan noted in a somewhat different context, we need also to look to the structure and values of the society in which we’re proposing that such a change come about. What we presently do, and what we ultimately decide to do with respect to health reform, as the late Senator Kennedy observed, says much about us as a society. We can continue on our present path, or we can choose to more clearly opt for one set of values over another.

Values in Major Current Coverage Reform Proposals

Current health reform efforts in Congress – or at least the ones getting all the publicity – prioritize many if not most of the same goals we presently further through our health coverage system. We all know what’s going on in Congress right now. All the health coverage reform bills under serious consideration now in Congress build and expand on our present, fragmented, and largely private but substantially publicly funded health coverage system. They would require everyone to obtain coverage, largely through the private market, give subsidies to lower- and middle-income Americans, and expand Medicaid. While a public plan option for Americans who don’t have coverage through work appeared dead as of August, chances are looking slightly – _slightly_ – better for its passage, though it’s still likely that it won’t make it in any final bill that might be enacted.

Under any of these proposals, justice in both of the senses I outlined earlier will continue to be only partially served: while more people will have access to coverage, in part through redistribution of the wealth, many others will not due to inadequate subsidies in a market that will continue to be private and for-profit. Social responsibility will exist via copious tax subsidies and public program expansions, but the labyrinthine nature of the system will continue to obscure the effect this could otherwise have on fostering solidarity, instead allowing many to continue to believe, whether correctly or incorrectly, that coverage is provided for the most part via one’s own efforts and financing. Lastly, the treatment of health care as a commodity from which to profit will continue with little if any abatement.

So to what extent, if at all, could a pragmatic single-payer advocate support the major features of the primary congressional bills under consideration, as making sufficient improvement, however flawed, to the present system while also laying at least some groundwork, if not a foundation, on which to ultimately achieve their goals?

Obama and the Democrats who wrote the major House and Senate bills deliberately chose to keep the current system more-or-less intact. They feared that, if they attempted wholesale change, Americans who presently have coverage – the majority – would oppose them and kill reform altogether. It was a pragmatic move, as many have observed. But almost no matter how one defines what it means to have an adequately functioning health coverage system, the one thing nearly everyone, on any side of the political spectrum, can agree on is that our present system isn’t working. If the reform fails to make certain key changes or additions to the system, particularly regarding benefit plan and capital investment regulation, provider payment reform, and security and affordability of coverage, then a tremendous opportunity will have been lost.

All the major bills under consideration include a mandate that individuals obtain health insurance, or else pay a penalty. Additionally, all of them except the Senate Finance bill also contain some form of mandate that employers provide coverage for their employees. While the House bill penalties have some teeth, the Senate penalties for failing to obtain coverage for oneself or provide coverage for one’s employees are minimal in comparison to the price of insurance. In exchange, they require insurers to guarantee issue and renewability, to institute modified community rating, and to set minimum benefit standards for the individual and small group markets. They also provide subsidies for people buying coverage on the nongroup market to ensure that coverage costs for them don’t exceed a certain percentage of their gross income, say between 2 and 12%, depending on the bill.

Now, these mandates could be quite reasonable if, for example, health insurance plans were tightly regulated in the benefits they offered, if plans jointly negotiated provider payments, and if prices were kept within the legitimate means of all Americans, whether through subsidies or otherwise. After all, in the absence of universal, government-provided coverage, we would need some way of ensuring that everyone obtains coverage, thereby spreading the risk most broadly and, ideally, helping to avoid financial disaster for those who incur substantial medical costs. But the proposed subsidies are pretty meager for middle-income Americans. The expectations regarding the maximum appropriate percentage of income for individuals to pay for health coverage are not reasonable, and they don’t include all out-of-pocket expenses. Administration of the credits will not be simple, and will require Americans seeking them to also seek and undergo eligibility determinations. All-payer negotiations aren’t under consideration. And the ability of risk-spreading mechanisms to accomplish what they’d need to do is questionable at best. If you advocate universal, single-payer health coverage, and believe that, as a pragmatic minimum, coverage must be genuinely affordable, cover most reasonable and necessary medical expenses without substantial out-of-pocket expense, and must provide relatively uniform and stable access for everyone, then these provisions simply don’t do the job.

The Medicaid expansion poses other issues. On the one hand, the proposed expansion eliminates eligibility categories and protects the lowest-income Americans from the heavy out-of-pocket expenses they’d otherwise incur if they were instead forced into the private market for coverage. Both make sense, and deserve support, particularly from supporters of universal coverage of nearly any form. However, nothing will be done to ensure adequate provider payment. Given that the Medicaid expansions will ultimately cost states substantially more money, because the population covered will expand dramatically in most states, this practically guarantees that providers will continue to be poorly reimbursed in relation to other plans, and hence likely reduce access for Medicaid beneficiaries. The disparate access it will likely engender would be difficult for even the most pragmatic and compromising single payer advocate to swallow.

Then there’s the public plan. Not only did the Senate Finance committee not include a public plan option in their bill, but the White House went to some lengths over the summer to indicate that, while it supports a public plan option, it doesn’t consider it to be an essential part of any legislation that might ultimately pass. If you’re a single-payer advocate, then a robust public plan option, one with cost controls and that’s available to a wide range of Americans, is essential. If the public option were successful in providing decent, stable and affordable coverage, it could provide a basis on which ultimately to expand. This, of course, is precisely what single-payer opponents fear, and why they’ve vociferously blocked such an option. Then again, this is what was originally said about Medicare, and it’s been nearly 45 years now without such a transformation. Nevertheless, a public option won’t likely make it into any bill that’s ultimately passed, even if only Democrats are on board, except perhaps in a very attenuated form.

So where does this leave our pragmatic single-payer advocate? Community and solidarity are little to be found in any of the bills under consideration. While they do reform some particularly ugly features of our present health coverage system – and this is a good thing – they largely retain the fragmentary nature of our system, and give Americans little reason to feel jointly invested in it. While they improve the ability of many, particularly lower-income, Americans to obtain coverage, they hardly guarantee health security. People can still lose their coverage in any number of ways, and they can still go broke paying for medical care. Perhaps a very, very pragmatic advocate of universal, single-payer coverage could hold his or her nose and support at least the Senate HELP bill or two of the three House bills. But these bills run far astray from the principles such an advocate holds dear.