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Or the research technique described in the OP?
I, too, wish we had better candidates to choose between.
Mandated private insurance (in Germany it's generally through regional or industry-wide co-operatives, which is something I'm in favor of looking at; this was actually proposed by Baucus, of all people, and I wish it had gotten more attention) paying for most health care.
The big missing piece is we need prices from providers to come down; we spend twice as much per capita on physicians and two and a half times as much per capita on hospitals as the OECD average.
And as much as I hate to say this, Medicare is actually in the way here. Hear me out.
Private insurers mostly start with the Medicare rates as their basis for negotiations. But the Medicare rates have been subject to regulatory capture, because physicians and hospitals lobby Congress to keep their reimbursements high (google "Medicare Doctor Fix"
with the threat of accusing anyone against those rates of "cutting Medicare". Private insurers mark up those prices slightly to insure acceptance. But they're far too high (much higher than in Canada or Europe) to begin with.
For all of the problems with private insurance, its one big advantage is that unlike Congress, it can't be lobbied. That's why Germany and the Netherlands and Switzerland keep private insurance around. Canada, meanwhile, does this by a pricing board that is politically independent -- that's also a great idea.
But, at any rate, that is the magical step the US is missing: some board somewhere that sits around and says "A leg MRI can cost $500, period, no matter who's paying for it". (Or, alternately, we can pay providers by capitation, though that also has its own problems.)
What a disastrous idea that is. Didn't any legislator think that physicians would act in their personal best interests at the expense of the specialty?
And I agree in broad strokes, yes, even the medicare part. Unfortunately there is likely not going to be such an independent board because that actually could be cast as a government "death panel". Sometimes I think our country is reaping the just rewards of a poor education system, that we actually do elect the government we deserve. 
snip*Latest to step up is Paul Starr, co-founder of the American Prospect. Normally the dull embodiment of tepid liberalism, Starr has unleashed a redbaiting philippic — a frothing one, even, by his standards — aimed at Bernie Sanders.
Sanders is no liberal, Starr reveals — he’s a socialist. He may call himself a democratic socialist to assure us that he’s no Bolshevik — Starr actually says this — but that doesn’t stop Starr from stoking fears of state ownership and central planning. Thankfully the word “gulag” doesn’t appear, but that was probably an oversight.
Starr does have one substantial point — Sanders’s tax proposals wouldn’t be up to financing a Scandinavian-style welfare state. Taxing the rich more could raise substantial revenue, but nowhere near enough.
And part of the point of steepening the progressivity of the tax system is hindering great fortunes from developing and being passed on. A good part of the reason that CEO incomes have gone up so much since the early 1980s is that taxes on them have gone down; stiffen the tax on them, and there’s far less incentive to pay überbosses so much in the first place. It’s like taxing tobacco or carbon — you can raise revenue by doing it, but you’re also trying to make the toxic things go away.
But, really, you don’t need a Swedish or Danish tax structure to pay for free college tuition and single-payer health care, which are highly achievable first steps of a Sanderista political revolution. As I wrote back in 2010:
It would not be hard at all to make higher education completely free in the USA. It accounts for not quite 2 percent of GDP. The personal share, about 1 percent of GDP, is a third of the income of the richest ten thousand households in the US, or three months of Pentagon spending. It’s less than four months of what we waste on administrative costs by not having a single-payer health care finance system. But introduce such a proposal into an election campaign and you would be regarded as suicidally insane.
That last sentence turned out to be not a bad prophecy.
Starr really loses contact with earth when he writes about single-payer. In one sense, this is surprising, since he wrote a fat book on the history of medicine in America, and, although it was thirty-four years ago, is presumably still familiar with the territory. But the pressures of a political campaign often dislodge an apologist’s higher cerebral functions. That’s the only plausible explanation for why he wrote this:
Sanders’ single-payer health plan shows the same indifference to real-world consequences. The plan calls for eliminating all patient cost sharing and promises to cover the full range of services, including long-term care. With health care running at 17.5 percent of gross domestic product, Sanders’ plan would sweep a huge share of economic activity into the federal government and invite that share to grow. Another way of looking at single payer is that it would make Washington the sole checkpoint, removing the incentive for anyone else—patients, providers, employers or state governments—even to monitor, much less hold back, excessive costs. It would leave no alternative except federal management of the health sector.
Where to start with this? Why, as a matter of principle, should patients “share costs”? They’re already paying for the services with their tax dollars. According to Hillary’s “skin-in-the-game” theory, forcing patients to pay up will reduce demand, thereby keeping spending down, but this is a brutal form of cost control. Co-pays often force people to forego needed care, resulting in higher costs down the road, and more importantly, needless suffering.
A far more effective form of cost control is having the government use its buying power to demand lower prices from hospitals and drug companies. That’s the way it works in civilized countries, though that fact looks to have passed Starr by, probably because he was too busy trying to make precisely the opposite argument: single-payer would “invite that share to grow” by “removing the incentive for anyone else . . . even to monitor, much less hold back, excessive costs.” Just what is wrong with “federal management of the health sector”? Medicare does it for the over-sixty-five portion of the population; it works very well and is enormously popular.
Starr cites the 17.5 percent of GDP we devote to health care without putting that figure into any reasonable context — the sort of move that is supposed to provoke a “gee-whiz” moment of surrender. Here’s an interesting graph based on data from the Organisation for Economic Cooperation and Development (OECD), a Paris-based quasi-official think tank for the world’s rich countries. It shows the share of GDP devoted to health care for a subset of the OECD’s thirty-four members, divided into public and private. (Put them together and you get the total.)
?w=500
There are several striking features in this graph:
Most striking of all is how far ahead of the pack the US is: we spend 16.4 percent of GDP on health care, compared to a 10.1 percent average for all the other countries shown. (That’s the dotted vertical line on the right.) And recall that all those other countries cover almost their entire populations, unlike the US, where a tenth of the population is uninsured (and many of the insured have terrible coverage), with little change since the drop when Obamacare first took effect. (Gallup has 12 percent of the population uninsured, slightly higher than the Census Bureau, though with a similar trajectory of initial decline followed by flatlining.)
Another striking, though less obvious, thing is that US public spending alone, 7.9 percent of GDP, is just 0.1 point below the average of 8 percent. In other words, the government already spends as much as many other countries do while accomplishing far less. That 7.9 percent is also not much less than the entire health bill for Italy, Australia, and Britain, public and private combined.
Yet another striking thing is the outlandishly large share of private spending on health care: 8.5 percent of GDP, more than four times the average of the other countries and almost three times Canada’s private share.
Does all that spending produce better outcomes? Seems not: our life expectancy, 78.8 years, is three years shorter than the average of all the other countries.
So just about everything in Starr’s quoted mini-lecture about the real world is at odds with the real world.
There’s a perverse form of American exceptionalism circulating around the Clinton camp: just because things work in other countries doesn’t mean they can work here. As Hillary herself put it, “We are not Denmark. I love Denmark, but we are the United States of America.” True enough, but that has no bearing on why single-payer couldn’t work here. The only obstacles are political — elites, which include Hillary and Starr, don’t want it.
The rest of Starr’s piece is a highly unsubtle rant about socialism and how bad it is, even though Sanders isn’t really a socialist. That sort of thing may resonate with people who grew up during the Cold War — though not with all of us! — but it seems not to move the younger portion of the population, many of whom seem charmed by the concept. It’s not like capitalism has been doing all that well for them, really. But Starr doesn’t want to hear about that.
Starr also finds the style of Sanders’s politics in bad taste:
Sanders is also doing what populists on both sides of the political spectrum do so well: the mobilization of resentment. The attacks on billionaires and Wall Street are a way of eliciting a roar of approval from angry audiences without necessarily having good solutions for the problems that caused that anger in the first place.
But people have a lot to resent — why shouldn’t it be mobilized politically? And free tuition and single-payer are pretty good solutions for some of those problems. Starr just doesn’t like them. Best leave the tuition issue to some vague, incomprehensible scheme (that apparently involves lots of work study and online learning) and health care to a lightly regulated and generously subsidized insurance industry.
Establishment Democrats haven’t merely gone post-hope — they’ve declared war on it.
https://www.jacobinmag.com/2016/02/hillary-clinton-bernie-sanders-single-payer-starr-american-prospect-redbaiting-socialism/
Single payer in the Democratic debate
snip*Comment:
By Don McCanne, M.D.
Although today’s message does not seem appropriate for this forum since it is political and our agenda is on policy, actually it is apropos since it represents a disagreement over single payer policy, even though framed as a political debate.
Of the three candidates for the presidential nomination who have mentioned single payer, Donald Trump has recently clarified his stance by releasing a health reform proposal that made no mention of single payer. So the debate over single payer is really between the two remaining Democratic candidates - Hillary Clinton and Bernie Sanders.
In this election season, single payer is a political issue. Bernie Sanders is the first leading presidential candidate to support a bona fide single payer Medicare for all. Hillary Clinton continues to support private health plans in a multi-payer system, originally as her managed competition model 25 years ago, and now as incremental expansion of the Affordable Care Act. She opposes single payer since it would eliminate the private insurers.
The politics have been somewhat bizarre. The Republicans have not had to take a high profile position against single payer since many in the progressive community have done their work for them. Although often presented as policy arguments, the substance of the opposing arguments by these progressives has been political. We can only speculate that their reasons have more to do with their support of a particular political candidate than they do with their position on single payer. In fact, the leading analysis being used to oppose single payer was written by an academic who has authored other single payer proposals. Fortunately, many others in the progressive community have stood up to insist that single payer be accurately portrayed.
Instead of trying to wade through the proxy arguments of these outside experts, it would be better to listen to the words of the two candidates themselves. What did they have to say in last night’s debate?
Sanders reiterated his views on a truly universal Medicare for all, whereas Clinton reiterated her views on rejecting single payer and building on the Affordable Care Act which she mentions has us at 90 percent coverage. These are policy issues.
When you look at their respective plans (links above), you can see that, from a policy perspective, Sanders’ proposal automatically covers everyone, whereas Clinton’s proposals barely nudge us in that direction but cannot come close to universal coverage. In addition, Sanders points out that the current private insurance products frequently do not meet the needs of those insured because of the exposure to high out-of-pocket costs. Again, regardless of the politics, these are fundamental policy issues that often determine whether or not people will receive the health care that they need.
We’ll continue to speak out on policy and leave it to others to get the politics right.
Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.
http://www.pnhp.org/news/2016/march/single-payer-in-the-democratic-debate
Policy experts debate viability of Sen. Bernie Sanders’ health care plan
Southern California Public Radio, KPCC, Jan. 28, 2016
PNHP note: The following are excerpts from an unofficial transcript of a debate between Dr. Steffie Woolhandler of Physicians for a National Health Program, a practicing primary care physician and professor in the City University of New York School of Public Health at Hunter College, and Avik Roy, senior fellow at the Manhattan Policy Institute and current health care adviser to Marco Rubio. Only the remarks of Dr. Woolhandler, PNHP’s co-founder, have been transcribed here. A link to the full audio of the debate is provided at the end.
Host Larry Mantle (LM): So Bernie Sanders’ claim is that if you take the profit out of American health care on the insurance side that there are huge savings there. If the government can negotiate with a position of great leverage drug manufacturers, you can drive down prescription drug rates. And without Americans having to pay health premiums, that the taxes would essentially even out with the savings that would be provided. We’re going to examine that claim and talk about what impact overall Sanders’ proposal would have on the American health care system.
With us is Dr. Steffie Woolhandler with Physicians for a National Health Program, an organization that advocates universal, comprehensive, single-payer national health care. Dr. Woolhandler, thank you for being with us. We appreciate it.
Steffie Woolhandler (SW): My pleasure.
LM: So first of all, let’s talk about, just real briefly, how a system like this would work. It sounds like he’s saying this would work for everybody the way Medicare works for seniors.
SW: Yes, and actually it would work a little bit better than Medicare works. Canada does have a single-payer program. It covers 100 percent of health care costs, first dollar to last dollar, for doctors’ care, for hospital care. Some provinces have pharma care, some don’t. When you have pharma care then drugs are folded in as well. The reason Canada can do this affordably is because they get such huge administrative cost savings by eliminating private health insurance. Total administrative costs in health care are only about 16 percent of spending in Canada. You have to compare that to 31 percent of total U.S. health spending that goes for overhead and paperwork and administration. So the difference between those percentages is about 14 percent of total health spending that you can save through administrative simplification with a single payer is a huge amount of money, about $400 billion annually that would be freed up to improve care.
LM: Let’s talk about what the federal government, in expense, would have to do ramp up though, because already Medicare fraud is a huge expense to taxpayers. So presumably you’d have to bulk up the federal government’s capacity to investigate fraud considerably, you’d have to build a much larger federal infrastructure for health care. How would that cost compare to what the costs are for the private insurers.
SW: You’re absolutely wrong on that. In fact, if you have a single-payer system it’s potentially easier to identify fraud. So there was, for instance, a doctor in Canada who was billing for $125,000 worth of urinalysis tests, which is a ridiculous number of tests. That’s fraud. It was very easy to detect because all of the bills were sent to the single payer, and you could see what’s going on. So actually you’re in a much better position to identify and eliminate fraud if you have a single payer that sees all of the bills that the doctors and the hospitals send. The other thing I want to say is that we know how much a public bureaucracy costs. We can look at Canada, where the overhead on insurance is about 1 percent. We can look at our Medicare program, our traditional fee-for-service Medicare program. That overhead is about 2 percent. And you have to compare that to the overhead in private insurance firms which averages about 14 percent, but sometimes rises as high as 20 percent. So you get huge insurance overhead savings due to single payer, that’s not theoretical – we know it’s true from the data from our own Medicare program and the Canadian single payer.
http://www.pnhp.org/news/2016/february/policy-experts-debate-viability-of-sen-bernie-sanders%E2%80%99-health-care-plan
Policy experts give Hillary’s plan a passing grade?
Posted by Don McCanne MD on Thursday, Mar 17, 2016
http://www.medpagetoday.com/Washington-Watch/ElectionCoverage/56734
snip*review: Not a very exciting article. And that’s the point. When you read Hillary Clinton’s proposals, they all fall under the category of mere tweaks to our current dysfunctional system.
Tens of millions will remain uninsured; underinsurance will not be eliminated; Medicaid would be expanded without addressing its deficiencies in access; administrative excesses, including waste in marketing would increase; the undocumented would be allowed in without a way to pay for it; an ineffectual public option would continue to be offered through Section 1332 waivers; and so forth. Lower co-pays and deductibles along with a higher tax credit would be helpful, but to be effective, it would require significantly higher taxes when we have a Congress that continues to resist, on a bipartisan basis, any tax increases.
Although the title of this article indicates that the health policy experts cited give her efforts a “passing grade,” they basically do not see much more than fine tuning of the status quo. There is no suggestion that we could achieve reform goals of universality, affordability, increased provider choice, greater access, greater administrative efficiency, and optimal equity in the financing of health care.
Many of the Clinton measures proposed would further increase health care spending while falling short on goals. That would be a shame when instead we could place effective controls on spending through a single payer national health program – an improved Medicare for all – while achieving all of the listed goals of reform.
Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.
The ACA vs Single Payer - Accessibility, Affordability, Cost Control
Despite the ACA’s modest benefits, the law (1) will not achieve universal coverage, as it leaves at least 30 million uninsured (and 26,000 deaths/year), (2) will not make health care affordable to Americans with insurance, because of high co-pays and gaps that leave patients vulnerable to financial ruin in the event of serious illness, and (3) it will not control costs.
Why is this so? Because the ACA perpetuates a dominant role for the private insurance industry.
That industry siphons off hundreds of billions of health care dollars annually for overhead, profit and the paperwork it demands from doctors and hospitals;
It denies care to increase insurers’ bottom line; and
It obstructs any serious effort to control costs.
In contrast, a single-payer, improved-Medicare-for-all system would achieve all three goals – truly universal, comprehensive coverage; health security for our patients and their families; and cost control.
It would do so by replacing private insurers with a single, nonprofit agency like Medicare that pays all medical bills, streamlines administration, and reins in costs for medications and other supplies through its bargaining clout.
Research shows the savings in administrative costs alone would amount to $400 billion annually, enough to provide quality coverage to everyone with no overall increase in U.S. health spending.
Contrary to the claims of those who say we are “unrealistic,” a single-payer system is within practical reach.
The most rapid way to achieve universal coverage would be to improve upon the existing Medicare program by excluding private insurance participation (through so-called Medicare Advantage plans) and expand it to cover people of all ages.
There is legislation before Congress, notably HR 676, the “Expanded and Improved Medicare for All Act,” and HR 1200, the “American Health Security Act,” which would do precisely that.
Polls show such an approach is supported by about two-thirds of the public and a solid majority of physicians.
What is truly unrealistic is believing that we can provide universal and affordable health care in a system dominated by private insurers and Big PHARMA.
Healthcare under the Accountable Care Act
Yes, there are some good things about the ACA – insurance will be available to half of
those who do not have it now, there will be some limits on insurance company abuses,
preventive medicine will get a boost, there is money for new community clinics, and more.
But overall, the ACA facilitates the corporate takeover of medicine.
Corporate takeover of our medical system and the ACA
Private insurance is strengthened by millions of new patients with gov’t subsidies – increasing money for political influence and the power to obstruct serious efforts to control costs.
Increasing horizontal consolidation of health care payers – insurance companies buying each other, increasing their influence and bargaining power.
Increasing vertical consolidation of healthcare – hospitals now employ 70% of physicians. Insurance corporations buying hospitals, doctors groups and ACO’s equals physicians as “assets’ working for corporations.
Pressure on providers to increase the corporation bottom line pitting investor interest vs. their patients’ interest – increased workload, decreased staff help, deteriorating doctor/patient relationship, career satisfaction and quality of life.
ACA - more people will have insurance, but the new standard is underinsurance
Increased deductibles, co-pays, and coinsurance remain barriers to using insurance and seeking health care. US has highest rate of unnecessary deaths and decreased life expectancy due to healthcare barriers.
ACA will not the affect the rate of personal bankruptcies (Massachusetts experience), foreclosures, and family financial disaster for those who develop a significant illness.
ACA - exchanges are not equitable
Four plan options (Platinum, Gold, Silver and Bronze (Lead)) with different coverage, premiums and out of pocket expenses. Families with lower income levels will choose the cheaper plans (actuarial values covering only 60-70% of expenses) with less coverage and more exposure to financial disaster.
ACA - wishful thinking on cost control measures
EMR – studies show increased cost from upcoding and more studies ordered in hospital systems. More provider time required.
Health IT/Evidence-based medicine – may be good for patients but hasn’t been shown to decrease costs.
Chronic care management – may be good for patients but hasn’t been shown to decrease costs.
Pay for Performance – no studies show no decreased costs or increased quality. Sets up competition between doctors. Easily gamed by upcoding and avoiding caring for high-risk patients.
.
ACO’s (Accountable Care Organizations) – no track record that can be generalized to ACA’s future costs. Wishful thinking that it will control costs and improve quality, given past negative experience with the similar HMO’s and with the increased corporatization the ACA supports.
ACA - a setback for safety-net hospitals
ACA’s reduced Medicare payments earmarked for hospitals that support unfunded care and for residents education will not be counteracted by expected increased payments from increased numbers of Medicaid patients and the newly insured, especially in the safety-net hospitals like Harborview. Community clinics will be flooded with the remaining uninsured.
ACA - an incremental step toward health care justice?
Overall, it may be a step backward as it empowers the corporate takeover of medicine.
People will “wait to see what happens” with more suffering in the interim.
Where do we go from here?
Is Single Payer realistic?
Most polls over last decade show 2/3rds of public would support a publically financed government program guaranteeing medical care to all.
60% of physicians would support a single payer national health program.
Unrealistic to think that a universal, affordable health care can be achieved in a system dominated by the insurance industry and big PHARMA.
What once seemed politically impossible has come to pass because of grassroots movements – women’s suffrage, civil rights in the South, Medicare, and recently in our state, marriage equality and legalization of marijuana.
How do we get to improved Medicare for All?
We need a grassroots movement based on Health Care is a Human Right and traditional American values of freedom (from disease and financial disaster), equal opportunity (that requires good health) and justice for all (that requires government guarantees).
Medical students and residents need to take a leadership role as their future and that of their families and patients depends upon it.
Current Single Payer Efforts
National
1. HR676 – Improved and Expanded Medicare for All (Conyers)
2. HR1200 – American Health Security Act (McDermott)
States
1. Vermont on the road to achieve single payer Green Mountain Health Care in 2017
2. More than 20 other states with single payer bills in their legislatures.
3. Washington Health Security Trust – HB1850 (WHST) introduced in WA House of Reps (Senate bill shortly). Designed to be substituted for the ACA in WA State in 2017, after a waiver granted by the federal Dep’t of Health & Human Services.
Local Organizations working for Improved Medicare for All and the WHST:
PNHP-Western Washington Chapter – www.pnhpwesternwashington.org
Health Care for All Washington – www.healthcareforallwa.org
United for Single Payer - www.unitedforsinglepayer.org
Single-Payer System: Why It Would Save US Healthcare
Why America Should Have a Single-Payer System
By Leigh Page
Medscape, Sept. 29, 2015
Donald Berwick, MD, helped launch the Affordable Care Act (ACA)—considered at the time to be the only health reform this country would need—when he was administrator of the Centers for Medicare & Medicaid Services (CMS) in 2010 to 2011.
But 5 years later, Dr Berwick and millions of other Americans are calling for a new round of reform that would involve much deeper changes: a single-payer system. Dr Berwick says he still supports the ACA—"It's been a step forward for the country," he says—but adds, "The ACA does not deal with problem of waste and complexity in the system."
Other single-payer advocates are less forgiving. They think that the ACA has pampered the commercial insurance industry, providing it with millions more customers and allowing it to jack up charges to levels that fewer Americans can afford.
The single payer would be the US government.
http://www.pnhp.org/news/2015/september/single-payer-system-why-it-would-save-us-healthcare
