Sen. Bernie Sanders (I-Vt.) wasn’t scheduled to come onstage to talk healthcare until after 11 a.m. But college students started lining up as early as 5 a.m. — the Sunday morning of Halloween weekend, no less — in the hopes of scoring what appeared to be the weekend’s hot ticket.
In Washington, D.C., Sanders is often portrayed as a radical, a politician on the fringe. The popularity of his 2017 campaign for the Democratic presidential nomination caught party insiders off-guard and much of the political establishment views his signature single-payer health plan as unworkable or impractical.
But here at the University of Toronto’s Convocation Hall, flanked by Ontario’s premier, Kathleen Wynne, and leadership from Canada’s left-wing New Democratic Party (NDP), Sanders received a celebrity’s welcome.
“He’s a bit of a folk hero up here,” said Dr. James Sugiyama, a Toronto-based family physician, who, after failing to procure a ticket to Sunday’s lecture, watched the event with friends on a Web-based livestream at a restaurant down the street. “We’re staunch supporters and believers that what Bernie is talking about is the right thing to do.”
Canada’s universal healthcare system, which dates to 1968, is beloved by much of its citizenry — it’s a point of pride, many locals say.
Sanders’s speech capped off a weekend trip to Toronto, which included hospital visits and roundtables, and which his office framed as an educational tour of the Canadian health care system — an example of the single-payer approach that Sanders often cites in speeches on his home turf. The lecture was the one public component of the trip, which also grabbed headlines from the Canadian Broadcasting Corp. and other local outlets.
Tickets were snapped up well in advance, though the 5 a.m. college students eventually made it off the waitlist. Organizers estimated about 1,700 tickets were available, which sold out in about 30 seconds, according to Sanders’ office.
The lecture took on the tenor of a practiced American rally — albeit, one where the crowd was warmed up by a string quartet — featuring Sanders’ familiar talking points, repurposed for a new audience.
James Sugiyama, a Toronto-based doctor, watched Sanders’ speech on a livestream from a restaurant down the street. (Shefali Luthra/KHN)
Sanders’ comments went well beyond universal health insurance, touching on the importance of a $15 minimum wage and combating climate change. And there were the standard critiques of Obamacare repeal efforts in Washington, of income inequality and of the influence of so-called special interests.
The audience — which included left-leaning doctors, politicians and college students — was there to experience the Sanders’s magic, to “feel the Bern” firsthand. They snapped photos and burst frequently into claps, cheers and whistles, even for policies that more obviously affected their American neighbors to the south. They gave more than one standing ovation.
“Our mission is to have the courage to ask the questions … to take on the incredible special interests who have so much power in my country, your country and all over the world,” he said.
A new survey finds that almost half of the physicians polled support a single-payer healthcare system. The ever expanding paperwork to deal with private- and public-sector insurers has a lot to do with the desire for simplification that would come from “Medicare for all.”
The survey, conducted in February by LinkedIn, found that 48 percent of the 500 doctors who responded said that they would support a single-payer system that would cover all patients.
The physicians said that the current fragmented and vastly expensive system blocks patients who don’t have health insurance or can’t find a doctor who accepts their coverage.
“I think healthcare is something that should be available to everyone from cradle to grave,” Keith Paredes, M.D., a now retired obstetrician-gynecologist in Lakeland, Fla., told LinkedIn.
Foes of a single-payer system, however, fear that it would reduce their earning potential. U.S. physicians are the highest paid in the world. Some other findings from the survey:
64 percent of the physicians are using new measures to collect from patients with high-deductible plans.
One-third offer payment plans to patients while 26 percent require up-front payment.
19 percent have added staff to handle payment issues.
54 percent said they negotiate with insurance companies — work that requires an average of four hours a week.
After a raucous debate lasting nearly a year, the Democrats are united on health care. But that unity does not include a call for a single-payer “Medicare for all” health system.
“This campaign is about moving the United States toward universal health care and reducing the number of people who are uninsured or under-insured,” Sen. Bernie Sanders (I-Vt.) said Tuesday in endorsing his rival Hillary Clinton, the presumptive Democratic presidential nominee.
Sanders did win a few health care concessions in the negotiations leading to the endorsement. Clinton vowed to support more funding for community health centers and access to a “public option” government insurance plan, which she has supported in the past.
But on Sanders’s top health priority — his “Medicare for All” plan — there was not a word. At the Democratic Platform Committee meeting over the weekend, an amendment to add a single-payer plan to the document was defeated.
It wasn’t much of a surprise.
Most health-policy analysts — including those who are sympathetic to the idea — say moving from the current U.S. public-private hybrid health system to one fully funded by the government in one step is basically impossible. And that’s making a huge assumption that it could get through Congress.
“To try to do it in one fell swoop would be massively disruptive,” said Paul Starr, a professor at Princeton who was a health policy adviser to President Bill Clinton.
The U.S. healthcare system, said Jeff Goldsmith, a healthcare consultant and health futurist, is “the size of a country — it’s bigger than France — and it employs 16 million people.”
In moving to a single-payer system, he said, “you’re talking about reallocating $3 trillion, reducing people’s incomes and creating” in effect a single entity that would set prices for all medical services. Single-payer supporters dispute the idea that getting from here to there could not be done.
“We’re so used to such a complicated system in the U.S. that we envisage any change would be incredibly complicated as well,” said Steffie Woolhandler, a physician and one of the founders of the single-payer advocacy organization Physicians for a National Health Program. “But what you’re doing with single-payer is actually simplifying the system.”
For example, said Woolhandler, “the latest data are that U.S. hospitals are spending 25 percent of their total budget on billing and administration, and hospitals in single-payer nations like Canada and Scotland are spending 12 percent.”
But while a single-payer system would undoubtedly produce efficiencies, it would also bring huge disruptions. Said Starr, single-payer supporters “haven’t worked through the consequences.”
One of the biggest is exactly how to redistribute literally trillions of dollars. The problem, said Harold Pollack, a professor at the University of Chicago, is that the change will create losers as well as winners.
“Precisely the thing that is a feature for single-payer proponents is a bug for everyone who provides goods and services for the medical economy,” he said, since their profits — and possibly their incomes — could be cut.
And it’s not just the private insurance industry (which would effectively be put out of business) that could feel the impact to the bottom line. Parts of the health care industry that lawmakers want to help, like rural hospitals, could inadvertently get hurt, too. Many rural hospitals get paid so little by Medicare that they only survive on higher private insurance payments. Yet under single-payer, those payments would go away and some could not make it financially. “You would not want to wipe out a third of the hospitals in Minnesota by accident,” Pollack said. “And you could,” if payments to hospitals end up too low.
There are also questions about how feasible it would be to have the federal government run the entire health care system. “It’s hard to be nimble” when a system gets that big, said Ezekiel Emanuel, a former health-sector adviser in the Obama administration now at the University of Pennsylvania. “No organization in the world does anything for 300 million people and does it efficiently.”
The politics of Medicare — which serves roughly 50 million Americans — already make some things difficult or impossible, he said, pointing to a current fight in which doctors and patient advocacy groups blasted a proposal to move to a more cost-effective way to pay for cancer drugs. “You already can’t do certain things in Medicare because of the politicization,” he said. ”When you cover the whole country, it would be a lot of gridlock.”
Pollack agreed, and pointed out it’s not just the health care industry that could revolt. When the full Affordable Care Act was rolled out in 2013, he said, “the people who couldn’t keep their old plans — a very tiny number as a percent of Americans” were furious. “We saw how difficult that was and how angry the public was when that promise wasn’t kept. Now imagine the major shift we’d have to do to move to a single payer system.”
There’s also the question of whether it’s simply too late to go back to the health care drawing board.
Single-payer supporter Woolhandler insists it is not. “Other nations have gone to single-payer systems,” she said. “It usually can be done in about a year.”
The last industrialized country that did the switch was Taiwan, in the mid-1990s. Taiwan, however, with its 23 million residents, has a population larger than New York and smaller than Texas, and had no existing private health insurance system at the time.
“What I’ve often said is we could have done this in the 1940s when Harry Truman proposed it,” said Starr, who has written at length on the history of American health politics. “Health care at that point was probably about 4 percent of [gross domestic product] and there existed at that time a relatively small private insurance industry.” Today health care spending in the U.S. is approaching 18 percent of the nation’s GDP and the private health insurance industry accounts for half a trillion dollars per year.
Both Starr and Pollack, however, said it would be possible to make a switch, although it would have to be carried out over a very long period of time.
“You could imagine some kind of long transition, where you gradually expanded Medicare,” said Starr, “for example moving it down to age 55” and then in later years continue to lower the age threshold.
But even if the U.S. did manage to execute a single-payer system, said Pollack, it would likely prove problematic, particularly in how it would be financed.
“The major value of a single-payer system would be to help the bottom third of the income distribution, and that means the top 20 percent of the population will have to pay more,” he said. “I’m actually in favor of that, but let’s not kid ourselves. That’s a knife fight that’s going to be had.”
Healthcare has emerged as one of the flash points in the Democratic presidential race.
Vermont Sen. Bernie Sanders has been a longtime supporter of a concept he calls “Medicare for All,” a health system that falls under the heading of “single-payer.”
Sanders released more details about his proposal shortly before the Democratic debate in South Carolina Sunday night. “What a Medicare-for-All program does is finally provide in this country health care for every man, woman and child as a right,” he said in Charleston.
Sanders’s main rival for the nomination, former Secretary of State Hillary Clinton, has criticized the plan for raising taxes on the middle class and said it is politically unattainable. “I don’t want to see us start over again with a contentious debate” about health care, she said Sunday night.
Some of the details of Sanders’s plan are still to be released. But his proposal has renewed questions about what a single-payer health care system is and how it works. Here are some quick answers.
What Is Single-Payer?
Single-payer refers to a system in which one entity (usually the government) pays all the medical bills for a specific population. And usually (though again, not always) that entity sets the prices for medical procedures.
Single-payer is not the same thing as socialized medicine. In a truly socialized medicine system, the government not only pays the bills but owns the health care facilities and employs the professionals who work there.
The Veterans Health Administration (VA) is an example of a socialized health system run by the government. It owns the hospitals and clinics and pays the doctors, nurses and other health providers.
Medicare, on the other hand, is a single-payer system in which the federal government pays the bills for those who qualify, but hospitals and other providers remain private.
Which Countries Have Single-Payer Health Systems?
Fewer than many people think. Most European countries either never had or no longer have single-payer systems. “Most are basically what we call social-insurance systems,” said Gerard Anderson, a professor at Johns Hopkins Bloomberg School of Public Health, who has studied international health systems. Social insurance programs ensure that almost everyone is covered. They are taxpayer-funded but are not necessarily run by the government.
Germany, for example, has 135 “sickness funds,” which are essentially private, nonprofit insurance plans that negotiate prices with healthcare providers. “So you have 135 funds to choose from,” Anderson said.
Nearby, Switzerland and the Netherlands require their residents to have private insurance (just like the Affordable Care Act does), with subsidies to help those who cannot otherwise afford coverage.
And while conservatives in the United States often use Britain’s National Health Service as the poster child for a socialized system, there are many private insurance options available to residents there, too.
Among the countries that have true single-payer systems, Anderson lists only two — Canada and Taiwan.
Are Single-Payer Plans Less Expensive Than Other Health Coverage Systems?
Not necessarily. True, eliminating the profits and duplicative administrative costs associated with hundreds of different private insurance plans would reduce spending, perhaps as much as 10 percent of the nation’s $3 trillion annual health care bill, Anderson said. But, he noted, once that savings is achieved, there won’t be further reductions in following years.
More important, as many analysts have noted, is how much health services cost and how those prices are determined. In most other developed countries, even those with private insurance, writes Princeton Health Economist Uwe Reinhardt, prices “either are set by government or negotiated between associations of insurers and providers of care on a regional, state or national basis.” By contrast, in the U.S., “the payment side of the health care market in the private sector is fragmented, weakening the bargaining power of individual insurers.”
Would Medicare For All Be Just Like The Existing Medicare Program?
No, at least not as Sanders envisions it. Medicare is not nearly as generous as many people think. Between premiums (for doctor and drug coverage), cost-sharing (deductibles and coinsurance) and items Medicare does not cover at all (most dental, hearing and eye care), the average Medicare beneficiary still devotes an estimated 14 percent of all household spending to health care.
Sanders’s plan would be far more generous, including dental, vision, hearing, mental health and long-term care, all without copays or deductibles (which has given rise to a lively debate about how to pay for it and whether middle-class families will save money or pay more).
WouldPrivate Insurance Companies Really Disappear Under Sanders’s Plan?
Probably not. Private insurers are fully integrated into Medicare, handling most of the claims processing and providing supplemental coverage through “Medigap” plans. In addition, nearly a third of Medicare beneficiaries are enrolled in private managed care plans as part of the Medicare Advantage program.
Creating an entirely new federal claims processing structure would in all likelihood be more expensive than continuing to contract with private insurance companies. However, Sanders makes it clear that insurers in the future would no longer be the risk-bearing entities they are today, but more like regulated utilities.
Sen. Bernie Sanders releases details on his single-payer, “Medicare for all” plan. He says it will dramatically cut healthcare costs for most Americans as it raises taxes on the rich.
Benjamin D. Sommers, M.D., a physician and healthcare economist, in a New England Journal of Medicine piece headlined “Health Care Reform’s Unfinished Work — Remaining Barriers to Coverage and Access,” concludes:
“{T}he ACA is succeeding in expanding coverage and access, with promising indications for population health. But challenges remain; the fundamental political question is how — and whether — they’ll be addressed. Though some members of both political parties favor replacing the ACA entirely, that seems unlikely to happen. Liberals who believe a single-payer system is the easiest method of eliminating cracks in our patchwork coverage approach must face the political realities that derailed a single-payer effort in liberal Vermont and have made it so challenging to implement even a centrist national health care reform law. Many conservatives still advocate ‘repeal and replace,’ but the almost-certain backlash against taking coverage away from more than 15 million Americans makes it hard to imagine this rhetoric becoming reality….”
“What’s likely, then, is healthcare reform version 1.1, rather than version 2.0. We’ll probably see substantial debate over refining the ACA rather than replacing it, much as occurred after the enactment of Medicaid and Medicare in 1965. Perspectives on how to do so will vary; some policymakers will argue that the law isn’t generous enough, while others will insist that it’s already too costly and intrusive. Ultimately, there are likely to be only incremental changes….”
This Medscape report suggests that more and more U.S. physicians, and Americans in general, are warming to the idea of single-payer health system — aka, “Medicare for all” — to succeed the convoluted Affordable Care Act.
While many still oppose it, many other experts see it as a way to increase efficiency and cut waste and costs by dramatically reducing the many-layered complexity and confusion of America’s current hybrid healthcare “system” — which it far and away the most expensive in the world on a per-capita basis and yet produces remarkably mediocre medical outcomes in world rankings.
As Medscape noted, eliminating the current private-sector-public-sector arrangement and making the federal government the main payer “would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a workforce of 470,000. And those who favor single-payer say that for all practices, administrative costs would plummet because there would be only one set of payment rules. Prior authorizations, narrow networks, and out-of-pocket payments would be eliminated, proponents of a single-payer system maintain.”
Single-payer proponents also assert that it would restore more authority to physicians, more and more of whom are health system employees and must often follow the dictates of insurance companies.
But we at CMG, having lived in single-payer nations, would suggest that the elimination of the entire commercial-health-insurance industry would be highly unlikely since presumably individuals would still be able to buy extra insurance from private insurance companies as one can do in most single-payer nations.
