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Single-payer is a nice dream that distracts from realistic health care solutions

  • Author: Charles Wohlforth
    | Opinion
  • Updated: August 2
  • Published August 2

Providence Alaska Medical Center is viewed from the air on Wednesday, July 20, 2016. (Erik Hill / Alaska Dispatch News)

I love the idea of a health care system where money is not involved in doctor visits or hospital stays — no premiums, no deductibles, no settling up with insurance.

But the dream of a Canada-style single-payer system isn't practical for our country or our state, and not only for political reasons. Our society won't tolerate a massive nationalization of private assets and individuals' careers.

Progressives who wave signs for the idea may not have looked at the details, much as their conservative opponents failed to consider the consequences of repealing the Affordable Care Act before their disastrous attempts to roll it back.

We need real solutions now, not slogans.

I decided to do some homework on single-payer and talked to an expert due to visit Alaska, Dr. Carol Paris, president of Physicians for a National Health Care Program.

The single-payer concept is simple — far simpler than our current system — and its success can readily be seen in the long list of other countries that have national health care that costs far less and delivers better results than the American system.

Under a U.S. single-payer system, the government would pay for all essential health care. Taxes would cover the costs, as they already do for almost two-thirds of our health spending, according to peer-reviewed data quoted by Paris' group.

Our government currently pays more for health care per American than countries that already have universal coverage. Viewed that way, every private dollar Americans spend is going to something that doesn't improve health.

Paris' organization represents 22,000 doctors and other health professionals. She will speak in Fairbanks and Anchorage later this month.

For many doctors, especially those in fields with lower compensation, such as primary care or mental health, the prospect of no longer fighting insurance companies for payment is more than enough incentive to support government control.

Besides being more rational, Paris said single-payer would provide universal coverage, better benefits and lower cost — goals, at one time or another, of both Presidents Donald Trump and Barack Obama.

"As long as you keep the for-profit insurance industry in the equation, you really cannot accomplish those goals," she said. "The Affordable Care Act can't really be tweaked in a way to achieve what the goals are."

The outlines of the system she supports are found in House Resolution 676, a bill introduced by Rep. John Conyers, D-Mich., with 116 co-sponsors, all Democrats.

It would outlaw health insurance for all nonelective care and force health facilities to become nonprofit, essentially to be overseen by the government program. Cost savings would come from removing investor profits from health care and replacing the entire billing and insurance establishment with standard fee schedules.

Conyers' bill is scant on details, but consider the complexity of this enterprise.

Health insurance companies would presumably go out of business. For-profit hospitals, surgery centers and clinics would become nonprofit (unless doctor-owned), eliminating the value of their shares.

Check your 401(k) now for stocks among the $4.75 trillion market capitalization of the U.S. health care industry.

I asked Paris if anything like this has ever happened in the U.S. She said she didn't know. I'm pretty sure the answer is no.

Conyers' "Expanded and Improved Medicare for All Act" is not well-named for Alaskans' ears. Medicare has become a source of fear and frustration for many of our elders.

Their difficulty represents a core problem with government-managed care. Medicare rates set by the government are too low for doctors and facilities in Alaska, so elders can't find providers.

In our private system, we ration care through cost. Under Medicare, care is free, but rationing occurs in Alaska through a lack of providers.

The managed care model of Alaska's Native-owned health system doesn't have these problems. User ownership is a key to its high customer satisfaction, unlike a top-down national system.

But the Alaska Native system is not inexpensive. (Conyers' bill would eliminate it, folding the Indian Health Service into the nationalized system.)

Without radical cost-control measures — doing away with insurance companies and health care profits — a single-payer system could be expensive, too.

Vermont's state government went well down this road, but Democratic Gov. Peter Shumlin, an early advocate of the program, canceled it in 2015 because implementation would have nearly doubled the state budget, requiring huge tax increases. California has run into similar problems.

Vermont found that changing who pays can create major economic disruption.

Much of the money in health care now comes from private policy holders, who are mostly employers and unions. Under single-payer, that revenue would go away, but coverage would continue for all those workers.

The change would vastly benefit companies and employees while shifting enormous new costs to taxpayers. That's a complex economic equation with an unknown result.

Controlling cost remains the only long-term solution, regardless of the payment mechanism. In Alaska, that means money for doctors and hospitals, not just the cost of insurance.

It's great news that premiums in Alaska's individual market will go down next year — but that will happen only because more state and federal money came into the system. We cannot keep paying more from any of our pockets.

The ACA created an American expectation of universal coverage (which is fundamentally why Republicans failed in their repeal). But it follows that if the government is responsible for health care, it also has a responsibility to keep the system from destroying the economy.

In other areas of our lives, we find ways to use government regulation to make the private economy function, with anti-trust rules, banking and insurance regulation, and consumer rights, for example. Much of our political life is spent battling over those rules.

Given the size of the medical industry in Alaska, the state has paid little attention to monopoly market power that distorts fees and payments, price gouging and sneaky practices that we don't tolerate from other businesses.

Alaska could also use its huge buying power to muscle providers into giving better deals.

Those solutions may feel less satisfying than sweeping away the entire system and having a government agency run it. But it is much more likely to actually happen.

The views expressed here are the writer's and are not necessarily endorsed by Alaska Dispatch News, which welcomes a broad range of viewpoints. To submit a piece for consideration, email commentary(at)alaskadispatch.com. Send submissions shorter than 200 words to letters@alaskadispatch.com or click here to submit via any web browser.

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