Single payer reality

We interrupt you from all Brett Kavanaugh all the time to highlight Jon Cohn’s excellent piece on Taiwan’s single-payer health care system.  There’s a lot we could learn from Taiwan.  They are relatively new to single-payer, actually.  Back in the 1990’s they realized they needed to create a high-quality, national health care plan and studied countries around the world to see what made the most sense.  Their conclusion: single-payer.  The results: not perfect, but really, really good:

More than 99 percent of people living in Taiwan now have insurance through the NHI. They pay premiums based on a sliding scale, with employers contributing additional premiums, and they have to pay modest out-of-pocket costs for everything from prescriptions to hospitalization.

That last part might surprise people who think that single payer necessarily means “free” health care. It doesn’t, though the NHI waives copayments and deductibles for several key populations: the poor, pregnant women, children younger than three and people with serious, long-term conditions like diabetes or cancer.

“It protects the disadvantaged, it protects the sick, really well,” Cheng said. “When they set up the program, they said, ‘We should feel sorry for those who are sick ― on top of that pain and suffering, it’s an awesome financial burden. We should take care of that.’”

It’s easy to see how such a system could get expensive. But the Taiwanese government establishes a hard limit on overall health care spending, then negotiates fees for every medical service and supply. It’s cost control by brute force, and it works. In 2016, the overall budget worked out to less than 7 percent of Taiwan’s gross domestic product, compared to 16 percent in the United States. [emphases mine]

Some of the difference shows up in superficial ways, like Taiwan’s conspicuously spartan and utilitarian facilities. A popular pediatric clinic in northwest Taipei that I visited had curtains, not doors, on some room entrances, plus a waiting area that consisted of a bench crammed into a hallway. The large, cartoonish sign bearing the clinic’s name looked like it belonged on a fast-food restaurant or gas station.

But patients in Taiwan have the kind of access to medical care most Americans would envy. They can see any doctor or visit any hospital anytime they want, and pay just a small additional fee for specialty care without a referral.

And, hey, because Cohn (and me) are fair and balanced, there’s some definite downsides:

Every health care system has its trade-offs, and in Taiwan one of those is the effect of low fees on physicians, who have basically tried to make up in volume what they can’t get in price. The Taiwanese end up seeing the doctor more frequently than people in most other countries but spend less time in the office when they do. Doctor burnout is becoming a problem and a small but growing group are making regular trips to clinics in mainland China, where they can make more money because the People’s Republic, desperate to meet their fast-growing population’s need for care, now offers better pay.

Another place Taiwan has saved money is on cutting-edge treatment ― in particular, the latest cancer drugs. Taiwan’s government negotiates pharmaceutical prices directly with manufacturers, as pretty much every country except the U.S. does. But it typically waits a year or two after the release of a new drug before approving it, and then bases its payment on a mix of what other, larger countries are already paying. That has the effect of steering more people to older, cheaper therapies, even when newer ones are available.

Also, the politics in the US for something like this are really, really hard:

Proposals like the one Bernie Sanders has outlined envision wiping out private insurance, which would mean getting rid of the employer benefits through which the majority of working-age Americans now get coverage. It might be a change for the better, providing more comprehensive coverage, with no networks, and for lower cost overall. But making that case to the tens of millions who currently have employer benefits they like is difficult, and some people would inevitably feel, justly or not, like the transition left them worse off.

Yep.  That said, well short of single-payer, there’s some really good steps we could and should take in this direction:

A good place to start might be taking the critical step that Taiwan did. Policymakers could make sure that people with cancer, diabetes and other chronic, economically-crippling conditions don’t face out-of-pocket costs ― protecting those people from financial duress and reducing the likelihood they postpone necessary care because of cost. Introducing fixed fees and global budgets slowly, as Maryland is already doing on its own and California is contemplating, might also work. That could also help ensure that cuts were done in a way that didn’t deter important innovation.

Neither of those features is unique to Taiwan or even, as it turns out, to single payer. Many of the public-private hybrid systems in Europe have them too. One very real possibility is that a push for single payer could leave the U.S. with a system that looks more like what those other countries have, simply because the politics and policy of dislodging the current system would prove too difficult. It’d still be cheaper, and a lot more humane, than what exists now.

There’s lots of ways to go.  A couple things are for sure– currently, sadly, Republicans have absolutely zero answers to solving the real health care problems we face as a country and as individuals, and, we really could learn a lot from places like Taiwan.

About Steve Greene
Professor of Political Science at NC State http://faculty.chass.ncsu.edu/shgreene

7 Responses to Single payer reality

  1. R. Jenrette says:

    The major problem in the U.S.is the power of the pharmaceutical companies to stop government from even bargaining over drug prices. A lot of their power comes from Citizens United and the acceptance of anonymous money in our political system.
    Perhaps one day, most Americans will come to agree that the overall good of the United States and it’s people is worth the price financial and otherwise of a good, affordable health care system for all.
    Barring a miracle, we will recognize that day when pigs start flying.

  2. Nicole K. says:

    Yeah, I think that it would be more realistic if democrats focused on ending employer-sponsored health insurance that is subsidized by tax expenditure. If everyone bought insurance from subsidized exchanges like the ones that exist for Obamacare, it would be better for everyone. It would create very large, very stable risk pools, and people would no longer be handcuffed to a job because of they need health insurance. It’s a much less drastic reform than converting our system into a single payer system that our current health care infrastructure is not designed to provide.

    I just don’t think that getting everyone covered requires completely blowing up our current system, which is what a single payer conversion would require. It is just too large of a system, 17% of GDP, to change dramatically without causing a lot of painful problems.

  3. R. Jenrette says:

    I agree with you Nicole but I think eliminating employer paid health care for workers would be even more difficult to sell to the voters.
    Barring another miracle, we will recognize the day that the middle class gives up employer paid health care when elephants start flying.

  4. homeys44 says:

    Democrats can’t pass single payer without 60 senate votes, which isn’t ever going to happen. So, its a non solution/slogan. I was hoping some liberal states would step up with single payer, but even they won’t touch it. So, best accept ACA and figure out small reforms to it that may work and can pass. #1 might be the individual mandate.

    • Nicole K. says:

      Actually, that isn’t true. As I’m sure you’ll recall, there is a once a year procedure called reconciliation. That’s what the Republicans tried to use to repeal Obamacare until John McCain saved it. If that process is used, only 51 votes are required.

      None of this is going to happen, but actually talking about what would make the system work better is still worthy of discussion.

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