• On blogging, single-payer, and Harold’s post

    I’ve been getting quite a bit of email since Harold’s post on Saturday. A number of you have asked why I’m not irate, and why I’m not more supportive of single-payer in general on the blog (especially given this)?

    Well, first of all, I’ve already said my piece on this issue. And if you don’t think we blog about it here, you’re not paying attention. But I’ll say it again. I think single payer systems have a lot of positive things going for them. They are, of course, universal. They allow for major systems level experimentation and control. They can be used to change the delivery system fundamentally . Many other countries use them successfully. Ours does, too (Medicare), regardless of the rhetoric you hear.

    But they aren’t going to happen here right now (see again). Since the goal is a better health care system, I prefer to discuss a range of options that are politically possible. That has made some of you angry, but as I told a group recently, you can’t talk about health care policy these days without ticking someone off. If my goal was to have everyone love me all the time, I’d do something else.

    I have a lot of respect for many committed health care reform advocates (on both sides). Because of that, and because I want this blog to be about research, and not advocacy, I spend very little time talking about them directly. But, full disclosure, I belong to some organizations that do have advocacy arms. I’m a current member of the American Academy of Pediatrics and the American Medical Association. That doesn’t mean that I agree with all of their positions (nor they mine), so I ask that you judge me by my writings, and them by theirs. Same goes for other organizations I have belonged to in the past. And that’s all I’m going to say about them.

    But I will comment on single-payer. Yes, I think single payer health care systems are often great ways to achieve universal health care that is of excellent quality. But for containing cost? There’s no magic about single-payer there (again, Medicare). And this is where the advocates and I diverge. They claim that the administrative savings will pay to cover all the uninsured. Maybe. But, even if that’s true, we will still be spending $2.6 trillion on health care, and costs will not be slowed in the future.

    Less honest single-payer advocates ignore the issue entirely. More honest and thoughtful single-payer advocates sometimes address it by talking about central planning, global budgets, and transition away from any fee-for-service care. They also talk about moving to an all-non-profit-facility delivery system. And if you think single-payer is unpopular now, wait until people start hearing about those things.

    I get why many on the right are uncomfortable with this. There are days I am, too. But I’ll concede one point: if Medicare is so awesome for people age 65 and up, why is it socialism for someone who’s 64?

    Anyway. Since it’s not going to happen in the near future, and I want the health care system to be better now, we discuss a wide range of ideas here, from all comers. We try not to guess, nor impugn, the motives of others as they push for change. We try to see the positive and negative of all proposals. We bring evidence to bear when it’s available. We listen to you, especially when you make constructive fact-based arguments, and we correct the blog or change our minds when it’s approproate. It’s what we’ve always done, and what we will continue to do in the future.

    That’s The Incidental Economist way.


    • Aaron–

      Thanks very much. You’re right, single-payer isn’t going to happen anytime soon. This doesn’t mean that it won’t happen, but first we need to focus on creating an affordable, high quality health care system.

      It only makes sense to fix Medicare before trying to put everyone into some form of “Medicare for All.” Right now, tMedicare is extraordinarily wasteful. The consensus is that we’re squandering as much as 1/3 of Medicare dollars paying for a) ineffective tests and treatments that expose patients to risk without benefit. b) over-priced drugs and deviices that are no better than the products they are tyring to replace and c) redressing preventable medical errors .

      Medicare’s administrative costs are relatively low; thus An anallysis of Medicare spending — and waste–stands as profo that administrative costs are not the major driver of healh care inflaiton. (If you compere Medicare inflation to inflation in the private sector where administrative costs are undeniably higher, you’ll find that over 30 or 40 years, inflation in the private sector is only slightly higher. )

      Finally, I worry about single-payer being the only game in town during
      periods of time when Washington is ruled by conseratives–expeciallly conservatives who distrust science.
      One reason palliative care doctors and teams are so poorly paid iby Medicare s because many in Congress–and in the administration– object to the idea of Not “doing everything possible.” They will pay a fortune for chemo that will give the average patient an extra 3 weeks of poor-quality life, but will pay very little for a palliative care team willing and trained to spend hours with patients and their families, explaining their options, and letting the patient make the choice

      Meanwhile, some private insurers (even for-profits like Aetna) have
      recognized the value of palliative and hospice care and actively promoted their use. Aetna figured out that some patients live longer if they choose hospice care over continuing invasive treatments– and their end of life care is still less expensive.

      If the entire health care system had been run by the government during George W. Bush’s administration, would palliative and hospice care
      made the progress that it did during those years? I doubt it.
      And this is just one example.

      When health care is run solely by the government the danger is that it it wll be run by lobbyists. Medicare didn’t stop paying for Lipitor. Kaiser Permanente, Mayo and the VA did. (The VA would serve as a better model for single-payer, but it is able to do things that Medicare would never do precisely because it is healthcare for veterans– and because ti has establislhed itself as a separate system..)

      This is much to be said for multiple payors pursuing multiple strategies to get better Value for health care dollars. Ultimatley, I would love to see a public option competing with private sector insurers (preferably non-profit private sector insurers).

      In the worst-case scenario, single-payer can do great damage to our health care system (Think Margaret Thatcher.)

      I don’t mean to start the whole debate once again. We’ve gone round and round on this issue on my former blog (HealthBeat) until I , too,
      decided not to write about it anymore.

      I just want to indicate that the whole idea is more complicated than it might seem at first glance.

    • -As one who has followed the single-payer debate I find these partial concessions regarding the potential limitations or shortcomings of a single-payer/administrator encouraging signs of both intellectual honesty and rigor, but find myself wondering where they’ve been all of these years.

      Are these new conclusions or is the political timing better these days (honest question – really)?


      Are your claims about the percentage of Medicare spending that’s wasted based on the Dartmouth data, and if so, have the critiques articulated by Richard Cooper and others had any affect whatsoever on your confidence in them? Example post below:

    • Great link – with a very accurate summary of the flawed conclusions arising from the application of unsound methodologies to overaggregated health-care data and the damage that reform predicated upon them will do to the very people it’s ostensibly intended to help :

      “Is poverty the major factor underlying geographic variation in health care? It assuredly is. There is abundant evidence that poverty is strongly associated with poor health status, greater per-capita spending, more hospital readmissions and poorer outcomes. It is the single strongest factor in variation in health care and the greatest contributor to “excess” health care spending. It should be the focus of health care reform, but sadly, many provisions in the current bills will worsen the problem.”