Universal Publicly Funded Health Care: Establishing Accountability without Competition

Consider H.R.676, the House single-payer bill kept "off the table" during health reform negotiations. It proposes public financing of universal health care, but leaves care delivery (doctors and hospitals) private and independent. This is not the same as "socialized medicine," in which government owns the hospitals and employs the physicians. It uses a "social insurance" model in which everyone is included in a single risk-pool, with no exclusions from coverage based on health status, and it eliminates competing private health insurance plans. Effective government-sponsored programs may use private plans provided they are made to function as a single risk-pool, as in many European countries.   In these systems government requires universal and open enrollment, standardized benefits and fees, and risk-adjusted funding of plans. However, in general countries using multiple plans have higher health care costs.1 Single-payer financing is most cost-efficient.

-       Benefits are comprehensive, with minimal or no co-pays.

-       Patients have free choice of providers.

-       Health care is independent of employment status.

-       Universal health care is less expensive because it has much lower administrative costs and allows effective cost controls. Countries with universal health care spend about half of U.S. per-capita total health care spending, and they cover everyone. 1,2

-       Lower total health care costs means less pressure to restrict and control physicians' professional decisions.

-       Streamlined administration is much easier and less expensive for providers.

-       Quality improvement programs work much better in a unified market.

-       Public programs (Medicaid and Medicare) would no longer be dumping grounds for the sickest, most expensive populations. A universal risk pool would relieve their fiscal problems.

-       Universal health care can remove health care expenses from medical malpractice, worker's compensation, and automobile insurance, drastically reducing their costs.

-       Accountability in government is theoretically to the people, although this can often be sabotaged by special interests.

-       Government can be inefficient, irrational, and inflexible ("administration by acts of Congress," as with U.S. Medicare).

-       Special interest pressures often lead to bad policies in government programs.

-       A publicly funded plan means pressure to reduce taxes may lead to under-funding over time. This may lead to pressures to ration care, reduce fees, and control doctors, as is already happening with private insurance in the U.S. However, this would happen at a much lower total spending level than with competing private plans, because a single-payer system carries much lower administrative overhead.

-       No competition means we need another means to ensure accountability. (Of course, competition in U.S.-style health insurance does not provide accountability to quality health care anyhow.)

The legislative branch must define the broad structure of publicly funded health care and how it is to be financed. To prevent corruption by special interests, a public plan needs a carefully designed administrative structure, accountable to quality health care, but insulated from special interest pressures. This could be accomplished with a system of national, state, and regional boards, with representation from the essential stakeholders in health care: physicians and other professional providers, hospitals, and the public who are or will be recipients of care. These boards would be charged with assuring quality, cost-effectiveness, and fair reimbursement for hospitals and physician services.

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