During the health care debate, there will be an important conversation on Single Payer health care reform. I do broadly support Single Payer health care and I am cautiously optimistic that the legislation before the Senate will move us in the right direction.
I have long believed and still believe that the existing model of health insurance, which relies on employers to purchase health care insurance, is outmoded. Health care insurance relationships are so important that they should not be subject to disruptions through changes in employment. Additionally, health care is so expensive that the obligation to provide health insurance discourages hiring and also renders U.S. companies less competitive in world markets. I do believe that it is possible to create a model of publicly-financed health care which preserves consumer choice and is fiscally responsible — close to half of health care (45% in 2010 according to the Center for Medicare and Medicaid Services) is already publicly funded.
Senator Jamie Eldridge has sponsored an amendment that speaks to the issue. I’m sympathetic to the goals of the amendment and I appreciate his leadership and I’m respectful of the constituents who have urged me to support the amendment. I don’t feel that I can support the amendment as written. I’ve offered to engage in a discussion about how to refine the amendment.
I feel that the amendment leaves too many fundamental issues for later resolution by a newly created state agency. The amendment defines single payer health care very broadly as follows:
“Single payer health care,” a system that guarantees continuous, high-quality, publicly-financed health coverage for all state residents in a manner regardless of income, assets, health status, or availability of other health coverage. A single payer health care system shall, therefore, be guided by the following principles:
- Health care coverage must be universal;
- Health care coverage must be continuous;
- Health care coverage must be affordable;
- Health care costs must be affordable and sustainable for the Commonwealth as a whole;
- and Health care coverage must support patient-centered care, protecting the relationship between patients and their health care practitioners.
While specifying that the system should be publicly-financed — a proposal which would roughly double the state’s total budget — the amendment does not specify how the state should raise the necessary funds.
The definition also leaves very basic design questions unresolved– several very different approaches could be seen as meeting the definition in the amendment:
- A British model national health care system where doctors work for the government?
- A Medicare-for-all fee-for-service program that eliminates insurers but basically preserves the current cost-plus framework that encourages over-treatment?
- A managed competition among insurers model (as proposed by the Clintons in the 90s) that involves the government purchasing health insurance for individuals from insurers?
- A model that builds on recent progress towards Accountable Care Organizations (HMO’s done right) that gives consumers choices among ACO’s that compete through some kind of exchange?
In the latter case is there some kind of provision for consumers to contribute towards more expensive options even while the system is publicly financed?
I believe that the last among the design options above is the right way to go, but we don’t actually have many Accountable Care Organizations yet — expanding their role in patient care is a primary goal of the present legislation. My sense of the right migration path towards single payer health care is to encourage the private sector to build ACO’s which offer high quality, competitively priced care. Once we can demonstrate the feasibility of these organizations, we’ll be in a position to consider the possibility of moving to a single payer that would manage competition among these organizations.
The amendment also asks the newly created agency to determine whether single payer health care would be less expensive than the present system and specifies that if the agency reaches this conclusion “a process of implementing a single payer health system shall be triggered” in 2015. It’s hard to imagine how this computation would be done in a credible way or how this implementation would move forward in practice.
Given the number of open questions, I would support a version of the amendment that excised the last paragraph which contains this automatic trigger. Without the trigger, I think that the amendment would cause the new agency to make a solid contribution to the conversation about single payer health care. With the trigger, it puts an independent agency in a politically and practically unworkable position. I would like be able to make a symbolic vote for Single Payer health care, but just in case the amendment actually passed, I would like it to be workable.