The Single Payer Conversation

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.

Click here for the full text of the amendment or here for Senator Eldridge’s summary of the amendment.

Published by Will Brownsberger

Will Brownsberger is State Senator from the Second Suffolk and Middlesex District.

8 replies on “The Single Payer Conversation”

  1. Hi, Will.

    I was wondering how you were responding to this amendment and as usual you anticipated my questions with your thoughtful analysis.
    I’ve posted your assessment to the Facebook site of a friend in Dorchester who is supporting the Eldridge amendment to show that supporters of single payer and other social welfare strategies can differ in their approaches.
    I was also intrigued by Mike Dukakis’ recent Globe op-ed on cost regulation along the lines of workers’ compensation (he disagrees with you on the promise of ACOs, which he calls a “pipe dream.”). Favorite line: that other advanced industrialized nations “don’t indulge themselves in the notion that the market works in health care.” On that, at least, we agree.


  2. Senator Brownsberger:

    It is surprising and deeply disappointing to read this sort of double-speak coming from a long-time single payer supporter like you.

    First, your quandary regarding “where the funding will come from” is simply an invention. The funding would come from those same sources that feed our current system. We pay for health care three ways: first, through policy premiums (supplemented increasingly by copays and deductibles); second, with employer contributions; and third, via taxes (for Medicare and Medicaid; so-called “free care;” and public employee benefits). Upwards of 25% of these monies — more than enough to make health care financially sustainable and available to everyone — are squandered on administrative waste and insurance company “overhead” (a benign-sounding term that refers, in fact, to advertising costs, political lobbying expenses and executive salaries in the tens of millions). A single payer system would eliminate these unnecessary and (in the view of myself and increasing numbers of my colleagues) immoral costs.

    Second, you go on to suggest that we would somehow be forced to choose between four equally far-fetched scenarios: a totally socialized (government-run) health service like the UK’s; a totally fee-for-service system (flashback to 1960’s USA); the Clinton albatross; and most laughable of all, “HMO’s done right” (seriously, Senator — other than several dozen private insurance industry executives, industry lobbyists, and Cato Institute economists, who refers to ACO’s in this way?) But this is a false set of choices. Oversight and cost control in a single payer system is provided via the establishment of public health boards comprised of consumers and health care providers working transparently with elected officials.

    Many of us supported you in your senate run precisely because we felt we could trust you to work aggressively for social justice. Now you have a chance to show us we weren’t mistaken. There is still time for you to change your position here, and to support Senator Jamie Eldridge’s single payer amendment!

    Yours Truly,
    Jim Recht, MD
    Massachusetts Physicians for a National Health Program

    1. Hi Jim,

      As a legislator, I have to vote on specific language. Your characterization of what a single payer system is may be a good one, but it isn’t in the language of the amendment. The language is wide open.

      I’d also note that the language specifies that it should be “publicly-financed” not supported by premiums as you suggest. Not quarreling with your thought, just focusing on what I have to vote on.


  3. I would hardly call our current system a “market” driven. As Will points out “close to half of health care is already publicly funded”. Will, please do us a favor and take a page out of the auto insurance reforms. Less government + more competition = lower insurance premiums

  4. Senator Brownsberger:

    Thank you so much for this thoughtful reply. I appreciate the time and the attention that you are devoting to this critically important issue. My concern with your proposal for the single payer amendment is that, by excising any language about a “trigger” (a trigger that would initiate the development of a single payer plan), the law would have no teeth at all.

    The primary intent of Senator Eldridge’s amendment (as I read it) to set the conditions for “a process of EOHHS implementing a single payer health care system in Massachusetts.” The language specifies that such process be transparent, and conducted with public input.

    For Senator Eldridge’s amendment (or any version of it) to be of practical use, it needs to contain some sort of action plan such as this one.

    Finally, in regard to the phrase “publicly financed”: if the state were to redirect the money I currently pay toward my family’s over-priced, copay-heavy health insurance premium, and put that money (along with everyone else’s insurance premiums) into a single payer trust fund — that would certainly fit my definition of “public financing.” And it would be a very good thing!

  5. I recall as if it were yesterday a lecture I went to at the Harvard School of Public Health in the early 70’s. The lecturer pulled a $100 bill out of his pocket — a rare sight in those days — and taped it to the board. “If we don’t a grip on Health Care costs,” he said, pointing to the bill, “you’re going to burning through one of those every day you are in a hospital.”

    National health care costs have risen by an average of 2.5% over the sum of inflation and productivity for almost the last fifty years. It certainly looks as though there is at least one cost driver that is exponential in its effect. Perhaps there are more than one. In any case, until those drivers are identified and dealt with no saving is going to do more than buy time. (Which is OK so long as everyone understands that is all they are doing.)

    At least two such drivers are obvious: the aging of the population and the steady increase in the number of medically recommended procedures. Nothing to be done about the first, except perhaps revisiting the immigration laws. The second drives costs in two ways: by increasing the number of things to be paid for — Medicare now covers almost 14,000 procedures and services — and by keeping the age of the average procedure young. This drives costs because one of the key ways of lowering the cost of an intervention is by accumulating experience with it.

    So if you accept this line of reasoning, in the long run the explosion of costs is going to force us to stop buying new stuff. Once we do that prices will start to
    decline and all these issues will gradually become manageable. Not going to happen soon, though.

    Fred Hapgood

    accumulating experience

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