I have a few questions about government-funded single payer to consider before I sign on.
I’d suggest you give them some thought before signing up yourself.
I’m in favor of having a national health plan in our country, but I always worry about what kind of national health plan those who claim to support it have in mind. Have they really thought this idea through, or are they just against the current system because it is so obviously fraught with waste and corruption? Before I get on board, I’d like to see some of the questions listed below addressed.
1. Do all health care services get covered, whether medically necessary or not? Who determines whether a service is medically necessary? Should the government pay for medically unnecessary services?
Like many of the questions on this list, these questions probably seem rhetorical. Who would want to pay for unnecessary medical services, to say nothing about offering them? Yet everyday, insurance companies restrict the volume of care by refusing to pay for services they deem to be “not medically necessary”. Argue as much as you like about the correctness of their adjudication process, there is no denying that restricting access to care holds down costs.
If there are no restrictions on what is medically necessary, health care professionals are free to determine whatever they want as appropriate for them to treat and charge the government for. In a system of unfettered care, where no regulations restrict what kind of care can be offered, there is a tremendous risk of further ballooning out of an already swollen health care budget. If one were to concede that “medically unnecessary” care needed to be exempted from reimbursement, who gets to decide what is medically necessary and what is not? Inevitably this will lead to a battle with no clear means of resolving it that does not donsignificant harm to some people, either by way of under-covering what should be payed for, or over-covering what should not be.
2. Should illnesses caused by tobacco usage or other self-destructive behavior be covered by the government? Why should the people’s taxes pay for medical services caused by people who choose to make themselves sick?
Another apparent no-brainer. Why should our citizens have to pay for the illnesses people inflict upon themselves? Sympathetic as one might be to those who become addicted to cigarettes or other drugs, and even in acknowledgement that it is a form of addiction, it is difficult to countenance the converse notion: that all tobacco related illnesses should be fully covered by a national health insurance plan. This appears to expose the government to the accusation that the government is enabling tobacco smokers or addicts to persist in their harmful habits. Even assuming that we may want to parse this idea gingerly, and with plenty of compassion, it remains unclear how tobacco-related illnesses should be handled under a national health plan.
3. The same might be said for people who have illnesses that result from other kinds of behaviors that are known to be harmful or risk-prone, such as injuries resulting from riding without seatbelts, or riding motorcycles or bicycles without helmets, injuries that result from texting while driving, or drinking while driving, eating lots of junk food, such as fast food, sugar, soda, etc., exposing oneself to excessive radiation, including cell phones, sun exposure, and possibly others. At what point do we become a nanny state? How do we encourage good behavior without becoming medical policemen?
No one wants our government to be facilitating unhealthful behaviors, by underwriting all the costs of health care associated with these behaviors. This seems to be the height of fiscal folly, as well as downright unethical. But it’s not at all clear that illnesses can always clearly be ascribed to any one behavior, nor is it clear that those who fall prey to such behaviors should be left completely high and dry by the health care system. Some behaviors deemed harmful by some are not viewed as harmful by others. It would seem some compromise needs to be forged between the opposite poles of enabling the problem, and regulating or punishing people’s behaviors so much that we become a police state. Who decides this? How do we determine what the proper balance is between enabling behaviors that are anti-health and taking away people’s person freedoms?
4. Should the government cover illness caused by doctors (iatrogenic illness)? Shouldn’t doctors have to pay at least some of these costs, since they are responsible for the illnesses? Why should society at large have to pay for the mistakes of doctors?
Medical errors comprise a large portion of today’s health care budget, about $20 billion dollars annually, according to reports in 2019(https://www.ncbi.nlm.nih.gov/books/NBK499956/). This is therefore no small concern. It’s easy enough to give doctors a free pass on medical mistakes by acknowledging that no one can be perfect, and that errors are in this sense just the “price of doing business”. However, if there are no limitations to payments for medical mistakes, doesn’t this encourage a kind of sloppy approach to the practice of medicine? Doesn’t non-payment for medical mistakes encourage a more careful attitude? Still, by trying to avoid the Scylla of promoting sloppiness, which also includes paying for unhelpful and costly medical interventions, we also need to steer clear of the Charybdis of excessive punitiveness, which would discourage doctors from even attempting interventions which are known to be risky and possibly fraught with the possibility for not getting reimbursed. In addition, threatening doctors with non-payment for errors might create such high levels of stress in an already stressful profession that the practice of medicine might become intolerable.
5. Should the government pay for any and all medications, even when cheaper alternatives exist? Or should some of the more expensive drugs be paid for by the individual? If there is no check system, what’s to stop doctors from prescribing the most expensive drugs available?
Even while we recognize that the costs of pharmaceuticals is a huge problem in our bloated health care budget, it is never easy to determine which of the many high-priced pharmaceuticals should be sacrificed on the altar of cost saving. In some cases, more expensive drugs may actually be better tolerated or produce better effects than cheaper alternatives. In other cases, there may be no cheaper alternatives or the cheaper ones are far less effective. On the other hand, giving carte blanche to doctors to prescribe any drug they want without concern for cost seems to lead straight up the path towards financial ruination. Additionally, underwriting the rapacious costs of pharmaceuticals seems hardly justifiable, since it enormously enriches pharmaceutical companies at disproportionate rates to other industries. The only solution seems to be rationing, and government bargaining with pharmaceutical companies to obtain fairer prices. Even this seems to avoid the question of whether any and all medication should be covered, regardless of cost?
6. Should only medically trained individuals be eligible for coverage by a national health care system — e.g., M.D.s, D.O.s, R.N.s, P.T.s etc., but not naturopaths, acupuncturists, herbalists, homeopaths, etc? How do we decide where to draw the line between what and who is covered and what is not? Do doctors get to decide? Legislators? The public? The media?
Alternative medicine is presently only infrequently covered by private or public health insurance. There is limited coverage for chiropractors, acupuncture, when done by a physician, and possibly some other special circumstances. For the most part, naturopaths, acupuncturists, bodyworkers, herbalists, homeopaths, and a myriad of other alternative therapists must bill for services outside of the conventional health insurance system. One might believe that these services are trivial, useless, or even harmful, but there’s no denying
that many Americans use them and use them regularly. Recent government estimates are that about 38% of adult Americans use these services. Presumably they do so not do so because they find them ineffective or harmful. A growing body of research evidence has given scientific credibility to many alternative medical disciplines. “Integrative” medicine, which embraces many alternative therapeutic practices without renouncing conventional medicine, has recently grown in popularity and has even been given the imprimatur of conventional medicine in the form of being designated a board certifiable discipline. Many alternative practitioners take a more holistic and preventive approach to health care, which our country can scarcely afford to ignore in times of ballooning health care costs. Assuming we admit to even a limited role for alternative health care, who decides what the limits are, and what gets covered and what doesn’t. We again need to avoid the polarities of covering everything under the sun and excluding things that are truly beneficial. Who should make these decisions, and who gets to decide this?
7. What is the role for preventive health care in a national health care system? Is it funded? Is it built into the system in any way, or is it considered optional, only for those who are interested?
Preventive medicine, which overlaps considerably with the discipline of public health, addresses the problem of keeping people healthy, and improving health with or without frank manifestations of disease. It comprises disease prevention as well as health promotion. It is currently. Primary care physicians (PCP’s) are often viewed as the appropriate individuals to implement these kinds of interventions on a clinical level. Yet, PCP’s have only minimal training in the implementation of these kinds of interventions, which include lifestyle medicine, nutritional programs, exercise programs, and vaccination. Primary care physicians’ training, like all allopathic training, emphasizes disease management through medications, and this is the area of their greatest expertise. When it comes to lifestyle medicine, most PCP’s are more at the level of amateurs, unless they have specialized training in nutrition, lifestyle medicine, functional medicine or integrative medicine. The latter group probably comprises less than 1% of all physicians, and less than 5% of PCP’s. No wonder over 80% of current illnesses seen by PCP’s are based on preventable lifestyle behaviors! In view of the high prevalence of preventable illnesses, it would seem the height of folly to exclude preventive medical practitioners from being covered. The only question would appear to be how to make preventive medicine more routinized within a national health care system, so we can nip chronic diseases in the bud, and in the process presumably save millions if not hundreds of millions of dollars.
8. Are all elective surgeries paid for by the health care system, or just some? Who gets to decide which are covered?
Implicit in this question is the notion that some types of surgery, particularly cosmetic surgery, might not deserve to be covered by a national health insurance plan. There are other surgeries that seem scarcely better than more conservative treatment, such as surgery for lower back pain, which also seem of doubtful value. Yet, even as we try to exclude surgeries that don’t seem to deserve the financial support of our society as a whole, how to we avoid being too rigid, and denying coverage for cases where there may be unusual and extenuating circumstances that might merit making an exception? Who decides, and how do we prevent bias from affecting those who decide?
9. Are experimental treatments covered? What makes a treatment experimental as opposed to supported by evidence? What about lab tests? Does anything a practitioner orders deserve to be paid for, or are some lab tests unnecessary and not deserving of coverage?
One would think not covering experimental treatments is a no brainer, but what if it is you, whose life is at stake? What if there are procedures that show promise, and you have no other hope of remaining alive? It’s easy to say no to covering these procedures when it’s not you or your loved one’s whose life is in the balance. Yet, we clearly can’t permit all experimental procedures, all tests, all interventions to be covered in a carte blanche fashion. Who gets to decide, and would there be an appeals process? The responsibility for making these decisions is huge and there are no clear guidelines, so it will be inevitable that subjectivity will creep into the process. Can we do no better than this?
10. Are clinicians to be paid for missed or last minute cancelled appointments? If people fail to come to an appointment, and no service is provided, why should clinicians be paid? This is an expensive mistake that is no one’s fault in some cases, or only the fault of the patient. Why must society as a whole pay for this mistake? On the other hand, if people fail to come in, how can clinicians have any kind of reliable income if they aren’t paid?
Should people have to pay out of pocket for missed sessions, and if so how much? Should there be extenuating circumstances? What about people who can’t afford to pay out of pocket? How can clinicians maintain a practice if there is no penalty for missed sessions? People who take their responsibility to show up for appointments casually would lead to no-shows becoming more common, and clinicians’ incoming becoming more unpredictable. Clearly, having a single payor system needs to address these questions, and do so in a thoughtful and fair manner. What the solution is to this problem is far from clear.
11. If national health care really does provide people with readier access to health care, more people can be expected to use the system. By what mechanisms will the system hold down costs? How will the system prevent fraudulent billing? If people have no “skin” in the game, they have no incentive to make economical choices, so are we going to trust bureaucrats to decide what to pay for and what not to?
Much as one may find deplorable that our society fails to provide ready access to health care, and that the medical system can ruin people financially, if medical care is a complete “freebie”,
how can health care costs be preventing from growing? We may look at the Canadian, British, or French systems as models of successful single payer systems, but they have all had problems with providing the amount of care people want. The French have curbed doctor’s salaries, which led to a national strike. The Canadian system sometimes has resorted to long queues to receives certain treatment, and the British National System is having trouble making ends meet and is trying to limit coverage. We may applaud broad coverage, but there are some people who are drains on the system, consuming huge amounts of health care resources with little to show for it. To have a successful single payer system, some mechanism must take place to prevent these people from draining the system dry. No one is talking about what that mechanism might be.
Single payer certainly seems to be an advance over our current health care system, but if we embrace this option as a society without first tackling the above questions, we will be going out of the proverbial frying pan into the fire. So why don’t we start talking about them?