Professional blog

EYE ON WAsHINgtON

Ken Perez

What would be the price tag of “Medicare for All”? It’s an important question, given current bills under consideration in Congress, the primacy of healthcare thus far in the 2020 presidential election campaign and general public support for the Medicare for All concept.

On Feb. 27, Rep. Pramila Jayapal (D-Wash.) introduced the Medicare for All Act of 2019 in the House. The bill was touted as an improved version of prior bills proposed in the Senate by Sen. Bernie Sanders (I-Vt.) in 2013 and 2017. Not to be outdone, on April 10, Sanders and 14 of his Democratic colleagues in the Senate introduced a bill with the same title as the Jayapal bill.

In general, the Medicare for All bills would create a federally administered single-payer healthcare program that would provide comprehensive coverage for all Americans, across the entire healthcare continuum. All physicians would be effectively in-network, and there would be no deductibles, copayments or cost-sharing requirements of any kind.

Public attitudes Many Americans support the idea of Medicare for All. According to polls conducted by the Kaiser Family Foundation, public backing in 2019 for a single-payer system averaged 56% from January through April.a Similarly, a survey of 2,000  U.S. registered voters conducted from April 30 through May 5 by RealClear Opinion Research

a. Kaiser Family Foundation, “Public opinion on single-payer, national health plans, and expanding access to Medicare coverage,” June 19, 2019.

found 55% in support of Medicare for All.b

However, a January Kaiser Family Foundation Health Tracking Poll found that 60% would oppose Medicare-for-All legislation if it would require most Americans to pay more in taxes. Perhaps even more concerning — because it indicates a lack of understanding of the funda- mentals of the Medicare-for-All concept — 60% would oppose such legislation if it would threaten the current Medicare program and 58% would oppose it if it would eliminate private health insurance companies.

the cost of a single-payer system Citing the lower per-capita costs of healthcare in other industrialized countries that have single- payer systems, Sanders contends that national health expenditures (NHE), which totaled $3.5 trillion in 2017, would actually amount to $6 trillion less over 10 years under his plan compared with the current system.c Currently, the federal government’s spending on healthcare amounts to roughly one-third of NHE, about $1.1 trillion, funding Medicare, Medicaid, the Children’s Health Insurance Program, health insurance subsidies and related spending, and veterans’ medical care.d

Unquestionably, under a single-payer system, the federal government’s expenditures for healthcare would increase significantly. Sanders posits that $16.2 trillion would be the implied

b. Cannon, C.M., “Poll: ‘Medicare for All’ support is high—but complicated,” RealClear Politics, May 15, 2019. c. Friedman, g., “What would sanders do? Estimating the economic impact of sanders programs,” Jan. 28, 2016. d. Congressional Budget Office, “the budget and economic outlook: 2019 to 2029,” January 2019.

single-payer concept for u.s. healthcare requires close fiscal scrutiny

14 August 2019 healthcare financial management

expected increase in federal expenditures over a 10-year period under his plan.e However, several analyses have concluded that federal expendi- tures would rise by significantly more than Sanders projected, and NHE would be higher under Medicare for All than under the present multi-payer system.

The Urban Institute, a left-center think tank, has concluded that federal expenditures would increase by about $32 trillion over 10 years (2017-2026) — roughly twice what Sanders projected — and NHE would, in fact, increase, not decrease, by $6.6 trillion over the same 10-year period. Notably, the Urban Institute’s projection incorporates “provider supply constraints faced by current Medicaid enrollees,” which means not all increased demand for healthcare would be met under the program.f

Emory University professor of health policy Kenneth Thorpe has concluded that, under the Sanders plan, federal expenditures would rise by almost $25 trillion over the same 10 years.g To put the Urban Institute and Thorpe projections in perspective, total federal expenditures in fiscal 2019 will be roughly $4.5 trillion.

In July 2018, Charles Blahous, a senior research strategist at the Mercatus Center at George Mason University, estimated that the Sanders plan would increase federal expenditures by $32.6 trillion during its first 10 years of implementation.h

On May 22, Congressional Budget Office deputy director Mark Hadley testified at a House Budget Committee hearing on Medicare for All. Although Hadley declined to provide a cost estimate for the legislation, he noted that the changes required to implement a single-payer system “could

e. sanders, B., “Options to finance Medicare for All,” accessed June 22, 2019. f. urban Institute, “the sanders single-payer health care plan,” May 2016. g. thorpe, K.E., “An analysis of senator sanders’ single payer plan,” Jan. 27, 2016. h. Blahous, C., “the costs of a national single-payer healthcare system,” July 30, 2018.

significantly affect the overall U.S. economy” and be “potentially disruptive,” and he cautioned that “the amount of care supplied and the quality of that care might diminish.”i

Lessons from the states Four states have tried to garner public support for a single-payer system, but their plans all fell apart because of concerns about their programs’ high costs and requisite financing. In 1994, Califor- nia’s Proposition 186 was rejected by 73% of voters. Similarly, in 2002, Oregon’s Measure 23 was voted down by 79% and in 2016, 79% of Colorado voters rejected Amendment 69, a universal healthcare proposal.

Shedding light on the potential tax implications of a single-care program, in 2014, Vermont’s then-Gov. Peter Shumlin, a Democrat who had famously championed a single-payer system, abandoned his drive after concluding that 11.5% payroll assessments on businesses and sliding- scale premiums of up to 9.5% of individuals’ income “might hurt our economy.”j

A shift to a single-payer system requires rare objectivity The divergence between the desire for a single- payer system and equally strong opposition to the tax increases to fund it is emblematic of the human condition: Our wants often exceed our ability or willingness to pay. Ultimately, policy- makers and other stakeholders — especially voters, who generally are less aware of the fiscal realities associated with Medicare for All — must consider the downside risks and weigh the benefits of a single-payer system against alternative uses of public resources, from spending on other programs to avoiding signifi- cant tax increases.

i. sullivan, P., “CBO: Medicare for All gives ‘many more’ coverage but ‘potentially disruptive,’” The Hill, May 22, 2019. j. Wheaton, s., “Why single payer died in Vermont,” Politico, Dec. 20, 2014.

Ken Perez is vice president of healthcare policy, Omnicell, Inc., Mountain View, Calif., and a member of HFMA’s Northern California Chapter.

hfma.org August 2019 15

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ww.sciencedirect.com

p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1e1 5 2

Available online at w

Public Health

journal homepage: www.elsevier .com/puhe

Review Paper

Single-payer or a multipayer health system: a systematic literature review

P. Petrou a,*, G. Samoutis b, C. Lionis c

a Pharmacy Program, Department of Life and Health Sciences, School of Science and Engineering, University of

Nicosia, Nicosia, Cyprus b St George’s, University of London Medical Programme, Delivered in Cyprus by the University of Nicosia Medical

School, Cyprus c Clinic of Social and Family Medicine, School of Medicine, University of Crete, Greece

a r t i c l e i n f o

Article history:

Received 18 July 2017

Received in revised form

18 April 2018

Accepted 9 July 2018

Available online 5 September 2018

Keywords:

Health system

Single payer health system

Multipayer health system

Universal health coverage

Health Insurance

* Corresponding author. E-mail address: [email protected] (P.

https://doi.org/10.1016/j.puhe.2018.07.006 0033-3506/© 2018 The Royal Society for Publ

a b s t r a c t

Objectives: Healthcare systems worldwide are actively exploring new approaches for cost

containment and efficient use of resources. Currently, in a number of countries, the critical

decision to introduce a single-payer over a multipayer healthcare system poses significant

challenges. Consequently, we have systematically explored the current scientific evidence

about the impact of single-payer and multipayer health systems on the areas of equity,

efficiency and quality of health care, fund collection negotiation, contracting and budget-

ing health expenditure and social solidarity.

Study design: This is a systematic review based on Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (PRISMA) guidelines.

Methods: A search for relevant articles published in English was performed in March 2015

through the following databases: Excerpta Medica Databases, Cumulative Index of Nursing

and Allied Health Literature, Medical Literature Analysis and Retrieval System Online

through PubMed and Ovid, Health Technology Assessment Database, Cochrane database

and WHO publications. We also searched for further articles cited by eligible papers.

Results: A total of 49 studies were included in the analysis; 34 studied clinical outcomes of

patients enrolled in different health insurances, while 15 provided a qualitative assess-

ment in this field.

Conclusion: The single-payer system performs better in terms of healthcare equity, risk

pooling and negotiation, whereas multipayer systems yield additional options to patients

and are harder to be exploited by the government. A multipayer system also involves a

higher administrative cost. The findings pertaining to the impact on efficiency and quality

are rather tentative because of methodological limitations of available studies.

© 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Petrou).

ic Health. Published by Elsevier Ltd. All rights reserved.

p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1e1 5 2142

Introduction

Universal healthcare coverage is ‘the most powerful concept that

public health has to offer’.1 The redistribution of health risks lies

at the core of a universal coverage health system (UCHS),

thereby protecting the citizens who are in the greatest need of

healthcare services.

Despite the diversity in the design of health systems

worldwide, all health systems have the same desired attri-

butes of efficiency, trustworthiness and affordability.2 The

healthcare system can be defined by three functional pro-

cesses: (i) service provision; (ii) financing and (iii) regulation,

which must be governed by the following principles: (a) eq-

uity; (b) financial protection and (c) efficiency and quality,

respectively.3,4

The payer type, whether single payer or multipayer, is a

highly debatable issue for any country contemplating

healthcare reforms.4,5 A single-payer health system is

delineated by universal and comprehensive coverage, while

the payer is a public entity. A multipayer healthcare system,

on the other hand, features two or more providers in charge

of administrating the health coverage. This assumes that a

certain level of competition exists and usually the rules of

competition, along with the basic principles of healthcare

coverage, are demarcated by a governmental body. Cyprus

and Ireland are examples of two European countries without

a UCHS.6 In Cyprus, a parliament-approved National Health

System has not been implemented because of concerns

about its fiscal sustainability and the lack of consensus

among social stakeholders and health professionals. Out-of-

pocket payment (private expenditure that does not include

copayments in the public healthcare sector) exceeds public

funding, while the ability of people to fund their healthcare

has been compromised because of the financial crisis and the

reduction of household disposable income.6 The public

healthcare sector has been severely strained, while the

financial recession had impaired affordability for private

sector health services, whose costs burden patients, thus

exposing them to potentially catastrophic expenditure. The

current situation begs for the introduction of a universal

coverage health system (UCHS). This systematic review aims

to enable informed decision-making in the context of Cyprus’ healthcare sector, while still being relevant to an interna-

tional audience, as many countries are actively pondering

reforms to improve their healthcare systems.

Objectives

The objective of this article is to systematically investigate

current scientific evidence about the impact of the single-

payer and multipayer health system on the areas of equity,

efficiency, quality of care and financial protection through a

systematic literature review.7

Methods

Based on the available literature and the theoretical back-

ground of universal coverage framework,4,8 the term health

protection, a major determinant in the context of a UHCS,

encapsulates:

a) Equitydtimely access not linked to employment status or

ability to pay;

b) Efficiency and high-quality health caredproviding the

highest possible level of health with the available

resources;

c) Financial protection against catastrophic health expendi-

ture, which can be further stratified into the following

categories:

� Fund collection, which is a policy norm.9 Fund collection

is a weak stand-alone tool, unless accompanied by

pooling of contributions and cross subsidisation of

health costs.

� Social solidarity.

� Negotiation, contracting and budgeting, comprising the

efficient use of health resources. This includes the se-

lection of providers and implementation of cost-

containment measures and even performance targets.

� Health expenditure that provides the funds to meet the

health needs of the population.

Studies reporting at least one of the aforementioned health

protection parameters were included in the review.

Search strategy

Our research strategywas to look for (a) original and published

studies (randomised controlled trials, observational, quanti-

tative, qualitative, meta-analyses); (b) published between 01

January 1980 and 28 February 2015; and (c) studies that discuss

single-payer and multipayer health systems, efficiency, soli-

darity, cost risk sharing and quality of care.

We searched the following databases: Excerpta Medica

Databases, Cumulative Index of Nursing and Allied Health

Literature, Medical Literature Analysis and Retrieval System

Online through PubMed and Ovid, Health Technology

Assessment Database, Cochrane database and WHO publica-

tions. We also searched for further articles cited by eligible

articles.

Screening process

The screening process was conducted in two stages: first, the

titles and abstracts were screened by the lead reviewer to

exclude distinctly irrelevant references. If the abstract did not

provide sufficient data to enable selection, full articles were

reviewed. Second, full-text manuscripts were screened for

compliance with inclusion criteria of the review by two in-

dependent reviewers. Disagreements were resolved by dis-

cussion or by consulting with the lead reviewer.

We adopted the Preferred Reporting Items for Systematic

Reviews and Meta-Analyses (PRISMA) statement for reporting

systematic reviews andmeta-analysis in health care10 (Fig. 1).

The PICO terms are the following:

1) Population: beneficiaries enrolled in health systems

2) Intervention: single payer vs multipayer health system

3) Comparison: single payer vs multipayer health system

Records iden�fied through database searching

(n = 888)

Sc re en

in g

In cl ud

ed El ig ib ili ty

Id en

�fi ca �o

n

Addi�onal records iden�fied through other sources

(n = 126)

Records a�er duplicates removed (n = 898)

Records screened (n = 898)

Records excluded based on �tle

(n = 703)

Full-text ar�cles assessed for eligibility

(n = 195)

Full-text ar�cles excluded, with reasons:

Not related (n = 107) Perspec�ve (n=11)

Not sufficient data (n=28)

Studies included n=49

Fig. 1 e Flow Diagram of literature review of single-payer vs multipayer health systems using Preferred Reporting Items for

Systematic Reviews and Meta-Analyses (PRISMA).

p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 1 4 1e1 5 2 143

4) Outcomes: equity, solidarity, costs, efficiency, risk pooling,

contracting negotiation and budgeting.

We used theMedical Subject Headings terms: ‘ Single Payer

System’, ‘Healthcare Disparities/statistics & numerical data’,

‘Insurance, Health/classification’, ‘System, Single-Payer’,

‘Single-Payer Plan’, ‘Insurance Coverage/statistics & numeri-

cal data ’, ‘Health Insurance, Voluntary’ ‘Insurance, Voluntary

Health’, ‘Group Health Insurance’, ‘Insurance, Group Health’,

‘Reimbursement, Health Insurance’, ‘Third-Party Payments’,

‘Payment, Third-Party’, ‘Payments, Third-Party’, ‘Third Party

Payments’, ‘Third-Party Payment’, ‘Health Insurance Reim-

bursement’, ‘Insurance Reimbursements, Health’, ‘Re-

imbursements, Health Insurance’, ‘Third-Party Payers’,

‘Payer, Third-Party’, ‘Payers, Third-Party’, ‘Third Party Payers’,

‘Third-Party Payer’, ‘Health Program, National’, ‘Health Pro-

grams, National’, ‘National Health Program’, ‘Program, Na-

tional Health’, ‘Programs, National Health’, ‘National Health

Insurance’, ‘Health Insurance, National’, ‘Insurance, National

Health’, ‘National Health Insurance, Non-U.S.’, ‘Health Ser-

vices, National’, ‘National Health Service’, ‘Service, National

Health’, ‘Services, National Health’, ‘National Health Ser-

vices’, using Boolean operators (AND, OR).

Data collection

Data relating to study characteristics, such as study popula-

tion, outcome measures and analysis undertaken, were

extracted on a data extraction form by the lead reviewer and

independently checked for accuracy by two independent re-

viewers, individually. Disagreements were resolved by dis-

cussion or by consulting with the lead reviewer.

Study selection

We identified 888 potentially eligible articles and an additional

126 through other sources (including snow-ball citations of

the included articles). Deduplication led to 898 articles of

which 703 were excluded based on title and 195 were further

assessed for eligibility. A total of 112 were

The post Single-payer Systems What Works (and What Doesn’t Work) Outside of the United States After researching a country (outside of the United States) with a single-payer health care system first appeared on Writeden.