It appears that the debate over healthcare in the USA will once again dominate the political campaigns of the country in 2020. Regardless of whether the political rallying cry is “Repeal Obamacare” or “Medicare for All” or “Keep My Healthcare”, it is likely that emotions will run high, rhetoric will run hot, and confusion will run deep.
This Post is NOT intended to advocate for any specific position or policy recommendation for the future. We can save that debate for a future posting.
But, as the debate begins to get louder and more emotional, it does appear that some clarification is needed around the issue of “SINGLES”.
• Single payers.
• Singe providers.
• Single offerings.
These terms and concepts are critical to the upcoming debate, and yet confusion over these three concepts is widespread. Some of this confusion is certainly unintentional…the result of healthcare always being a confusing and complex topic. But some of that confusion is also intentional – the result of trying to twist the debate in favor of or against various proposals that are being advocated.
Thus, to clarify these three concepts, three distinct definitions…
1.0 SINGLE PAYER: The government FINANCES the health care system for all people. A Single Payer System tends to equalize the financial burden of healthcare across the entire population and generally guarantees that income and personal financial resources do not become a barrier to receiving care. Under a Single Payer System, money is paid to providers for all citizens who receive care. The Medicare System in the USA is a Single Payer System, but it only pays for citizens who are 65 or older. A Single Payer System does NOT automatically…
1.1 Determine Price – A Single Payer System can be set up to simply reimburse providers based on charges or market prices. This was once the case with Medicare – providers were paid based on what they spent and the government did not set price. That changes over time, but price setting is not automatically required in a Single Payer System.
1.2 Eliminate Insurance – A Single Payer System can be set up to pay for individual or group insurance, which would then pay providers for care.
1.3 Set Standards – A Single Payer System may or may not require standards of performance to be met. A Single Payer System could require provider certification, quality standards, and or levels of consumer satisfaction…or it could require no standards at all.
1.4 Guarantee Specific Treatments – A Single Payer System can be established to pay for any and all health care delivered…or it can be set up to pay only for specific treatments, drugs, and healthcare interactions. For example, a Single Payer System might pay for an annual check-up by a doctor, or such a visit could be excluded by the Single Payer.
2.0 SINGLE PROVIDER: One organization is responsible for the DELIVERY of all health care services for all people. In short, a Single Provider is a MONOPOLY and is both responsible for and privileged to deliver actual health care services. A Single Provider System establishes control over the operation and design of health care services to be provided. This includes location of services, level of services, and oversight of outcomes. Therefore, a Single Provider System tends to create a system of Accountability – one single authority responsible for solving problems in the system. There are few Single Provider Systems around the world that are absolute monopolies, but the Veterans Administration Healthcare System is an example in the USA of a (mostly) Single Provider System. A Single Provider System does NOT automatically…
2.1 Centralize Ownership – A Single Provider System can control and deliver services by using sub-contractors…independent providers who are neither owned by or directly controlled by the Single Provider. In short, a Single Provider System can be designed to contract with private entities for the deliver of some, or even all, services. For example, the U.S. Armed Forces are a “Single Provider of International Security” and yet the Armed Forces contract independently with manufactures, vendors, and even private security forces to deliver the protection services required.
2.2 Provide Funding – A Single Provider System may or may not be fully or partially funded by a Single Payer – i.e., the government. In other words, a Single Provider System can be designed to be funded if and only if it is able to attract customers or business activity. For example, government hospitals in Australia – a hybrid system to be sure — are only partially funded by the government. Government health care systems must also attract private customers with private insurance if they are to remain financially viable.
2.3 Guarantee Consistency or Uniformity – Either by design, or by default, a Single Provider System does not guarantee equity across an entire region or population. Delivery of care might vary dramatically between one location or another and a Single Provider might choose to focus on one healthcare need (i.e. maternal care) over another (i.e. mental health).
3.0 SINGLE OFFERING: Onley one, uniform BUNDLE OF SERVICES is offered and made available to all eligible citizens – the same type of care, the same services, at the same (or similar) level of financial burden. In a Single Offering System, the delivery and financing of health care is somewhat simplified and disparities of health care can potentially be removed between individuals. A Single Offering System tends to create a unified Consumer Base – all people receiving the same services and thus all people either uniformly satisfied or uniformly disappointed in their care coverage. This allows both preferences and expectations to be more easily isolated and addressed in a political or business setting. A Single Offering System guarantees social equity across a population when it comes to access of healthcare services. Within each of the 50 states, the Medicaid System for low income individuals tends to be a Single Offering System – no choices of coverage are allowed and all recipients receive the same services. Likewise, within many businesses, all employees are subjected to a “Single Offering” with the employer determining what all employees do or do not receive in terms of care and coveage. A Single Provider System does NOT automatically…
3.1 Determine Intensity or Quality of Services – A Single Offering System can be built around a low level of service with everyone getting basic care only, or around a high level of service with every recipient given a wide range of services.
3.2 Create Oversight or Control – A Single Offering focuses on the product that is offered to a consumer and may not address Provider inequities or quality. In fact, a Single Offering may actually diminish differentiation between providers and may make it more difficult to identify high or low performing providers of care.
3.3 Promote Innovation – Although it can be argued that a Single Offering creates competition amongst providers to be the “Best Amongst Equals”, a Single Offering does not promote product differentiation or innovation of new services. The “sameness” of a Single Offering focuses providers on “Today’s Services” and does not systematically reward invention and innovation.
As said, the purpose of this Posting is NOT to argue for or against any of the three “SINGLES”. Many people feel passionately about one or all of these concepts – some individuals believing they are “must haves” in the future of healthcare, while others believe them to be avoided at all costs. But, the debate can be useful only if these concepts are clearly delineated and kept separate. It is important to remember that these concepts are…
#1) NOT MUTUALLY EXCLUSIVE: A healthcare system can combine one, all, or none of these concepts. For example, it is possible to build a Single Payer System that relies on multiple providers and diverse product offerings – Medicare Advantage, for example, offers multiple products and services, providing by a diverse array of providers, even though the system is a Single Payer funded system. Almost all healthcare systems around the world do, in fact, mix an match these concepts regularly – it is almost impossible to find “pure examples” of a Single Payer, a Single Provider, or a Single Offering System that does not allow some exceptions to the norm.
#2) NOT GUARANTEES of QUALITY: Healthcare continues to suffer from poor outcomes. In fact, Medical Error continues to be a leading cause of avoidable death in the USA. None of these “SINGLE” concepts – payer, provider, or offering – guarantee that high quality services will be available or required. Quality is a result of good service design and delivery. That happens only with a mix of regulatory mandate, proper human incentives, scientific research, system transparency, high quality measurement, and consumer (patient) involvement and activation.
#3) NOT AUTOMATICALLY COST EFFECTIVE: Healthcare costs are an exorbitant percentage of the USA economy. None of these “SINGLES” are guaranteed to control costs. Cost Control – regardless of whether it is forced and required by a Single Payer System, whether it is the result of underfunding a Single Provider System, or whether it is a byproduct of a bares bone Single Offering – causes pain for those who currently profit from the status quo. Reducing costs will come from only two mechanisms – political pressure or innovation. And both disadvantage those providers who profit from the healthcare system as it is currently designed and funded.
#4) NOT the ONLY CONSIDERATIONS: Perhaps most importantly, it is critical to remember that “healthcare” is a complex concept. It is not just about your doctor and your nearby hospital…
o High quality healthcare requires education systems that can quickly and effectively prepare people for healthcare related careers.
o High quality healthcare requires research and investment funding for new technologies, data harvesting, and new clinical treatments.
o High quality HEALTH, not just healthcare, requires a focus on social factors of poverty, transportation, environment, and lifestyles.
In short, the SINGLES may generate the most debate, but we must all remember that the “answers” to high quality health and healthcare are far more complex than just those “single factors”. So, with a bit more clarity (we hope), let the debates begin!