SINGLE PAYER IN WASHINGTON
STATE: CHALLENGES AND
APPROACHES
John Geyman M.D.
Professor Emeritus of Family Medicine
University of Washington
November 9, 2013
THE BIG FOUR PROBLEMS
REQUIRING REFORM
1. Soaring, uncontrolled health care costs.
2. Increasing unaffordability of health care.
3. Restricted access for uninsured & underinsured.
4. Variable, often mediocre quality of care.
ACA Potential Benefits
• Extends Health Insurance to 27M people by 2019
• Subsidizes premiums for lower income
• Allows children up to age 26 on parents’ policies
• Prohibits insurance limitations on pre-existing illness and bans
annual and lifetime limits
• New funding for community health centers
• Government sponsored insurance exchanges in each state
• Establish Patient-Centered Outcomes Research Institute (PCORI)
Geyman, J.P. Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform.
Friday Harbor, WA. Copernicus Healthcare, 2010
How Insurers Are Gaming
the Affordable Care Act
･ Broad definition of medical loss ratio
･ Continued escalation of premiums
･ Limited benefit policies
･ Lobbying for minimal benefit requirement rules
･ Narrow networks
･ Short term policies
･ Cancellation of policies
･ Coordinated pushback against state regulators
HOW EMPLOYERS ARE
GAMING THE ACA
• Shifting more employees to part-time
• Limited benefit policies
• High-deductible plans as only option
• More cost shifting to employees
• Low annual limits (e.g. McDonalds Corp. $2,000)
What Happens To Insurers
After Passage of ACA
1. Consolidation through mergers and acquisitions.
2. Increased tiering of health plans (60 to 70 percent actuarial
value) with higher deductibles
3. Decreasing choice of physicians and hospitals-”Narrow
Networks”
4. More use of pre-authorizations.
5. Further privatization of Medicare and Medicaid.
6. PR blitz promoting “consumer-friendly” expanded roles.
Problems With ACOs
In the grand scheme of healthcare spending,
ACOs' savings will be slight.
ACOs won't work when healthcare still operates
in a fee-for-service system. So now the chatter is
Pay-for-performance (P4P).
ACO’s can’t work and/or can’t create
competition in rural and many suburban areas.
Long-Term Harmful Effects
of the ACA
1. Solidifies insurance company strangle-hold on the medical
economy.
2. Accelerates the migration of primary care to
institutionalized medicine with new layers of waste and
bureaucracy.
3. Risks convincing the country that the government only
makes health care worse.
4. Legitimizes leaving 50 million people un-or under-insured.
ACA Does Not
Control Costs of:
• Fee for Service
• Incentivized Salaries
• Unnecessary Procedures
• Administrative Waste
• Multi-level Fraud
• Upcoding
• Insurance Company Overhead and
Profits
• Pharmaceuticals and DME
ACA Also Does Not:
• Assure Access and Affordability
• Improve Quality
• Assure rebuilding of primary care
• Defragment our national health care
• Address the needs of rural health care
• Address the costs of medicalization
Alternative Solutions
1. Free market with multi-payer
financing
1. Single payer financing coupled
with private delivery system
HOW HEALTH CARE FREE
MARKETS FAIL PATIENTS
1. Predatory pricing
2. Perverse incentives for profit
3. Consolidation and market power
4. Inefficiency and bureaucracy
5. Inadequate quality control
6. Volatility and unreliability
FREE MARKETS
(cont’d)
7. Unethical practices
8. Outright fraud
9. Opaque policies, procedures, prices
10. Emergency nature of many encounters
11. Asymmetric information
IS THE ACA A PATHWAY
TO SINGLE PAYER?
NO: for all its inherent flaws re inadequate access,
lack of cost containment, increased bureaucracy,
unsustainability, etc.
YES: if its failures become widely understood
and a broad non-partisan backlash promotes the
only viable option—national single payer, with
perhaps some states leading the way.
CHALLENGES TO SINGLEPAYER IN STATES
• Pass a strong bill for universal health care, including authority to set
rates, establish claims processing, and plan capital expenditures (WHST)
• Integrate all federal funds for health care into state budget
(interagency
process, IAP bill of Rep. Jim McDermott as enabling
legislation).
• Dealing with workers’ compensation benefits
• Dealing with employers and getting waiver from ERISA
• Determining how to pay for program; premium reduction vs. taxes
SOME APPROACHES TO SINGLEPAYER IN WASHINGTON STATE
• Complimentary emphasis on state and national efforts
• Reframe the debate based on evidence
• Educate legislators
• Build coalitions; use of social media per California
example?
• Reach out to business and opponents of single payer
• Build on experience of other states
REFRAMING THE
HEALTH CARE DEBATE
• Economic argument: Friedman’s and previous reports; all
will save money and get more with single payer.
• Social/political argument: single payer and American
values; crosses party lines
• Moral argument: health care as a right; U.S. as outsider in
world; cruelty of present system; who is health care system
for?
SHIFT IN CONSERVATIVE
PUBLICATIONS
“For-profit health insurance has undermined our economy and
society. . . We lost the positive aspects of affiliation health insurance
starting in the 1960s and through the 1980s when Wall Street
discovered there was money to be made turning nonprofit health
insurers, hospitals and nursing homes into investor-owned
companies. What we got was a massive conflict-of-interest—profit vs.
public good—that has culminated in a dysfunctional health delivery
system that has undermined our economy, reduced our national
wealth and torn our social fabric.”
—John E. Girouard, The capitalist case
for nonprofit health insurance. Forbes, 2009
CONSERVATIVE CASE FOR
UNIVERSAL HEALTH CARE
“It is time for American conservatives to add health care to fire
and police services as minimal government services needed to
enable individuals to thrive at minimal financial costs. The
question for conservative leaders who deplore wasted
potential, free-riding, financial waste, and inefficiency is not
whether they can support universal access to needed health
care. It is how they can not support universal access without
betraying their own values.”
—Donald Light and Paul Mentzel,
Hastings Center Report, 2006
REASONS FOR OPTIMISM THAT
SINGLE-PAYER IS ACHIEVABLE
IN OUR OWN TIME
• ACA is failing, Republicans have no plan, and there’s no
other alternative.
• Rising public backlash; growing support for single payer
• Increasing frustration among health care professionals.
• Continued decline of employer-sponsored insurance
• Needs of business to escape rising burden of health care
costs
• Probable liberal-conservative convergence for real reform
• Power of social action from the grassroots
• Stein’s Law: “If something cannot go on forever, it will
stop.”