If you think health care is expensive now, wait till it’s free.”
Explore This IssueACEP Now: Vol 38 – No 10 – October 2019
By the common definition, America currently has “universal health care.” Health care services are largely available to almost all Americans via a combination of publicly and privately funded systems based on individual demographics. However, not all Americans choose to avail themselves of the options for health insurance to pay for these services and protect their assets.
Prior to the Affordable Care Act (ACA), or Obamacare, about 83 percent of Americans had some form of health insurance. Of the remaining 17 percent, half could have had coverage if they had chosen to pay a modest monthly premium (eg, to add family coverage at work) or simply applied for Medicaid. After ACA, the uninsured rate dropped to about 10 percent, largely due to expansion of Medicaid.1 As before ACA, perhaps another 5 percent could be covered if they choose.
With these facts in mind, the current discussion on health care is really about how to fund it and not about universal coverage. This brings us to the crux of the issue. How you fund health care directly determines what health care you get (or is even available). Nationalization of the health care system in America (eg, via “single-payer”) will be much different than our current private health insurance market. And much of this simply comes down to choice.
In a single-payer system (government funded, regulated, managed, and defined), politicians largely determine health care services and their costs. This is a “regulated monopsony.” In a market-based approach (even one that is highly regulated), individuals (or groups of individuals, eg, employers) largely determine services, and to some extent, the laws of supply and demand determine prices. Individuals have choices regarding insurance benefits or whether it is even worth the cost to purchase insurance.
Common Sense Analysis of Single-Payer Health Care
It is impossible to read, let alone analyze, everything that has been written about single-payer health care. Further, while various other countries are used as examples, the largest such country by GDP with single-payer is Japan, whose health care system (by total spend) is only about 9 percent of that of the United States. England is about 3 percent. We cannot be so naive as to believe a country the size of the United States can simply wholesale adopt a system that works for countries a fraction of our size. Even by population, the United States ranks third, and neither the first (China) nor second (India) most populous country has universal health care. There is simply no way to assume we can know the impact of adopting single-payer health care in the United States, and not just on health care but the entire economy and U.S. way of life.
The fact is, America has already largely achieved universal health care as defined as “available access to health care services.” Some simply choose not to avail themselves of readily available health insurance to protect against financial ruin due to an unexpected health care crisis. Failing to buy health insurance is like owning a car and failing to buy auto insurance. Then when you get into an accident, you complain about not having a car and suffering financial ruin after being sued by the other driver you hit.
Rather, the challenge with health care today is finding affordable insurance and/or care, a problem which largely stems from the ACA’s comprehensive coverage mandates and a lack of an efficient health care services market. Pharmaceuticals remain artificially expensive due to various federal policies.2,3 Direct hospital services are artificially expensive due to government price controls (cost shifting) and predatory pricing from some health plans.4 In fact, all of health care is artificially expensive due to a lack of a true market. Imagine how expensive anything might be if you could not comparison-shop because you did not know the price until after the goods and services were delivered. Amazon and eBay have revolutionized commerce, but health care has failed to keep pace. Nevertheless, a market-based approach will eventually prevail in virtually all aspects (including cost) if left alone to follow market forces. As noted, ACA mandates severely influence the upward trend in the cost of health insurance.4