After Senate Bill Falters, a Fresh Round of Single Payer Chatter

In the days since Senator John McCain (R-Arizona) turned down his thumb and became the third Republican to vote against the “skinny repeal” of the Affordable Care Act (ACA), creating a single payer system has been a hot topic among commentators, lawmakers, and private citizens, all looking for a long-term answer to treating patients with complex, chronic conditions. A public forum on the topic in California drew dozens.

“Single payer” calls for one public or quasi-public agency to be in charge of paying for healthcare, even though delivery is performed by private entities. It’s how Medicare, and especially Medicare Advantage, functions today—the federal government pays the costs, but insurers manage contracts and beneficiaries can pick a plan.

In his presidential bid, Senator Bernie Sanders (I-Vermont) called it “Medicare for all.” He is bringing back the idea, and he’s not alone. Talk of single payer, or versions of it, are making the rounds as a way to deal with the thorniest problems facing the ACA—how to deal with patients whose care is so costly the risk must be spread beyond a single company or small groups of individual market customers.

While coverage touting the merits of a single-payer system is a staple for progressive outlets like Rolling Stone and Mother Jones, it also showed up this week in Gastroenterology and Endoscopy News, where Michael Kirsch, MD, wrote, “I have written many times that I believe that Obamacare was designed to be an interim measure until a full and complete government nationalization of our health care system could be accomplished."

Single payer has support from a physicians’ group, Physicians for a National Health Program, which outlined a proposal published in the American Journal of Public Health in May 2016. A handful of Democrats are getting a jump on the 2018 House races and supporting a single-payer platform, bolstered by a recent Pew Research poll that found support for single payer has grown since the ACA passed in 2010.

Given the makeup of Congress—not to mention President Donald Trump's presence—a conversion to a pure single-payer system seems highly unlikely. But hybrid plans that combine free-market elements with single-payer solutions for high-cost populations aren’t so far off the table.

That’s what a pair of writers in The Hill, a Washington, DC, mainstay, proposed Tuesday.

“The best way forward is to resort to the free market first, and then, if affordable insurance (especially for pre-existing conditions) is not obtainable, direct government subsidy would be permissible,” wrote Joshua Ronen, of NYU Stern School of Business, and Kenneth A. Sagat, a lawyer at Sagat Burton LLP.

The hybrid option deals with the toughest cases, while a pure single-payer system would be unsustainably expensive, some say. Billionaire Mark Cuban is in this camp, as he explained in a wave of tweets that began “Dear politicians” and ran from Sunday night into Monday morning. He tweeted

Exactly why single payer won't work. You will get lower cost health care but get taxed into oblivion

— Mark Cuban (@mcuban) July 31, 2017