Learning From Other Countries and Dispelling Myths of a Single-Payer System

As the United States debates the feasibility and benefits or harms of a single-payer system, the important thing is to have a fact-based discussion and to ask questions, Jan Berger, MD, JD, chief executive officer of Health Intelligence Partners and medical director of the Midwest Business Group on Health (MBGH), said during a session at MBGH’s 39th Annual Conference, held May 8-9 in Chicago, Illinois.

She also pointed out that research has shown the United States is last out of comparable high-income countries in cost and quality of care. A 2017 study in Annals of Internal Medicine highlighted America’s poor primary care coordination compared with 11 other countries,¹ while other research has shown the United States pays more for poorer outcomes than comparably wealthy and sizable countries.^2,3

Berger has consulted in 14 countries with both the government and private and consumer organizations. Using the knowledge she has gained in these countries, she set about laying out the facts of single-payer systems and dispelling some of the myths being brought up in the United States during the arguments over Medicare for All and single payer.

She used her own experience of receiving care overseas to highlight the difference in cost and care quality. Berger was in Africa for 2 safaris with a stay in between in Capetown, but after the first safari, she realized she had an infection on her shoulder. Before the second safari, Berger got care in Capetown. She was treated by a private primary care physician who had been trained in the United States, and the doctor drained the infection and treated it with a minor surgery done in his office. The cost was just $92.

“Would it cost $92 [in the United States]?” she asked. “Maybe $1092” or more, she said.

All countries, regardless of what sort of system they are under, face similar challenges with access and cost. Every country is facing issues with technology, aging, and lifestyle changes, Berger said, but the United States is unique in that it’s the only country where people go into bankruptcy or become homeless because of healthcare costs, and it is the only country that has made healthcare political, she contended.

“I don’t care if you’re left, right, middle, who you vote for—we’ve got to stop making [healthcare] political warfare,” she said.

One of the many myths Berger tried to address and dispel during her speech was that the United States does not have a public system. In fact, she said, more than half of US citizens are in a public system today between services like Medicare, Medicaid, Indian Health Services, and the Veterans Health Administration. One of the main Medicare for All bills being debated does not include the public options in the bill. However, the bill goes much farther than Medicare currently does. As it stands now, Medicare does not include eye and dental care as part of the basic coverage.

Recently, the Congressional Budget Office (CBO) released a report on a single-payer option, such as Medicare for All, and one of the statements that stood out to Berger was that implementing Medicare for All would lower the barrier to people getting medications, which would increase the utilization of medications and make people more adherent to those medications, all of which would cost the country a lot of money.

“Who would think that medications that are necessary for people, making them available is a bad thing?” Berger asked. “Shame on the CBO.”

She also highlighted that just because 14 countries are on a single-payer system, it doesn’t mean they all have the same financial or operational models. While all of them use taxes to pay for the model, some use a general tax whereas others use a directed tax with the money being collected going only to healthcare. How much is taxed, how often citizens are taxed, and how the healthcare tax is utilized differs in every country.

Spain has long-term contracts with consumers using public­—private partnerships. Having these long-term contracts builds up trust, and about 4 years into the program, the country is seeing positive results. The Netherlands has seen success with an individual market with health insurance exchanges, similar to what the Affordable Care Act set up.

It also isn’t true that there is no cost to the consumer under a single-payer system. Only the United Kingdom and Cuba have zero costs to the consumer, but every other country still has out-of-pocket costs. The claim that private health insurers will no longer exist is also not true.

“Actually, they do very well in a single-payer system,” she said. They do so well, she said, that she actually isn’t sure why private payers are so against a single-payer system in the United States.

Private payers are still used as supplemental insurance or as an alternate. While basic healthcare is covered by the government, private payers can be used so that a patient gets a private room in a hospital or gets bumped up to the front of the queue to get care.

The myths that single-payer systems dictate how doctors treat patients or that they destroy innovation also aren’t true, Berger said. Healthcare quality and care pathways are important, and doctors are asked to pay attention to that, but they are not told what to do to deliver care. She also highlighted innovative programs around the world to address health issues. The Netherlands has a unique program to help patients with memory issues that has resulted in them being on fewer medications and being less aggressive and violent. Cuba’s maternity model has resulted in lower infant and maternal mortality rates than in the United States. France, meanwhile, is addressing aging and end of life with a major initiative.

“As we have a conversation as a country…we don’t have to be somebody else, but we have to learn from somebody else,” Berger said. “We have to learn from what has worked [and] what hasn’t worked.”

References

1. Penm J, MacKinnon NJ, Strakowski SM, Ying J, Doty MM. Minding the gap: factors associated with primary care coordination of adults in 11 countries. Ann Fam Med. 2017;15(2):113-119. doi: 10.1370/afm.2028.

2. Schneider EC, Sarnak DO, Squires D, Shah A, Doty MM. Mirror, mirror 2017: international comparison reflects flaws and opportunities for better US health care. The Commonwealth Fund website. interactives.commonwealthfund.org/2017/july/mirror-mirror. Published July 2017. Accessed May 8, 2019.

3. Sawyer B, McDermott D. How does the quality of the US healthcare system compare to other countries? Peterson-Kaiser Health System Tracker website. healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries. Published March 28, 2019. Accessed May 8, 2019.