The United States spends more than 14 percent of its gross national product on healthcare, more than any other in the developed world. Yet the U.S. is the only industrialized nation in the world that does not guarantee health insurance to all of its citizens. The current presidential campaign has seen several proposals put forward to address this national scandal, ranging from expansion of existing public programs to tax incentives to entice more employers to provide insurance to their workers, to privatization of the Medicare program.
This brief summary attempts to answer some of the most common questions that people ask about a universal, single-payer health care system. Most of it is drawn from the “Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance” that was published in the August 13, 2003 issue of the Journal of the American Medical Association.
Here are the four principles that shape their proposal:
1. Access to comprehensive health care is a human right. It is the responsibility of society, through its government, to ensure this right. Coverage should not be tied to employment.2. The right to choose and change one’s physician is fundamental to patient autonomy. Patients should be free to seek care from any licensed health care professional.3. Pursuit of corporate profit and personal fortune have no place in caregiving. It creates enormous waste and too often warp clinical decision making.4. In a democracy, the public should set health policies and budgets. Personal medical decisions must be made by patients with their caregivers, not by corporate or government bureaucrats.”
The big question is, how would it work? Here are a few key points:
Who is eligible and what is covered? A single public plan would cover every American for all medically necessary services, including long-term care, mental health, dental, and prescription drugs and supplies. As the authors point out, “Only a single comprehensive program, covering rich and poor alike, can end disparities based on race, ethnicity, social class, and geographic region that compromise the health care of the American people.” Private insurance would not be allowed, as it would undermine the public program and inevitably lead to a “two-tiered” system of care.
How do hospitals pay their bills? The National Health Insurance (NHI) program would pay each hospital a monthly lump sum to cover all operating expenses. The hospital and the regional NHI office would negotiate the amount of this payment annually based on past budgets, clinical performance, projected changes in demand for services and input costs, and proposed new programs. Hospitals could not use any of their operating budgets for expansion, profit, excessive executives’ incomes, marketing, or major capital purchases or leases. Investor-owned hospitals would be converted to not-for-profit status and their owners compensated for past investment.
How do doctors make a living? Physicians and other practitioners could choose to be paid salaries from the clinic, hospital, or HMO where they work (the money would be drawn from the institutions’ “global budget” paid by NHI). Or, they could go with a “fee-for-service,” where they would submit bills directly to NHI for all services, and would be paid promptly based on a simple, binding fee schedule. Global budgets would allow institutions to virtually eliminate billing, while assuring them a predictable revenue stream. Such funding could also stimulate the development of community prevention programs whose costs cannot be attributed (or billed) to individual patients.
What about long-term care? The NHI program would cover disabled United States citizens of all ages for all necessary home and nursing home care. A local public agency in each community would determine eligibility and coordinate care. The NHI program would pay long-term care facilities and home care agencies a lump sum budget to cover all operating expenses. For-profit nursing homes and home care agencies would be converted to not-for-profit status. Since most elderly people and people with disabilities would prefer to remain in their homes, the program would encourage home- and community-based services. Nurses, social workers, and an expanded group of trained geriatric physicians would assume leadership of the system.
What about buildings, equipment, investments, and profit? The NHI budget would fund the construction of health facilities and the purchase of expensive equipment, making sure that capital funds would go to excellent and efficient projects in areas of greatest need. The NHI program would compensate owners of investor-owned hospitals, HMOs, nursing homes, and clinics for the loss of their clinical facilities.
Would medications and medical supplies be paid for? The NHI program would pay for all medically necessary prescription drugs and medical supplies, based on a national formulary. Outpatient suppliers would bill the NHI program directly for the negotiated wholesale price, plus a reasonable dispensing fee, for any item in the formulary that is prescribed by a licensed practitioner.
How would all of this be paid for? People are so worried about this that I will cover it in a separate section. Suffice it to say that the NHI system, which would cover all currently uninsured people, pay for long-term care, and fully cover needed prescription drugs, would cost the nation no more—and possibly less—than we are spending now.