Calls for universal health care, some under the banner of Medicare for All,” are growing among some policy makers and presidential candidates looking to run in 2020. As a response, the Chairman of the House Budget Committee in the U.S. Congress, Rep. John Yarmuth (D-Ky.), asked the Congressional Budget Office (CBO) to develop a report outlining definitions and concepts for a single-payer health care system in the U.S.





The result of this ask is the report, Key Design Components and Considerations for Establishing a Single-Payer Health Care System, published on 1st May by the CBO.

The report provides a useful baseline/outline of single-payer plans, comparing general features of U.S. health plan design with plans offered in several other countries to provide context and contrast.

This Health Populi post summarizes key themes of the CBO report, followed by a few Hot Points below the digital fold for my lens on the prospect for Americans to achieve health citizenship that I describe in my book, HealthConsuming: From Health Consumer to Health Citizen

Let me begin with a quote from the first couple of pages that sums up how integral health care is to the larger U.S. macroeconomy: “Because health care spending in the United States currently accounts for about one-sixth of the nation’s gross domestic product, those changes could significantly affect the overall U.S. economy.”

The support for U.S. single-payer health insurance is driven by the fact that some 29 million people under 65 were uninsured in an average month in 2018, CBO noted in a previous report.

There are four features that embody a single-payer health plan, CBO lists:

  1. A government entity operates a public health plans, responsible for the operational functions of the plan, from defining the eligible population to paying providers for covered services
  2. The eligible population is required to contribute toward financing the system
  3. The spending shows up in the government entity’s budget
  4. Private insurance, which can be allowed, generally plays a small supplementary role.

The CBO points out that Medicare in the U.S. is a single-payer system — covering a defined population of older and disabled Americans. But arguably, aspects of Medicare aren’t purely “single-payer:” a key argument here is that private insurers play important roles in implementing and operating aspects of traditional Medicare and Medicare Advantage.

CBO notes that pure single-payer systems are found in Australia, Canada, Denmark, England, Sweden and Taiwan; and, in Germany, the Netherlands and Switzerland, universal coverage has been achieved through multi-payer systems where more than one insurer provides health care coverage for all health citizens.

To that point, CBO recognizes that depending on the design of the single-payer system, some people could be allowed to retain private coverage that supplements the public plan. [Personal sidebar: I had this when I worked in the United Kingdom, covered by the National Health Service single-payer plan but supplemented by a BUPA health plan provided by my employer].

“Government spending on health care would increase substantially under a single-payer system because the government (federal or state) would pay a large share of all national health care costs directly,” CBO notes.

There are opportunities and risks if the U.S. adopts a single-payer plan, CBO identifies. On the upside, single-payer would probably generate lower administrative costs. Furthermore, in a single system, there would be an incentive to invest more in prevention and programs that improve peoples’ health and reduce costs.

On the risk side of the single-payer scene, expanding access on the demand side of patient-enrollees could challenge the (limited) supply side of physician and hospital services, CBO foresees. Consumers could also have limited options available in the plans-as-defined by the government operator.

And, to be sure there would be many unintended impacts based on the integral nature of the health care economy in the larger national economy of the U.S.

The CBO was smart to include a discussion on a single-payer system’s information technology infrastructure. In the U.S., interoperability has been challenging since the adoption of electronic health records systems were fostered by the HITECH Act (part of the Stimulus Bill under President Obama).

The report then covers what health care services a U.S. single-payer plan would/could cover. This discussion inevitably leads to concerns about rationing, queueing up for services, and cost-effective analysis as performed, for example, by the NICE organization in the UK.

Would Americans in a single-payer system have to deal with cost-sharing in the forms of co-payments, deductibles, coinsurance, or out-of-pocket maximums? CBO asks. Depending on the plan design, yes, indeed, U.S. health citizens in a single-payer plan could still face cost-sharing, even in a publicly administered plan.

Given that possibility, there’s a potential role for privately provided supplementary insurance to complement the public plan, CBO notes. Supplemental private health insurance is indeed part of the universal health care/single-payer programs in Canada and across the European Union.

Other features and factors are considered in the CBO report, including how different single-payer plans deal with prescription drugs (both in terms of access and payment methods), ownership of hospitals (private vs. public), and cost containment programs.

Health Populi’s Hot Points:  As President Trump recognized just weeks after his taking his seat in the Oval Office, “Nobody knew health care could be so complicated.”

It’s interesting to me that another public agency inside the Beltway, the GAO, published research last week on cost-savings that could be generated by Medicare Advantage implementing telehealth benefits. The bottom line: MA’s adoption of telehealth could save the plan over $500 million in costs.

This single workflow change which helps us re-imagine what healthcare delivery looks and feels like can at once generate cost savings which can help cover more U.S. health citizens for care and access, as well as promote consumer engagement and service satisfaction. A recent Accenture study found that most U.S. health consumers would welcome the opportunity to receive care in virtual and community-based settings, shown in the graphic.

The current U.S. health care delivery system is based on workflow that is, largely, cost-increasing. If the U.S. moves toward universal health care coverage of any flavor, we must modernize care delivery capitalizing on the benefits of the cloud, enhanced interoperability, data analytics, and more effective consumer engagement in self-care.

A post-script added later about workflow: After I posted this blog, I happened upon a recently-published survey from Vidyo assessing telehealth adoption in 2019. I have known that Henry Ford Health System has successfully adapted workflow to take on more value-based care by implementing telehealth (partnering with Vidyo) through their Epic electronic health records system. In Vidyo’s survey, the top two ROI criteria ranked in importance of telehealth adoption were (1) improved patient outcomes and quality measures, and (2) increased patient satisfaction.

This is exactly what I had in mind when I addressed the issue of re-imagining workflow via new modalities and platforms to drive outcomes, enhance the patient experience, lower costs and, in the case of the Vidyo survey findings, benefit physicians’ experience, too.