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Single Payer Health Care Systems
- 1. SINGLE PAYER HEALTH CARE SYSTEMS Lynn A. Blewett, PhD University of Minnesota School of Public Health Presentation to the Minnesota Medical Association August 19, 2014
- 2. Overview • Overview of term “Single Payer” Click to edit Master title style Click to edit Master text styles Second level • Examples of Single Payer Health Care Systems Third level around the world Fourth level Fifth level • Vermont proposal for Single Payer • A few pros/cons and a few comments…. 2 Thanks to Mary Cobb, SHADAC doctoral student, for her assistance.
- 3. Some Click to Definitions edit Master title style Socialized Click to edit Medicine: Master text Medical styles and hospital services that are provided by a government and paid for by taxes. Second level Third level Single Payer Health Care System: Universal coverage Fourth level through a single, publicly-financed insurance plan that Fifth level provides comprehensive health care. Universal Health Care: System that ensures that all people obtain the health services they need without suffering financial hardship when paying for them (World Health Organization, 2014). 3
- 4. Centralized Click to edit Single Master Payer title System style Click to edit Master text styles • Concentrated Financing Second level • Government is dominant payer Third level • Funded Fourth primarily level through taxes • Providers, Fifth hospitals level can be mix of public and/or private • Universal access – No uninsured! • Minimum to no OOP spending • Private insurance is limited 4
- 5. A few more…. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level 5 • Government is the revenue collector – system organizers – generally one central authority • Core benefit package required but not all services covered (dental, vision, alternative medicine) • Most countries consider access to healthcare as a right (either legal or moral) • Patients can usually choose providers but generally some gatekeeping provided
- 6. Click Variation to edit in Single Master Payer title Systems style Click to edit Master text styles • Payment Models – price regulation, FFS, captitation and/or global budgets Second level • Service Delivery – providers and facilities can be public Third level or private sector, or some of each Fourth level • Financing – general tax revenue or a specific earmarked Fifth level tax (payroll tax is common), additional premiums if authorized • Private Supplement – some countries allow option to buy private insurance as a supplement or alternative to the national system but generally limited to what it can cover • Benefit Designs, Co-payment Requirements – these also vary, for services and pharmaceuticals 6
- 7. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level 7 COMPARING MODELS-FINANCING
- 8. Click Four Financing to edit Master Models title style 1. Click Canada to edit Master Public text styles Health Insurance Program 2. Second UK level Public Health Service 3. Norway Third level National Health Insurance 4. Germany Fourth level Social Health Insurance Fifth level 8 All could be considered a form of Single Payer • All provide universal coverage • All treat coverage as a right • Mostly publicly financed • Limited role of private health insurance
- 9. Follow the Money: Canada Click to edit Master title style Regionally-Administered Public Health Insurance Public 70% Private 30% Click to edit Master text styles Second level Third level Fourth level Fifth level Provincial income/sales taxes Province Provider Choice Any provider nationwide Any provider in province Any provider in network/plan Patient chooses/registers with a GP -65% buy supp. coverage for non-covered services but no cost-sharing for covered services – mostly through employers -Premiums charged in 3 provinces -Providers mostly private -Provincial level benefit sets -Hospitals operate under global budgets
- 10. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Provider Choice -11% buy Supp. Ins. for private facilities/elective surgery -No general cap for OOP -GP mostly private/hospitals public -GP as gatekeeper Follow the Money: England Payroll Tax-18% National Health Service Patient chooses and registers with GP Public 94% Private 6% National Health Service
- 11. Follow the Money: Norway Click to edit Master title style National Health Insurance Click to edit Master text styles Second level Third level Fourth level Fifth level Central Government Taxes 4 Regional Health Authorities • Secondary/ Tertiary Care 19 Counties • PH/PH Dental 428 Municipalities • Primary Care Patient chooses and registers with GP Public 85% Private 15% Provider Choice -10% Supp. Ins. mostly via employers for quicker access -Cost-sharing ceiling approx. $350 yr. -GP private/hospital public -GP as gatekeeper -National benefit set -Per capital grants to cities
- 12. Follow the Money: Germany Click to edit Master title style Social Health Insurance Click to edit Master text styles Second level Third level Fourth level Public 70% Private 30% Fifth level Employee/er Payroll Tax 134 Private Sickness Funds Provider Choice Any provider in province -11% of population opt out of SHI and purchase private insurance -Sickness Funds can charge premiums -Buy-in to SHI for low-income/ unemployed -Individual Insurance Mandate -National benefit package
- 13. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level 13 Germany Canada UK Norway Single-Payerness Concentration of Financing (HHI)
- 14. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level 14 COMPARING MODELS-OUTCOMES
- 15. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 1980 1984 1988 1992 1996 2000 2004 2008 US ($8,508) NOR ($5,669) CAN ($4,522) GER ($4,495) UK ($3,405) Dollars ($US) Average Health Care Spending per Capita, 1980–2011
- 16. Health Care Spending as a Percentage of GDP, 1980–2011 Click to edit Master title style 18 Click to edit Master text styles Second level Third level Fourth level Fifth level 16 14 12 10 8 6 4 2 0 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 US (17.7%) GER (11.3%) CAN (11.2%) UK (9.4%) NOR (9.3%) 16
- 17. Wait Times for Specialist Appointment Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level Less than 4 mos. More than 4 mos. Canada Germany Norway United Kingdom USA
- 18. Access Click to to Doctor edit Master or Nurse title When style Sick or Needed Care Click to edit Master text styles Second level Third level Fourth level Fifth level Same-Day or Next Day Apt Waited 6+ Days for apt Canada Germany Norway United Kingdom USA
- 19. Out-of-Pocket Costs in the Past Year-2013 (spent Click $1,000 to edit U.S Master or more) title style Click to edit Master text styles Second level Third level Fourth level Fifth level Canada Germany Norway United Kingdom USA
- 20. Health System Views-2013 Click to edit Master title style Half of population say fundamental change Click to edit Master text styles Second level needed Third level Fourth level Fifth level Works Well Fundamental Change Canada Germany Norway United Kingdom USA
- 21. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level 21 VERMONT’S SINGLE-PAYER INITIATIVE
- 22. Click Vermont: to edit Green Master Mountain title style Care • Gov. Peter Shumlin campaigned on single-payer, 2010 Click to edit Master text styles • Law enacted in 2011; state to build system by 2017 Second level • Set up exchange as required under ACA, plan to transition Third level • Major aspects: Fourth level Fifth level - Funding (some new taxes, some from federal waivers) - Waivers for Medicaid, SCHIP, Medicare, and ACA - ERISA compliance (self-funded plans not included) 22
- 23. The Purpose of Green Mountain Care Click to edit Master title style Provide comprehensive, affordable, high-quality, publicly-financed Click to edit Master text styles health care coverage for all Vermont residents regardless of income, assets, health status, or availability of Second level other health coverage by: Third level (1) providing incentives to residents to avoid preventable health Fourth level conditions, promote health, and avoid unnecessary emergency room visits; Fifth level (2) establishing innovative payment mechanisms to health care professionals, such as global payments; (3) encouraging the management of health services through the Blueprint for Health; and (4) reducing unnecessary administrative expenditures. 23
- 24. Click to edit Master title style Vermont is Unique Click to edit Master text styles • Small population - 626,000 • One Second larger level private insurer Third level – BCBS covers 90% of enrollees in Exchange • High coverage Fourth level rates already Fifth level – 6.5% uninsured in 2012 – 3rd lowest uninsured rate in US • Generous public coverage program – Dr. Dynasaur: children up to 300% FPL; Pregnant women up to 200% FPL • History of progressive social policies and voting patterns 24
- 25. Click to edit Master title style Click to edit Master text styles Second level Third level Fourth level Fifth level 25 SINGLE-PAYER PROS AND CONS
- 26. A Few Pros Click to edit Master title style • Potential for cost control and lower Click to edit Master text styles admin/overhead costs Second level Third level • Can negotiate or set prices for drugs and services Fourth level Fifth level • Like all universal coverage models, has higher population coverage than current U.S. system • Relying on single source of revenue may encourage more rational, deliberate trade-offs between cost and quality/quantity (Glied, 2009) 26
- 27. A Click Few Cons to edit Master title style • Political feasibility in US – polarized parties Click to edit Master text styles • Public perceptions/concerns of higher taxes, Second level government Third level control, excessive rationing, socialism Fourth level Fifth level • Potentially less financially-stable than a multi-payer universal coverage model potentially more dependent on fluctuations in economy • If financed with general taxation and global budgets, vulnerable to annual budget processes. 27
- 28. Click Conclusions to edit Master title style Click • Country to edit financing Master text and styles delivery models are unique • Yet one can find similar components in most Second level Third level Fourth level Fifth level systems • Other countries movement toward more local decision-making and control, less centralized authority • Few centralized single payer systems (UK) • Most systems developed over time with a focus on universal coverage as fundamental right of citizenship 28
- 29. Click Resources to edit Master title style Comparing Models: Commonwealth Fund. International Profiles of Health Care Systems, 2013. November 2013 Click http://www.commonwealthfund.to edit Master org/~/media/Files/text Publications/styles Fund%20Report/2013/Nov/1717_Thomson_intl_profiles_hlt_c are_sys_2013_v2.pdf Second level Karen Davis, Kristof Stremikis, David Squires, and Cathy Schoen. Commonwealth Fund. Mirror, Mirror, on the Wall: How the Performance of the U.S. Health Care System Compares Internationally. June 2104. http://www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf Third level Fourth level World Health Organization. Health Systems: Health Systems Financing. http://www.who.int/healthsystems/topics/financing/en/ Fifth level Glied, Sherry. “Single Payer as a Financing Mechanism.” Journal of Health Politics, Policy and Law. 2009. http://jhppl.dukejournals.org/content/34/4/593.full.pdf+html Vermont: Owen Dyer. “America’s First Single-Payer System.” The BMJ (formerly the British Medical Journal). January 2014. ttp://www.bmj.com/content/348/bmj.g102 Sarah Kliff. Forget Obamacare. Vermont Wants to Bring Single Payer to America. Vox Media. April 2014. http://www.vox.com/2014/4/9/5557696/forget-obamacare-vermont-wants-to-bring-single-payer-to-america Nathan Blanchet and Ashley Fox. Prospective political analysis for policy design: Enhancing the political viability of single-payer health reform in Vermont. Health Policy. June 2013. https://www.clinicalkey.com/#!/ContentPlayerCtrl/doPlayContent/1-s2.0-S016885101300064X
- 30. Click to edit Master title style Contact Information Click to edit Master text styles Second level Third level Professor, Dept. of Health Policy and Management Fourth level Fifth level Lynn A. Blewett, PhD Director, SHADAC University of Minnesota blewe001@umn.edu 612-624-4802 www.shadac.org @shadac