• Does Single Payer Have Friends in CBO Places?

    "Blame it all on my roots, I showed up in boots and ruined your black tie affair"
    -- Garth Brooks

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    Last week, the Congressional Budget Office released a report titled "Key Design Components and Considerations for Establishing a Single-Payer Health Care System." As you can imagine, it caused quite a stir in the health policy world.

    The Academy recently released its own report outlining policy objectives and approach to health care reform, including many of the same topics covered in the CBO report. That document, "Health Care for All: Moving to a Primary Care-Based Health System in the United States," is available to all AAFP members.

    The CBO report is extremely well done and deserves praise. It is comprehensive and objective. Its authors avoid putting a thumb on the scale and simply discuss the structural, operational and financing challenges of a single-payer health care system. (It is important to note that the CBO was not asked to theorize here about possible financing mechanisms.)

    I'm up to three mentions of the phrase "single payer," so I've likely lost a few of you. But everyone should read the report, which is relatively short and includes a chart and table (on pages 2, 4 and 5) that may be the best overviews of what would be required to establish a single-payer system and how other countries have done so.

    The complexity and cost associated with single payer leads many to dismiss the concept out of hand, but I believe the concept deserves evaluation and scrutiny. The health care system is leaving behind millions of frustrated Americans. Those patients won't be alone in their openness to doing big things to fix health care.

    So, let's take a look at what the CBO had to say. The report's introduction states the obvious: "Establishing a single-payer system would be a major undertaking that would involve substantial changes in the sources and extent of coverage, provider payment rates and financing methods of health care in the United States."

    "Major undertaking" seems a little nonchalant. I would describe it as a "monumental undertaking, if things go well." On the other hand, just because something is difficult does not mean it's unworthy of evaluation or action. Lots of hard things get accomplished, and countless easy things don't -- that's politics.

    The CBO does an excellent job of describing the elements that would need to be addressed in a single-payer system. Each of these comes with its own opportunities and challenges, and each would have proponents and opponents. The report identifies them as

    • administration,
    • eligibility and enrollment,
    • covered services and cost sharing,
    • the role of the current system,
    • provider roles and rules,
    • payment rates, and
    • cost containment and financing.

    Each of these would require that multiple layers of detail be established through legislation and regulation -- and every step would bring numerous important questions. The work also would present an opportunity for the AAFP to influence and shape the outcome, something we are poised to do.

    For valuable context, the report includes some discussion on the pros and cons of a single-payer system compared with what we're used to. This segment focuses heavily on the ways in which highly regulated multipayer systems work in other countries. The CBO does a good job here laying out the give and take of both options.

    Among the report's most valuable take-aways are these key observations:

    • "Total national health care spending under a single-payer system might be higher or lower than under the current system, depending on the key features of the new system, such as the services covered, the provider payment rates, and patient cost-sharing requirements."
    • "In addition to its potential effects on the health care sector, a single-payer system would affect other sectors of the economy beyond the scope of this report."
    • "Moreover, unlike private insurers, which can experience substantial enrollee turnover over time, a single-payer system without that turnover would have a greater incentive to invest in measures to improve people's health and in preventive measures that have been shown to reduce costs."

    Two primary concerns about a single-payer health care system are the methods it would use to pay clinicians and set payment rates, both of which would directly affect government spending, national health care spending and clinicians' revenues. This impact on revenues would, in turn, affect incentives to deliver services.

    The report also includes a little comic relief. In the "Standardized Information Technology Infrastructure" section comes this statement: "A standardized IT system could help a single-payer system coordinate patient care by implementing portable electronic medical records and reducing duplicated services."

    And then: "Establishing an interoperable IT system under a single-payer system would have many of the same challenges as establishing an interoperable IT system in the current health care system with its many different providers and vendors."

    As usual, the truth is either really funny or completely demoralizing. Basically, the CBO is saying that the federal government, powerful as it may be, cannot compel IT vendors to do the right thing.


    Health care continues to be front-of-mind for voters, as it has been for the past two decades. According to a Gallup tracking poll, health care remains one of the top three noneconomic domestic policy issues for voters, along with government leadership and immigration.

    Why? You already know. According to the most recent Kaiser Family Foundation Health Tracking Poll, Americans' top five health care priorities, further delineated by party affiliation, are

    • lowering prescription drug costs: 68% (Republicans, 66%; Democrats, 77%; independents, 64%),
    • maintaining protections for coverage of preexisting conditions: 64% (R, 47%; D, 82%; I, 62%),
    • protecting patients from surprise billing: 50% (R, 45%; D, 55%; I, 49%),
    • implementing Medicare for All: 31% (R, 14%; D, 47%; I, 26%), and
    • repealing and replacing the Patient Protection and Affordable Care Act: 27% (R, 52%; D, 16%; I, 22%).

    The KFF poll's more meaningful revelation, though, might be that words matter. The question "Do you have a positive or negative reaction to [each of the following terms]?" yielded huge gaps in how respondents weighted different labels for essentially the same idea:

    • universal health coverage: 63% positive, 31% negative;
    • Medicare for All: 63% positive, 34% negative;
    • national health plan: 59% positive, 36% negative;
    • single-payer health insurance system: 49% positive, 32% negative; and
    • socialized medicine: 46% positive, 44% negative.

    Clearly "socialized medicine" is a bogeyman for many. But the positive-negative spread for universal health coverage and Medicare for All are basically the same. The former was the preferred language during the ACA debate and, as a policy objective, it continues to have strong support.

    As the 2020 presidential election looms, I anticipate that health care will become an even more hotly debated, contentious issue. I welcome your feedback, insights, insults and hot takes on the CBO report; I am genuinely curious what your reactions might be to the opportunities and challenges it identifies.


    Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.  Read author bio »


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