Louisville Medicine Volume 67, Issue 10 | Page 33

THE FINANCIAL CASE FOR SINGLE-PAYOR O DOCTORS' LOUNGE AUTHOR Michael Flynn, MD ne of the benefits of a single-payor health care system would be that most of the complexity and inef- ficiency of the current for-profit health-insurance-company-driv- en-system would be replaced. The high unaffordable health insurance premiums, the deductibles, the copayments, the surprise medical bills, the uncovered ser- vices and the denial of coverage would either simply go away or be reduced so much that they would not cause the financial ruin of the average American. The over 70 million uninsured or underinsured Americans as of 2017/2018 would no longer be vulnerable to medical debt and bankruptcy (1) . Medical bankruptcy would no longer be an issue for the hundreds of thousands of US families (2, 3) . An exact number of medically initiated bankruptcies in any specific year is difficult to pinpoint; the range can vary from 200,000 to 800,000 (3) . The Epic EMR that we have all grown to know and love is insanely more complex in this country compared to other countries using the same vehicle because of US billing issues and requirements (4) . There are over 1,000 for-profit health insurance companies in this country, each with 25-30 different plans. This creates an administra- tive nightmare for medical practices. A medical or surgical clinical practice must hire multiple staff members to navigate the process of justification of insurance coverage, the details of any specific plan, the pre-authorization process, the limits of coverage in any plan and the endless hassle of eventually getting paid for the service provided, often many weeks or months after the billing date. Under the Canadian system, a surgical practice employs a fraction of the staff needed in this country (5) . There is minimal hassle regarding imaging studies and tests. The bill is sent to a single source, and the payment is received in two to three weeks. By definition, single-payor health care would be a government run health insurance program (6) . The health care delivery process would not change. The hospitals, physician offices, pharmacies, etc. would continue as they do today. Depending on the final product of the political process, a single-payor system could be run by the federal or state government or some combination. All residents of this country would be eligible for medically necessary services. Generally accepted medically necessary services include hospital and physician care, preventive care, long term care, mental health, reproductive care, dental, vision, hearing, prescription drug and medical supply costs. The exact definitions of medically necessary services, and which of these options might be covered, would also be subject to the political process. One of the major issues of a single-payor system is how it would be funded. The 2018 single-quarter profits of the top 85 publicly traded (for-profit) health insurance companies was $47 billion (7) . Multiplied by four, this represents just under $200 billion paid to insurance companies as premiums for health care coverage which is not used for health care—rather, simply kept as profit. Another recent study shows that comparing the Canadian single-payor system with the US profit-dominated system, there is a $812 billion price tag related to the costs of the insanely complex administrative re- quirements in order to accommodate the for-profit health insurance companies (8) . A huge amount of money is being extracted from the health care system in this country either because of the inefficiencies of the current system or the unconscionably high profit margin. The end result allows a small number of executives and investors to get rich off the backs of US citizens by cheating them out of the health care that they are paying for, often with outrageously high premiums. Everyone expects these premiums to cover their health care costs, but instead they get bills for deductibles, out-of-network emergency care, etc. The reality of a single-payor system is that some taxes will be raised. The 2017 tax bill provided major tax reductions for corpora- tions and the rich and exploded the deficit. There are large amounts of money sloshing around Wall Street that are either not taxed or under taxed. If the hedge fund managers and brokers were working in Haiti or the Central African Republic, it would not be possible for them to be as successful in making money as it is in this country. Therefore, it is not unreasonable to expect that these companies and individuals contribute to the infrastructure and public welfare in the country that allows them to get rich. On the other side of the coin, the health insurance premiums, the copayments, the deductibles, the surprise billings, the uncovered services, the service denials, the medical debt and medical bankruptcies would all go away. Getting cancer would not mean going broke. At the end of the day, the details and the funding of a single-payor system would be the outcome of political negotiation. The negoti- ation to pass the Affordable Care Act (ACA) allowed the for-profit health insurance companies to keep 20% of the premiums paid for health insurance as profit (Medicare has a 2% administrative cost) and precluded a public option. If a single-payor health insurance plan becomes a serious consideration, the final product remains to be seen. Should either a public option added to whatever is left of the ACA or a single-payor health insurance system become a serious consid- eration, heads will explode in the corporate offices of the for-profit health insurance companies and the pharmaceutical industry. They will mount a very well-funded anti-change campaign, with all the usual dog whistles, “Socialism/communism, government takeover, death panels, massive tax increases, lose your doctor, etc., etc.” This will be an interesting insight into the members of the political ruling class who are feeding at the trough of the corporate generosity of the for-profit health insurance and pharmaceutical industry. (continued on page 32) MARCH 2020 31