The Case For A Single Payer Healthcare System

March 27, 2012

In a 2009 interview, Jon Cohn sat down with Dr. Michael Chen, Vice President and CFO of Taiwan’s National Health Insurance Bureau, the government office in charge of managing Taiwan’s government-run health insurance program. Some excerpts from the transcript, via PNHP:

Jonathan Cohn (JC): You have what most people refer to as single payer health insurance - the government is the main insurer for everybody.
Dr. Michael Chen (MC): Yes.
***
JC: How did you decide on that model - the single payer? Why did you go in that direction?
MC: Well, we sent our people around the world to learn their programs, including the United States. Actually, the program is modeled after Medicare. And there are so many similarities - other than that our program covers all of the population, and Medicare covers only the elderly. It seems the way to go to have social insurance…
JC: Now, one issue that comes up in the United States when people talk about a single payer system, or even any kind of a system where the government is defining the benefits, there’s a big concern that there’s not enough choice. People in America… we want to know that you can choose the kind of insurance you want - how much coverage, what services. Is that an issue you dealt with in Taiwan? Was that a concern?
MC: Not at all, because in Taiwan the benefit package is rather comprehensive… We maintain a very long list for prescription drugs - more than twenty thousand items. And the benefit package includes inpatient, outpatient, and dental service which is usually not covered in this country.
JC: Now the flip side is that if you are offering such a generous package, that’s very expensive, is it not? I mean, how do you pay for it?
MC: Not the case.
JC: Not the case. What percentage ofGDP?
MC: Six percent of GDP,so that’s very affordable. The premium on average that the family pays is about two percent of the household income because the premium is shared by your employer.
JC: … In this country we spend far more than that, and even looking at Europe - Switzerland, France - they spend a lot more than that also. Are there waiting times for services in Taiwan? Is there something that people are going without? I mean that’s a lot of services for such a little amount of money. I’m trying to figure out what it is that you’re not getting.
MC: No waiting lines.
JC: No waiting lines? I can see a doctor any day I want…
MC: If you are not too particular.. you can visit even a specialist in a matter of minutes…
***
JC: … If I were to be sitting here with a doctor in private practice in Taiwan - I know in this country doctors worry a lot that Medicare doesn’t pay enough money and that it’s very bureaucratic - what kind of complaints would I hear from them?
MC: Of course, doctors would complain in public, but appreciate it in private - because, you know, especially in this economic downturn, how can you find an industry with assured growth rate annually? Right now they enjoy somewhere between four percent to five percent increased rate, and this is a sure thing.

Much like any institution or business, a single-payer system can be poorly run or competently run. When they are competently run, most of the systemic horrors that people like to attach to “socialized” healthcare delivery systems become apocryphal phantasms. That doesn’t mean people are never going to have trouble, or that tragedies won’t happen. No system will ever be perfect. But the question is which system is “least worst” among those that are available. Taiwan’s system is both viable and effective without sacrificing outcomes or access.

Ezra Klein notes that if the Individual Mandate in Obamacare is ruled unconstitutional, then Progressives will be left with no way to achieve universal health insurance coverage without pressing for a single payer program. Interestingly enough, I’m sure conservatives would very much prefer Obamacare (or perhaps Romneycare) over a single payer system. But in the absence of these programs, all we are left with, it seems, is a giant tax credit, which does nothing to solve the problem of pre-existing conditions. Private insurers will continue to deny coverage to people with pre-existing conditions who are not profitable unless they have a mandate that forces everybody to pay in to the risk pool, which allows them to use the premiums of healthy (i.e. profitable) people to pay for the care of sick (i.e. unprofitable) people.

If the rest of the civilized world is any indication, market-driven delivery systems for health insurance are a beast of antiquity. That’s because no amount of deregulation or tax credits can resolve the anti-patient incentives that health insurance companies must reconcile. It remains the only industry in America where, the more you need their product, the less they want to give it to you. That’s an impossible dichotomy to reconcile without regularly screwing people over. As one J.C. might put it, you cannot serve two masters.

We know that other approaches work. We know that ours doesn’t. Taiwan’s system has an 80% approval rating. In America, it’s closer to 50% on a good day. So if the mandate is found unconstitutional, Conservatives may find themselves in a difficult position, because the only route to universal healthcare at that point is through a single-payer system. Indeed, if the mandate is struck down, that may be the political capital that progressives need to get single-payer on the national agenda. Winning the battle, for Conservatives in this case, may mean losing the war.

5:07pm | URL: https://tmblr.co/ZMMjnxIfXH0u

(Notes: 40)