It is not too late to fix the US healthcare system. But every day spent in this folly, the problem gets worse. It is time to move this conversation forward.

Source of image: https://www.bcaction.org/the-republican-healthcare-bill-is-a-health-hazard/

We are excited to share that in November 2021, the American Public Health Association (APHA) formally adopted a policy statement titled “Adopting a Single-Payer Health System”. The authors shared this adoption with an executive summary of the policy, recently published in our journal, Medical Care.

Since 1976, APHA has had a history of calling for a universal, centralized healthcare system. The terms have changed over the decades, the problem continues to worsen, but the central argument remains largely the same. The US health insurance systems waste an average of $3,000 per person per year, according to Dr. Michael Fine.

Some colleagues, and some of our readers, may bring up the political barriers to achieving health reform on this scale. That the United States is still discussing the need for Single-Payer is a testament to significant political barriers to implementing such a system.

Call to Action

We, the authors, as well as the Governing Council of the APHA, believe that the political barriers won’t change unless we all do everything we can.  We must take action now to move the conversations forward. These conversations don’t just occur in Congress. They are being held by our community leaders, service providers, private insurers, and, yes, by our elected representatives.

We know it can work better. More importantly, we have strong evidence to support a better approach. We must move the conversations forward until everyone supports a system that works more efficiently, effectively, AND fairly for EVERYONE.

In developing and recommending public health policy, we heed the evidence, not the soothsayers.

Recently, D’Angelo and colleagues called for public health academics to get involved in advocating for a Single-Payer system, which brings us to APHA’s 2021 policy slate. The writing team from the APHA Medical Care Section spent over a year compiling the evidence and drafting a strongly worded policy. The team included several thought-leaders with decades of experience in the SP advocacy movement. The goal was to ensure APHA is once again standing in the front row, pushing on the barriers of apathy and misinformation to realize sustainable change.

“APHA urges CMS to expand Medicare and Medicaid to provide universal coverage of a harmonized package of health care services (including vision, hearing aids, and behavioral health, dental, and long-term care) and pharmaceuticals without exception — regardless of race, sexual orientation and gender identity, citizenship, residency, or carceral system or institutional status — to include all of those living in the United States.”

International Comparisons

“APHA joins other national and international organizations in declaring that health care is a human right.”

National health expenditure in the US grew by 9.7% in 2020, to $4.1 trillion ($12,530 per capita). This accounted for 19.7% of the gross domestic product (GDP) at the time. The US spends nearly twice as much on healthcare compared to spending of other 37 countries in the Organisation for Economic Co-operation and Development. Due to fragmented systems, the US spends $2,000 more per person than the next-highest-spending country, Switzerland.

Since other countries have already achieved universal health coverage using Single-Payer or hybrid systems, the US can benefit from their experiences. By simplifying financing mechanisms, countries with Single-Payer systems experience significant cost savings over their multipayer counterparts by:

• streamlining billing and insurance procedures,
• creating a more equitable and predictable spread of risk across all populations, and
• leveraging bargaining power to control costs.

Three Examples

In our analysis, we drew on three countries’ experiences of implementing SP systems:

• In Taiwan, the National Health Insurance system covers all citizens and foreign residents with uniform and comprehensive services. Patients in Taiwan can choose their doctors or hospitals without being limited to a certain network of providers like in the United States.
• The Canada health system is administered by the provinces through a funding partnership with the federal government. Comparative analyses of physician utilization between Canada and the US demonstrate higher utilization of appropriate services among vulnerable populations in Canada.  This suggests that more equitable allocation of resources in the US could lead to improved public health.
• Australia provides coverage through a hybrid public-private SP system available to Australian citizens and permanent residents. The system maintains centralized control over most resource allocation and policymaking. However, it also allows for some freedom at the regional and local level in how funds are used.

Supporting Stronger Primary Care

“APHA urges appropriate budgetary and revenue collection reforms of federal health care financing and CMS administration policies to create and sustain a single funding mechanism to support a whole health focus on comprehensive, universal coverage by U.S. health care providers.”

A recent post on this blog laid out key reforms needed to turn primary care around in this country, calling for a major movement within communities and the healthcare system. The authors also posted a follow-up with interview questions and responses from the author, Dr. Michael Fine. With SP, providers could focus on delivering optimal quality services rather than navigating a system with incentives to limit costs.

Addressing Disparities in Healthcare Access and Delivery

“…regardless of race, sexual orientation and gender identity, citizenship, residency, or carceral system or institutional status — to include all of those living in the United States.”

“APHA urges the Department of Health and Human Services (DHHS) and CMS to regulate, monitor, and report on health disparities as an accountability mechanism.”

One of the saddest failures of US healthcare is the persistent racial, ethnic, and gender disparities in access and outcomes. Single-payer is the best option to ensure equity, fairness, and priorities aligned with medical needs, providing incentives for wellness. Single-payer reimburses all care equally for all, resolving disparities in coverage, especially mental health services. State and local healthcare reimbursement policies become tied to measurable patient-centered outcomes. Also, SP benefits public health based on what works best for each individual and for the nation.

Critics contend that a Single-Payer approach will lead to rationing or wait times for time-sensitive services. There is no evidence to support this claim. Instead, Single-Payer could help address inequities and improve the health of the entire US.

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