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Why single payer is best for women


This great quote at Shakesville made me go look for the answer to that question, which I'd been wondering about, and at Our Bodies, Ourselves, I found this:

Our Bodies Ourselves supports the single-payer model as the most effective approach for solving the United States' health and medical care crisis.

The single-payer model creates a system that will best control costs, thus allowing existing resources to be allocated most equitably. First, it eliminates the $300-400 billion insurance companies spend on administrative overhead and waste. Second, it is best positioned to take on the enormous challenge of reducing or eliminating financial incentives that have led to both over-treatment and under-treatment.

Maternity care illustrates this phenomenon: We spend far more per capita than any other industrialized nation and yet do worse on many key indicators of maternal and newborn health.

So-called best practices – medical practices demonstrated to improve outcomes – are well-documented (e.g., "Evidence-Based Maternity Care: What It Is and What We Can Achieve," co-published by Childbirth Connection, the Reforming States Group, and the Milbank Memorial Fund). But they are not widely implemented in many care settings, even though doing so would lower costs and improve the health of mothers and babies.

For example, despite the World Health Organization’s recommendation of optimal cesarean section rates between 5% and 15%, nearly one-third of all women in the U.S. deliver their babies by cesarean section. One of the reasons is that most obstetricians and hospitals are paid more for a surgical delivery than for a vaginal birth. One national estimate found that in 2004, on average, hospitals got $2,090 more and health professionals got $723 more for a cesarean delivery.1  Such incentives not only raise costs, but ironically often produce worse health outcomes as more healthy women experience the risks of surgery without any benefits.

By reducing the ability of for-profit companies to siphon off huge sums of money for private gain, a single payer system is better able to expand best practices. The motivations to over-treat those who are well-insured, and to under-treat those with limited or no insurance coverage, will no longer be built into the medical care system.   

Why Single Payer is the Best Option for Women

Women in particular have much to gain from single-payer health care -- and not just because there are many areas where women experience the harms of both excessive and inadequate treatment.

Our country has an excess of medical specialists and is in desperate need of more primary care clinicians -- such as general internists, family practice physicians, physician assistants, nurse practitioners and licensed midwives -- who are often more aptly trained than specialists to provide the comprehensive services women need. A single-payer plan would eliminate the financial incentives that have been obstacles to investing in training more primary care professionals.

Here are other specific advantages of a single-payer system: 

The only national plan for health care reform that explicitly includes women's reproductive health services, including abortion, is HR-3000, sponsored by Rep. Barbara Lee (D-CA). Other sponsors of single-payer plans are also amenable to altering their language to be more explicit about women's reproductive health services.

Coverage is independent from employment. Because women are more likely to be self-employed, to work part-time, and to move in and out of employment outside the home (to reserve flexible schedules for family care-taking), they are now more likely either to lack coverage through work or to lose insurance when changing jobs. Should a plan with a “public insurance option” be passed by Congress and ultimately fail, women will be hit harder.

Coverage is independent from marriage. When their only option for health care coverage is through their spouse, women face additional risks for becoming uninsured as a result of divorce or a spouse's loss of employment. Again, should a plan with a “public insurance option” be passed by Congress and ultimately not work, women will be hit harder.

Single-payer system would encourage better care for chronic illnesses. Women utilize chronic care services far more than men. Because caring for people with chronic disease now accounts for more than 75% of all health care spending, women will benefit substantially from more efficient and effective ways to deal with severe chronic illnesses.

A third of Medicare dollars each year are now spent on chronically ill patients during their last two years of life. Alternative approaches to end-of-life care, such as hospice, work better for most people than expensive, hospital-based treatments. Numerous studies show that hospitals that treat patients more intensively and spend more Medicare dollars do not achieve better results. Only a system that eliminates the current financial incentives would encourage and promote these approaches.

Single-payer system would eliminate the need for Medicaid. Women who are unemployed and have functional limitations that exclude them from the private health insurance market would receive health and medical care on a par with women in general.

The percentage of women covered by Medicaid is higher than that for men for all levels of disability. Care available with Medicaid funding is now substandard in terms of access, quality and its bias toward funding institutionalization instead of home-based services. It also carries with it strict income eligibility requirements that force recipients to maintain their status as unemployed and live in poverty or else risk losing health care coverage altogether.

Single-payer system would address the cost issues that send women into debt and bankruptcy. Medical debt is an enormous concern for many women. A 2009 Commonwealth Fund study found that 45% of women accrued medical debt or reported problems with medical bills in 2007 compared to 36% of men.

Under one single-payer bill introduced to Congress (HR 676), a family of four making the median income of $56,200 would pay about $2,700 in payroll tax for all health care costs. There would be no deductibles, no co-pays, and no worrying about catastrophic coverage.

Single-payer system would reduce the number of medical malpractice lawsuits. Because people would not have to worry about paying for medical care whenever they experienced bad medical outcomes, they would be less likely to sue for compensation.

Single-payer system would enhance the working environment for health care professionals. There would be less need to spend hours on pointless documentation in order to justify billing for services.

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CMike's picture
Submitted by CMike on

First, it eliminates the $300-400 billion insurance companies spend on administrative overhead and waste.

Total annual United States health care expenditures are around $2.2 trillion. I've heard estimates that between 15 and 30% of private health care insurance dollars go to profits and administrative overhead including executive compensation.

Let's use the upper range estimate of 30%. That's something like 27% more than the administrative expenses of Medicare. Now go to page 2 of this two page Health and Human Services pdf. Only 35% of health care dollars flow through the insurance companies which would be $770 billion and 27% of that is ~$208 billion.

Except for nurses, all the other players are going to have to get haircuts to straighten out the expenditure issue. The too shaggy include pharma, hospitals, labs, medical equipment companies, and doctors.

Submitted by hipparchia on

a better way to phrase that is that because we have the insurance companies that we do, the medical industry wastes ~400,000,000,000/year in unnecessary administrative spending.

pnhp did a study a few years ago, attempting to add up all the the us spends on administrative stuff and all that canada spends on administrative stuff their conclusion was that canada spends ~16.7% of their health care $$ on administration [all administration, not just the insurance part] and the us spends ~31% of their health care $$ on administration, suggesting that we could cut our spending by a little over 14% if we got rid of insurance companies [or rather, if we made them into bit players, allowing them no more than the supplemental insurance market, like canada]. we're projected to spend $2.4 trillion on health care this year, so we could save $340 billion if our insurance companies were more like canada's.

through a refinement of their calculations, they figure we could perhaps save somewhere between 15-16% on total administrative spending if we go to single payer, which raises that number to $400 billion we could have saved this year if we'd had single payer.

not all of this spending ends up lining the pockets of insurance industry fatcats. much of it is spent on the legions of clerks and actuaries hired by insurance companies to keep from paying and clerks and managers hired by doctors and hospitals to try to get paid, but there are multiple points where money is leaking out of the system just because of the presence of this one industry.

i agree with you totally on who the shaggy are. if we clipped them too, then yes we'd save more like 30-50% of our health care $$, instead of the measly 14-15% we can save just by marginalizing [or dumping entirely] the insurance companies.

CMike's picture
Submitted by CMike on

But I'm a little lost. The 30%* of drainage from the health care system for administration and profits related to the private insurance sector would be grandly inclusive of all non-treatment costs to the system I would think. As that New England Journal of Medicine pdf you linked to said in 2002:

Canada’s national health insurance program had overhead of 1.3 percent; the overhead among Canada’s private insurers was higher than that in the United States (13.2 percent vs. 11.7 percent). Providers’ administrative costs were far lower in Canada.

Presumably other private expenditures; out-of-pocket, philanthropic, and whatever constitutes the rest, have much lower costs administrative costs associated with them.

Now then, riddle me this. Putting aside the calamities that are Medicare Part C and Part D, are you saying you would expect there to be substantial savings for administrative costs in the publicly funded sector of national health care expenditures, which makes up 46% of the whole now, if we went to "Medicare for all"? I don't follow.

[Weird. When I type: The 30%, without tags, the comment program creates that BibleGateway page link on its own.]

Submitted by hipparchia on

is a feature, not a bug!

but, on topic...

are you saying you would expect there to be substantial savings for administrative costs in the publicly funded sector of national health care expenditures, which makes up 46% of the whole now, if we went to "Medicare for all"? I don't follow.

the short answer is yes.

the longer answer is [you knew this was coming, right?] that...

... every doctor, every hospital, every clinic, every lab, every pharmacy, every provider of a health care service or product has to deal with multiple insurers. in general, most insurers make it difficult and expensive to deal with them. not only does each insurer have their own filing protocol, their own preferred forms to fill out, their own price structures for what they'll pay for and how much they'll pay for it [and many insurers have multiple plans in each market, each of which pays differently] blahdeblahdeblahdeblahdeblah, they also deliberately use the filing process to outright delay and/or deny payment.

this means that the drs, hospitals, etc have to employ several people to keep track of all the plans, all the different prices, all the different filing protocols, etc. they also need to hire people [and frequently the drs end up doing this themselves too] to argue back and forth with the insurers over whether a particular treatment is needed. i've seen assertions in the md blogosphere that this can take up a couple of hours or more daily for some primary care physicians [less so for specialists, since the pcp is the gatekeeper and doesn't send the patient on to a specialist without doing much of the arguing up front]. that's two hours every day that the dr could be doctoring and isn't, all because they're making phone calls and writing letters instead.

which boils down to the fact that the public option, even with medicare rates, won't save a whole heckuva lot of money. drs, hospitals, etc will still need to keep all these people on staff and would still spend a lot of time trying to get treatments approved ahead of time and/or paid for afterward for all those poor souls [150 million or so] still covered by private insurance.

so yes, removing these bloodsucking leeches from the system would allow doctors themselves to spend more time with patients, and it would allow them to operate with smaller office staffs. the one estimate i've seen [and can't remember where] for hospitals is that administration is 9% of the total costs, with that 9% split between 5% going to administer things like payroll and ordering supplies, and the other 4% going to administer all the billing and dealing with insurers.

as for your 'i don't follow', you are not alone. the whole thing is byzantine beyond belief and even the experts have to make educated guesses about where all the money is going. check this out for a glimpse into just the hospital portion of the equation.

and there's this too:

Dr. Himmelstein described the real-world meaning of the difference in administration between the United States and Canada by comparing hospitals in the two nations. Several years ago, he visited Toronto General Hospital, a 900-bed tertiary care center that offered an extensive array of high-tech procedures, and searched for the billing office. It was hard to find, though; it consisted of a handful of people in the basement whose main job was to send bills to U.S. patients who had come across the border. Canadian hospitals do not bill individual patients for their care and so have no need to keep track of who receives each Band-Aid or an aspirin.

"A Canadian hospital negotiates its annual budget with the provincial health plan and receives a single check each month to cover virtually all of its expenses," Himmelstein said. "It need not fight with hundreds of insurance plans about whether each day in the hospital was necessary, and each pill justified. The result is massive savings on hospital billing and bureaucracy."
Doctors in Canada face a similarly simple billing system. Every patient has the same insurance. There is one simple billing form with a few boxes on it. Doctors check the box indicating what kind of visit they provided to the patient (i.e., how long and whether any special procedures were performed) and send all bills to one agency.

Himmelstein returned to Boston and visited Massachusetts General Hospital, which was similar to Toronto General in size and in the range of services provided. Himmelstein was told that Massachusetts General's billing department employed 352 full-time personnel, not because the hospital was inefficient, but because this department needed to document in detail every item used for each patient and fight with hundreds of insurance plans about payment.

"U.S. doctors face a similar billing nightmare," Himmelstein said. "They deal with hundreds of plans, each with different rules and regulations, each allowing physicians to prescribe a different group of medications, each dictating that doctors refer patients to different specialists.

incidentally, thanks for asking your question. i'd been looking for that last link, comparing the boston and toronto hospitals, for ages. i'd lost it and didn't find it until just now, when i was looking for an example to give you. thank you, thank, thank you.

Submitted by lambert on

Can be defeated by putting the cursor immediately after the The in "The" and adding an empty tag, like The<em></em> 30:

The 30.

CMike's picture
Submitted by CMike on

Himmelstein was told that Massachusetts General's billing department employed 352 full-time personnel, not because the hospital was inefficient, but because this department needed to document in detail every item used for each patient and fight with hundreds of insurance plans about payment.

That I understand. But you, among others, have written that, though Medicare reimbursement rates to providers are lower than the private insurance and out of pocket rates, doctors and hospitals appreciate the big benefit to them of the prompt, no hassle feature of collecting from Medicare. There may be legions of people devoted to seeking payment from hundreds of private insurance companies and strapped co-paying and uninsured patients but very little man power is spent submitting claims to Medicare. Medicare is a sui generis plan.

Are you suggesting that doctors and hospitals are passing on some of their administrative costs for privately insured patients to Medicare now? If that were true then I don't think doctors and hospitals would be complaining about the Medicare reimbursement rates and avoiding, in some cases, serving Medicare patients. (I followed that link to your discussion of Medicare but if a doctor or hospital are pushing the limits of their limited capacities then they tend to prefer the well privately insured patient to the basic Medicare patient, right?)

If we go to "Medicare for all" the administrative costs to care for those currently covered by Medicare are not going to go down. And even if we had "Medicare for all," there would still be a separate VA system right? The VA's administrative costs are not going to change.

I've not read anything on the administrative costs for Medicaid and S-chip but they won't change will they? I mean Medicaid and S-chip might be replaced but the administrative costs for their beneficiaries will not go down. There may be fifty states but, when it comes to Medicaid, I would not think any doctor or hospital bills more than two or three states, and most bill only one state. I assume Medicaid and S-chip administrative costs are relatively low now -- except for maybe the initial paper work related to qualifying.

Added on after I posted the comment:

Himmelstein himself might be saying that the doctor shortage is being exacerbated by the hours doctors, themselves, spend trying tailor therapy regimens to particular patients with particular insurance plans. I don't know if I'm buying that. Doctors hire people to handle the paper work. And doctors pretty much leave it up to the patients to work out on their own their coverage restriction issues from what I've seen.

Card-carrying_Buddhist's picture
Submitted by Card-carrying_B... on

clinical documentation. The whole DSM is just a frame for billing.

It drives me mad, and thus drives me to my own therapist.

Who does not accept insurance.