Health Care Quality: Would It Survive a Single-Payer System?
2001-13
In recent years activists have been promoting effectively ending private health insurance and moving all Washington residents into a government-managed, single-payer health care system. But serous concerns have been raised over what a state-run system would mean for the quality of the health services we receive.
How does one determine what quality in health care really means? Is it an issue of access? Or is it related to "outcomes"? Does it mean the best care available? Or do convenience and cost play a role?
To answer these questions a new study from the Washington Policy Center examines the impact a single-payer system would have on health care quality in our state. This Policy Note presents a brief summary of our findings. The full study is available free by calling us or visiting the website listed below.
In a normal market, people make quality tradeoffs, sometimes substituting less quality for lower costs or greater convenience. However, when people are insulated from the cost of health care because the government is paying the bill, the role of value declines. Patients want quality at any price - because someone else is paying that price. Ironically, when someone else is paying the bill, the insistence upon quality declines because patients - indeed, any type of consumer - are willing to tolerate bad outcomes and poorer service when they are free.
Health care quality has been defined as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with the current professional knowledge."
Some quality factors are objective, while others are subjective; some can be measured, some cannot. We identify some factors below and explain why they should be part of any evaluation of health care quality under a single-payer system.
One of the most touted benefits of a single-payer system is that it is more efficient than the current system. People have a family physician who they can see regularly, rather than postponing needed care until they are forced to go to the emergency room, which is much more expensive.
However, getting to see a family physician under a single-payer system may not be as easy as proponents suggest. A recent flu epidemic in Toronto expanded the waiting times to see a family physician to five to six weeks - so far in the future that most patients either would have recovered from their illness and no longer need to see a doctor or would have become critically ill and gone to an emergency room.
Proponents of a single-payer system contend that when the government controls the cost of health care, the profit motive is removed, which means the same money can be spread over more people, which saves even more money as well as lives.
When most people enter the single-payer system, someone else - the government, - is picking up the bill. As a result, people are insulated from the cost of care and therefore tend to overconsume - driving health care spending much higher than it would be if patients were cost-conscious consumers. The irony here is that the process that makes health care affordable for the vast majority of people - a third party paying the bill - is the primary factor behind making the health care system unaffordable. In their effort to contain the cost escalation, single-payer systems step in to control health care utilization from the top down. How do they do it? Well, for government-run systems, administrators use spending limits and price controls.
As a result, there is never enough money to fund any program as much as proponents would like. Moreover, the decision on which programs get funded and by how much is often determined more by which group has the most political power rather than a program's true needs and merits.
In a single-payer system, the government makes the larger decisions about funding levels, leaving the doctors, hospitals and other health care providers to make the tougher individual decisions about whose care to ration. The targets of rationing are usually the marginal cases, the very young, the very old and the very sick. The patient is often simply told, "There's nothing more we can do for you," a true statement within the confines of the limited budget.
In England some kidney patients died while dialysis machines remained idle because hospitals said they did not have the resources to keep the machines running full time. In another case, an 89-year-old woman died in London after waiting 12 hours for a bed.
In Canada, 121 patients waiting for heart bypass surgery were removed from the list because their condition had worsened to the point that they could no longer survive the surgery.
In a single-payer system where health care budgets are tight, bureaucrats and politicians tend to see new technology as too costly for the benefit. As a result, they usually provide only enough funds to purchase a limited amount of the newest technology - if any at all. And the decisions on what to buy and when to buy it are often arbitrary and guided more by good politics than good medicine.
Stories abound of Canadians going to extreme measures in order to gain access to medical technology. For example, several years ago an enterprising hospital in Guelph, Ontario, decided to allow animals needing CT scans to enter the hospital in the middle of the night - charging pet owners C$300 apiece. There is nothing necessarily wrong with that except that thousands of people in Ontario were waiting up to three months for an appointment on the same machine.
Our study concludes that the best way we can expand health insurance coverage, while also expanding citizens' control over their own care, is to adopt free-market options that increase the number of insured while maintaining the high quality of health care. If instead state policymakers move toward a single-payer system that tries to impose universal coverage, they will find that Washington citizens will be left with neither care nor quality.