A few days ago, I read this post from Robert Reich, and it got me to thinking: I am becoming more and more convinced that the future of American health care financing will be single-payer. It’s not inevitable–at least not quite yet–because health reform just might work and just might preserve and strengthen the public-private balance we have today. The health reform legislation we have in Congress right now, however, is not going to be enough in the long term. There will necessarily be additional legislative fixes that we’ll have to figure out as we go.
In fact, Atul Gawande is back with another excellent piece in the New Yorker that highlights the very important role of demonstration projects in the health reform legislation intended to discover–by trial and error–which approaches to cost control actually work and which do not. He argues quite effectively on the basis of historical precedent in agriculture that this is the only way forward when there is no clear single answer to the problems confronting us. So, if reform passes, and we stumble upon some things that work to bring costs down, quality up, and the like, then there’s a chance that the advent of single payer will be delayed–perhaps indefinitely. That’s one scenario.
Or, despite the best of intentions, health reform will fail to control costs well enough. That wouldn’t surprise me, because the simple fact of the matter is that everyone seems to want to live forever (in theory) and that puts a pretty high ceiling on the amount that people are willing to pay for medical care with any potential for benefit. Never mind that all care also comes complete with potential risks or that people who are willing to pay exorbitant amounts are actually shielded from the majority of the costs associated with their decision to seek care. Those two factors are only akin to ignoring that you’re burning and dousing yourself with more and more gasoline. So costs increase, and we actually arrive at the much talked about point of unsustainability. Our health care system broken, the government has no choice but to step in and create a single payer system with global federal budgeting for health care. If you’re one of those people who likes to worry about the notion of socialized medicine, please feel free to envision this scenario and commence to freaking out now. That’s road number one to single payer.
Road number two also leads to single payer, but the payer isn’t the federal government. Instead, it’s a private insurance mega-corporation. We’re already seeing that in many states, one or two private insurers make up about 85% of the market. In fact, as Reich reports, these data are from almost 5 years ago. In the intervening time, the private insurance market has consolidated even further, and it shows no signs of stopping. If the trend continues, it’s not difficult to envision one or two extremely large insurance companies buying everyone else out. Ordinarily, the government would intervene in such cases to break up the emerging monopoly. But here’s the kicker: insurance companies are specifically excluded by law from all anti-trust provisions. That means nothing’s stopping Cigna or United Healthcare from taking over the whole show. And that’s the second road to single payer, which Reich describes bluntly as: “a national health care system that’s controlled by a handful of very large corporations accountable neither to American voters nor to the market.” The prospect of that, friends, is far more likely than I’d care to envision.