The single payer option (Medicare for all) is a tax-funded healthcare system run by the government, which covers essential healthcare for all its citizens. In this article by Oliver (2009), which discusses the merits and demerits of a single-payer model vis a vis a multiple commercial insurance models, commonly used in the US, he cites the English National Health Service (NHS) as a perfect example of such system. Throughout the article, he continuously argues that, contrary to the popular critics that the single-payer model leads to unacceptable health care rationing, the structure of the model is not the cause for this rationing. Oliver believes that other factors such as funding have a direct effect on the type of interventions put in place. This essay is going to explore Olivers article to explicitly show his stand on the mention popular criticism about the Single-Payer Option, identify the pros and cons of the model and evaluate how valid his argument is.
According to Oliver, the perception that single-payer model structure is the sole cause of the opposed excessive rationing in the health care is misleading. He asserts that the critics of the system completely ignore the fact funding plays a great role in rationing as it determines what intervention measures should be adopted in a system. Additionally, he observes that the long waiting time completely ignored by the critics just like other health systems it affects the NHS though with the slight difference. According to him, lengthy waiting time is not only inevitable in a single-payer system but also it is a perfect rationing apparatus. Another factor he identifies as the cause of the opposed rationing is cost balancing, which is virtually present in other systems. He argues that balancing the cost with the health outcome of a system can lead to misplaced priorities in terms of focusing more on specific interventions that may not be of much benefit to the patients. This is because health gain cannot be scientifically measured in terms of the value for money spent and such health economic evaluations tend to dismiss other important factors such as equity and the severity of an illness. His final stance is that the single-payer model of health care provision is the way to go in terms of structured rationing where everyone is subject to the same rules and thus treated equitably.
In Oliver (2009), merits of single-payer health system compared to the US health system are such as Universal Health Care Coverage where all citizens of a country have access to healthcare whether rich or poor. Healthcare is more of a right than a privilege. The UK National Health Service cares for 58million people, 100% of England populace, whereas the US healthcare service covers about 83million - 28% of US population. Also, a US healthcare sets age and income requirement for Medicaid or Medicare hence void for those who cannot afford insurance remains considerably large.
According to him, the universalization of healthcare is one of the biggest failures of the US healthcare system, which is characterized by adverse risk selection. This means that insurance companies offer premiums proportionate to customers risk where high risks are driven out as they are deemed to be too costly creating more room for lower risks whose premiums are set at a much higher rate. A good example is the US healthcare system where everybody is required to get health insurance, which greatly leaves the poor at a disadvantage, as most cannot afford it. However, US healthcare system has attempted to widen health insurance coverage to the less privileged through the introduction of since Medicare and Medicaid in 1965. Universalization of healthcare also has the benefit of promoting social cohesion across diverse socioeconomic groups. This promotes peace, which in turn promotes the stability of a nation.
Low Administrative Costs is another merit associated with the single-payer option. These are the expenses incurred by medical insurers that are not strictly medical such as the costs of assessing risks, claims review, marketing, and profit making. In Olivers view, a commercially competitive multi-payer system has to maintain market validity through profit maximization avenues such as offering a wide range of insurance packages as opposed to a single-payer model whereby a single public entity with no competition- provides an inexpensive comprehensive package with equitable access as its main goal rather than profit maximization.
Oliver (2009) does not completely dismiss the benefits of high administrative costs incurred by commercial health insurers in that they create employment for a lot of people in the insurance sector. However, he is keen to point out that if such costs were cut, it would mean net widening of social welfare programs to the many uninsured citizens of America.
Demerits of the single-payer system to the US healthcare system include- limited choice. Olivers choice, in this case, refers to aspects of the insurer, provider, and treatment. It can have both intrinsic and instrumental value. The intrinsic value here means a lack of personal choice which amounts to the infringement on the individual human autonomy i.e. in this case, transferring private health decisions to a single taxpayer-funded public entity. In the English National Health System, however, the choice is denied with regard to the insurer but citizens are at liberty to choose from different providers and alternative forms of treatment. For example, citizens can opt for private health insurance services (which are much smaller than the National Health Service) but can provide alternative complementary treatments.
The main aim of limiting choice in the English National Health Service is to reduce the additional strain it would cause on the collective funds especially with regard to unnecessary health demands. This, in contrast, would lead to complete policy failure in the American healthcare system where choice is not limited to citizens, especially on providers.
Excessive rationing is another popular con of the single-payer model. In Olivers opinion, rationing is inevitable, as health care demands will always exceed supply. He classifies rationing at NHS in three groups- rationing in terms of price, waiting for time and value for money.
Rationing by price. This is common with the US healthcare system, which is highly commercialized and not affordable to a large number of people. For example, age and income requirements were set for the Medicare and Medicaid healthcare program in the United States. On the other hand rationing of prices is not quite evident as healthcare is said to be relatively inexpensive with regard to the amount of GDP percentage it consumes.
Rationing by waiting times. The NHS is traditionally popular for this type of rationing through its gatekeeper system whereby patients are first required to see a primary care physician who then is only referred for specialized treatment if deemed necessary. However accident and emergency victims are exempted. This means that some patients are forced to borrow loans to acquire privatized medical services due to long waiting periods.
Rationing by value for money. This is a cost and benefit analysis of health interventions and how such information is used by decision-makers in the medical technology, health service, and pharmaceutical industries. This means that resources need to be used for cost-effective interventions so as to reap maximum health benefits for the population. For example, the National Institute carries out health economic evaluation in England for Health and Clinical Excellence (NICE), which evaluates certain interventions in relation to their value for money and consequently sets mandatory guidelines upon which NHS stakeholders must adhere (Oliver, 2009). Moreover, health economic evaluation is relatively easier to administer in a highly centralized healthcare structure such as that of the NHS.
It is evident that the establishment of a single-payer model of healthcare financing, in particular, The English National Health Service, was done with good intention i.e. to promote equity in terms of access to healthcare and cut down costs with regard to administration and service delivery. However, it also came with some unforeseen shortcomings, which include lack of autonomy in terms of choice of insurer, and excessive rationing which according to Oliver, is not as a result of the system is merely single-payer in the model rather due to limited funding. Rationing is necessary for any healthcare system and especially in a single-payer model to curb against unnecessary healthcare demands. However, Oliver, argues that health outcomes cannot be scientifically measured by the value of money and therefore the government should avoid setting too many bureaucracies or rather guidelines to be met by healthcare facilities as this may lead to falsification of health statistics and misplacement of priorities with regard to healthcare needs of the citizens.
Oliver, Adam. (2009). The single-payer option: a reconsideration., Journal of Health Politics Policy and Law. 34.509-30. 10.1215/03616878-2009-013
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