From the comments, on single payer

Single payer’s magic has historically worked via just a few channels:
1. Some amount of monopsony allows the government to bid down medical services below market rates.
2. Political imperatives lead to lower training burdens, lower staffing ratios, and lower certainty in diagnosis and treatment.
3. Obfuscation of possible alternatives diminishes demand for costlier care.

Option 1 means that you pay health professionals worse. There is some utility in this even. But it has some long run consequences that are only now being discovered. First, you see the exit of the most skilled people from medical careers. Second, the physicians unionize (or equivalent) and become political actors. Third, with everyone trying this and some semblance of open borders, it becomes ever harder to keep people in the places you need them (which rarely match the places where the sort of folks who can become Western physicians want to live). At some point you can no longer suppress wages below their natural clearing rate and it becomes ever harder to import foreign talent when other places (e.g. the US) offer a more lucrative immigration option.

US physicians are overtrained. But it also means that as things need ever more understanding to manage, we can deal better with things like CAR-T therapy and the like. And it is not like foreign docs are unaware of these things. As status is the important thing for most educated professionals, there will be continuous pressure towards increasing the prestige of the job at that comes with more training. As much as the government wants to have the minimally trained folks doing as much as possible, single payer countries are starting to see ever more pressure for their physicians, nurses, and the rest to match educational qualifications of the rest of the world.

Tying into all of this is the fact that the alternatives are quite visible. Everyone in the US these days can see an alternative where the masses do not have to pay out of pocket and theoretically fund health care by taxing someone else. But the flip side is also true. Wealthy Britons know that their American friends need not live with chronic pain for years for surgeries the NHS eventually will perform. They know that their American friends get screened more frequently and actually get treatment that cures diseases which are merely managed in Britain. They may still support the tradeoffs that come from single payer, but the days when these sorts of comparisons are no longer discussed are long gone.

Frankly I am always amazed at how much gets attributed to single payer. We know that, at most, only 25% of life expectancy outcomes are due to healthcare. We know that all of the correlates of single payer (e.g. percent of health expenditures paid by government) and health correlates (e.g. life expectancy) get vastly less favorable when you drop the US from the analysis as an outlier. We know that the UK has habitually adopted US practices a decade or so later, once the cost falls into the range where the UK can afford it.

But going forward, I think the old metrics that showed large advantages for single payer are going to continue to slide. Unions (formal or otherwise) are going to militate for higher pay. Governments are going to have to deal with one side of the political spectrum going into hoc to the health employees and the other polarizing to the folks in the disfavored region(s) who are lower priority for healthcare and pay more in taxes for the “giveaways”. And all of it is going to run into the trouble that the developing world is going to have fewer kids and hence fewer physicians while the relative advantage of immigrating is going to continue to fall.

Single payer was overwhelmingly built on the post-World Wars consensus and environment. It operates as a monopsony. What on earth would make us think that it would be stable into the future?

That is from “Sure.”

TC again: There is a natural tendency on the internet to think that all universal coverage systems are single payer, but they are not.  There is also a natural tendency to contrast single payer systems with freer market alternatives, but that is also an option not a necessity.  You also can contrast single payer systems with mixed systems where both the government and the private sector have a major role, such as in Switzerland.

I’ll say it again: single payer systems just don’t have the resources or the capitalization to do well in the future, or for that matter the present. Populations are aging, Covid-related costs (including burdens on labor supply) have been a problem, income inequality pulls away medical personnel from government jobs, and health care costs have been rising around the world.  Citizens will tolerate only so much taxation, plus mobility issues may bite.  So the single payer systems just don’t have enough money to get the job done.  That stance is conceptually distinct from thinking health care should be put on a much bigger market footing.  But at the very least it will require a larger private sector role for the financing.



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