Trade-offs in Public Health Insurance Design | Health Care Economics, Insurance, Payment | JAMA | JAMA Network

Trade-offs in Public Health Insurance Design | Health Care Economics, Insurance, Payment | JAMA | JAMA Network Comment by Don McCanne This article was selected because it represents the views of a respected and influential academic, Katherine Baicker, PhD, Dean of the University of Chicago Harris School of Public Policy. She says that there are large hidden costs in the trade-offs that we would have to accept in adopting a single payer Medicare for All program. We should try to understand what these trade-offs would be and what costs they would entail. First she contends that covering everyone with the same plan could make them worse off because people have different needs and preferences. But that partially defeats the purpose of insurance which is to spread the risk amongst everyone (though we would add "equitably distributed"). We certainly cannot predict unknown risks in the future, and selectively covering pre-existing disorders also fails to spread the risk. Everyone should be covered for all reasonable services. She states that the sharp increase in the costs of having a uniform public insurance benefit is due to the dramatic advances in health care, but that is not a unique feature of having a universal program. Everyone should be able to benefit from these advances, and an equitably-funded, universal risk pool makes that possible. Besides much of the increase in costs is due to price increases, and they are better contained in a public system. She states that the substantial growth in income inequality might influence the willingness to devote resources to expensive care, suggesting that decisions would be based on the ability to pay. But a single payer system would obviate the need for such a two-tiered or multi-tiered system. She states that higher tax rates would be needed because of the increased economic cost of raising funds to cover a public insurance program, but she doesn't mention here the offset of a reduction in private spending. Besides, financing the system though progressive taxes is what makes the financing equitable. She stretches logic when she says that the wealthy might be worse off if the benefits are too limited, while lower-income people might be worse off if comprehensive benefits result in fewer resources that could be devoted elsewhere. But all reasonable health care services would be covered, and the wealthy would be free to purchase whatever services are not included in the comprehensive benefit package. She suggests an alternative of establishing a basic public health plan for all with additional social insurance programs for those with low incomes and privately purchased wraparound plans for the wealthier, but this abandons the concept of single payer Medicare for All while perpetuating many of the deficiencies of the current system. (In my early novice years in health policy, I wrote a proposal for a basic public health plan with options to purchase additional coverage. Fortunately, Claudia Fegan was able to set me straight, and I got to work studying health policy, which I have continued to this day.) She says that the hope of reducing costs while expanding coverage cuts across the political aisle, but there is a sharp divide in faith in whether the government or the private sector is best able to effectively provide that care. It is surprising to note the number of policy academics who are driven by faith in markets when the objective literature paints a clear advantage for government programs. Think of how many private insurance programs rely on public funds yet manage to divert significant amounts of these funds to their own industry. Sounds like greed-driven faith. Confirming her belief in private markets versus the government, she touts competition of health plans, when what we need instead is cooperation within the health care delivery system. Single payer Medicare for All would promote the latter. It is interesting that she closes by stating, "None of this is meant to say that the current system is serving the US population well now" and calls for "implementing a fiscally sustainable, high-value public insurance safety net." Well, single payer Medicare for All would do that for everyone in a comprehensive system that we could afford as individuals and as a nation.