The horrifying specter of Trumpcare, the shortfalls of Obamacare and the continued rise in overall health care costs in the United States have provided an important opening for proponents to put single-payer back on the table. Attempts at creating a national health insurance scheme have come close but failed several times before in US history. However, while it is imperative to ensure that every American has equal access to quality care, single-payer is insufficient when it comes to ensuring our right to health and well-being.
Considering the organizing capacity, resources and political capital it would require to be successful in a single-payer campaign, we should be clear on what single-payer is and isn’t before we put all our eggs in that basket. Remember that the challenges single-payer faces are huge. Even if proponents are able to successfully manage the tax hike concerns that surround the issue, it seems highly unlikely in our current political context that a state could succeed in obtaining the multiple federal waivers necessary to implement a single-payer model. In California, where many assume single-payer legislation has the greatest chance of passing, the state constitution would also require voters to pass ballot measures on the state budget to lift the spending cap and reform legislation that mandates that around 40 percent of state tax revenue go to K-12 education.
So, what would single-payer do? Simply, it would provide all Americans access to comprehensive care regardless of income, pre-existing conditions or ability to pay — an extremely important achievement that would benefit many. However, insurance alone does not solve the serious, persistent and growing problems we have with health outcomes in this country.
Creating the conditions for health and well-being requires a lot more than insurance.
Many studies have shown that only about 20 percent of health outcomes are attributable to the care we receive. In reality, how long we live and how healthy we are during that time is largely determined by a combination of genetics, social and economic factors, and individual health behaviors. With “social determinants” like housing, employment and education accounting for a full 40 percent of health outcomes and the quality of the built environment we live in accounting for another 10 percent, it quickly becomes apparent that economic, social and geographic issues are health issues, and that creating the conditions for health and well-being requires a lot more than insurance.
While US health care costs have risen to over $3 trillion a year, representing almost a fifth of our economy, we consistently have some of the worst health outcomes among high-income countries. Americans have a shorter life expectancy, higher infant and maternal mortality rates, and higher incidences of many diseases. Moreover, we have significant and persistent disparities in those outcomes.
A recent Harvard study of 32 high- and middle-income countries found that the United States consistently reported the highest level of health and health care disparities across income levels. Lower-income Americans live shorter lives with higher incidences of heart disease, cancer, diabetes and mental illness, as well as dozens of other chronic conditions. One example starkly illustrates the type of disparities seen across the nation: the life expectancy in well-to-do Lyndhurst, Ohio, is a full 12 years longer than that of low-income Glenville, just 10 miles away.
Staggering health disparities are also observed between racial and ethnic groups in the United States. For example, African Americans are 77 percent more likely than non-Hispanic Caucasian Americans to develop diabetes, and people of color run two-to-four times the risk of reaching end-stage renal disease than whites.
Furthermore, these disparities cost us dearly as a nation. Not only are countless lives needlessly lost because of these inequities, but they come at a price of $300 billion a year in lost wages, health care costs and premature death, making a pretty good business case for addressing these harmful disparities.
Prioritizing health and well-being means prioritizing jobs, education and housing. It means meeting people’s daily needs and helping communities to flourish.
It seems, then, that we should be prioritizing health equity and the investment we need in our communities as we carry on this health care debate. Now more than ever, while we have this opening on such a critical issue, we need to be clear that prioritizing health and well-being means prioritizing jobs, education and housing. It means meeting people’s daily needs and helping communities to flourish.
Getting health care that works for everyone is really about having a say in how a fifth of our economy is spent. It’s about reversing the trend of disinvestment in our communities and ensuring the broad-based prosperity that allows us to lead healthy and happy lives.
Just imagine what would be possible if we were to redirect some of the massive resources that are currently funneled into a broken health care system to address the social determinants that go such a long way to defining health outcomes.
Increasingly, health systems themselves understand the connection between social determinants and health outcomes and are starting to take important steps to address those issues in the communities in which they operate. As such, some are experimenting with how to leverage their assets to benefit their local communities and, in turn, keep health care costs down. They are beginning with strategies like local hiring and procurement or providing on-site food pantries, just some of the many ways health systems’ resources can be invested “upstream” or closer to the root causes of health problems.
However, truly addressing social determinants necessitates a coordinated, national effort and it requires that we keep our eye on the ball. What we need is good jobs, strong communities, safe and stable housing, access to education and a healthy environment.
If structured well, a single-payer system would certainly be a step in the right direction. By properly deploying global budgets and moving away from a fee-for-service model, a single-payer system could reinforce an ethos of “value over volume” in the health care sector, a strategy which is already leading to some important advances in Medicare and Medicaid delivery. The Center for Medicare and Medicaid Innovation (CMMI), created by the Affordable Care Act, has been supporting and developing these kinds of alternative payment systems that aim to lower costs while improving care. This work is contributing to the growing evidence base for the effectiveness of value-based payments while experiments with Accountable Care Organizations and bundled payments are seeing providers taking on increased financial risk, prompting them to seek out new ways to help patients stay healthy. Projects that provide robust primary and preventative care services have also been sought out by CMMI as a way to bring down lifetime health care costs while allowing patients to live healthier lives by intervening earlier on in the progression of a disease or identifying risk factors before serious health problems occur.
Yet we must remember that countries with single-payer systems can still struggle with significant health equity issues. For example, while Canadians generally enjoy relatively good health compared to much of the rest of the world, a 2016 report from the Canadian Institute for Health Indicators found persistent or even increased income-related inequalities in the majority of health and well-being indicators tracked over the last decade. Immigrants, refugees and Indigenous populations also experience barriers to access in the health system, which add to the inequities in outcomes. Even the United Kingdom, which tends to score very well on health equity studies, has had health inequalities high on the agenda for years, recognizing the concerted effort needed to tackle this complex problem.
Since the issue of single-payer is on the table now, it is incumbent upon us to explore how to make a single-payer system maximally effective and to think beyond insurance to what else our communities need in order to thrive. If we take advantage of this opening on health care to envision what it would really take to transform our health care system into a system of health, we could be leaders in the drive toward health equity worldwide. Let us live up to that challenge — many of our lives depend on it.