The Pros and Cons of a Single-Payer Health Insurance System

A single-payer health insurance system is one in which there is one primary payer. A single-payer system is also called a national system because the primary payer is the government. A government agency pays providers in this system. In the United States, the single-payer system exists alongside private health insurance options.

The Veterans Administration (VA) Health Care System is a single-payer program in the U.S. In recent times, keeping the Affordable Care Act (ACA) versus adopting a nationalized health care system has been discussed. As the VA is currently an example of a single-payer system in the United States (Medicare is another (Stark, 2017)), it makes sense to use it as a reference in these discussions. If it is used as a reference, it must be determined whether the VA is a model for a larger single-payer system. There are arguments in support of this idea, which claim that the VA has spearheaded advances in medical technology (“The VA”, n.d.). There are arguments in opposition to this idea, which claim that the VA is inefficient and has longer wait times (Stark, 2017).

In light of the opposing views, both viewpoints will be discussed along with current affairs and controversies relating to the VA as a single-payer system. Based on the collected evidence, public policy will be suggested with contingencies for future evidence that needs to be collected. Finally, a conclusion will be made as to whether the VA can truly be considered a model for single-payer health insurance in the U.S.

First, some criteria need to be set. The criteria to be used to determine if the VA is a model for single-payer health insurance is the Triple Aim developed by Berwick, Nolan, and Whittington. The Triple Aim is a set of interdependent goals for improving health care (Berwick, et. al, 2008). The three aspects of Triple Aim are improving the quality of care, improving population health, and reducing the cost of care. The population that is being used as the sample for this discussion are those currently insured by the VA. Each of these criteria will be discussed with evidence in support of the VA as a model for a single-payer system, as well as evidence in opposition to the VA as a single-payer system.

EVIDENCE IN SUPPORT

Quality of Care

Quality of care is challenging to define and measure. The definition of quality of care that will be used for this discussion is how well health services increase desired outcomes, given current knowledge. Quality is assessed using predefined metrics. The VA uses a tool called Strategic Analytics for Improvement and Learning (SAIL) to assess performance on the desired metrics. The VA keeps track of each hospital’s performance quarterly. The VA also gives each hospital an End of Year Hospital Star Rating based on these metrics. A hospital may receive a rating of 1 to 5. As there are many metrics the VA uses, the star rating will be used to discuss how well the VA addresses the care component of the Triple Aim. Per the VA website, at the end of 2019 57% of VA hospitals improved their EOY Star Rating from the previous year (“Quality of Care”, 2019). More than half of the VA’s hospitals improved their performance between 2018 and 2019. Also, 81% of patients surveyed were satisfied with their care, as compared to 77% of Medicaid patients (Klein, 2014). Based on this information, it can be said that the VA is improving the quality of care and meeting the first criterion of the Triple Aim.

Population Health

Population health can be defined as the health outcomes of a group (Kindig & Stoddart, 2003). The VA refers to it as “Improving the health of each veteran, by understanding the health of all Veterans” (“Population Health Services”, 2015). The VA hospital system has a department that has created performance measures that it uses to make decisions that impact the health of all veterans. For example, the Population Health Services office of the VA uses Clinical Case Registry software to help doctors monitor, track, and coordinate care for veterans with chronic conditions. Using data that is gathered from this software, the VA makes informed decisions regarding care for its members. The VA is addressing the population health component of the Triple Aim.

Cost of Care

As of 2016, the VA reported annual out-of-pocket costs of $320 for its members (“The Affordable Care Act, VA, and You”, 2016). The VA boasts that it does not charge monthly premiums, enrollment fees, or annual deductibles. Members may pay copays for medication and primary, specialty, or inpatient care. As of 2020, the VA’s copay rates remain the same. Also, the VA only charges its members one copay per day, regardless of the number of appointments a member has (“The Affordable Care Act, VA, and You”, 2016). The VA has an 80% discount on prescription drugs, as compared to Medicare Part D (Oprysko, 2019). The VA also does not charge a copay for mental health counseling, care related to service, lab tests, EKG, and wellness programs. Members with at least 50% disability, or who cannot afford care, receive free care. As reducing each individual’s cost of care is an element of the Triple Aim, it can be said that the VA is meeting this criterion.

EVIDENCE IN OPPOSITION

Quality of Care

A common complaint about the VA health system is the long wait time. This means that care is not being provided in a timely manner. This is because there are not enough doctors, nurses, other medical staff, and hospitals to accommodate all VA members and their needs. This limits access to care, which is likely to decrease desired health outcomes as described in the definition of quality of care. It was also reported that claims for disability, which the VA uses to determine the amount of cost-sharing, can take up to 36 months in some areas (LaForce, 2017). This can also hinder access to care, which would decrease quality given the definition used for this criterion.

Population Health

Due to the long wait times experienced by some VA members, have resorted to going without care or (in some extreme instances) killing themselves (LaForce, 2017). As population health is related to the health outcomes of a group of individuals, if individuals in that group have declining health or are killing themselves it can be said that population health is decreasing rather than improving.

Cost of Care

Due to the VA assuming most of the risk as the single-payer, it has resorted to rationing care as a means of reducing its risk. If tax dollars will not cover care, care must be rationed. As stated previously, most veterans have low to no copays for most services and prescriptions. However, there is a tradeoff. While the VA is reducing the financial cost of care, there are other implications.

CURRENT CONTROVERSIES

Rationing of Care

As the VA offers low to no-cost insurance to its members, it resorts to supply-side, or nonprice, rationing to control utilization. With this type of rationing, resources are limited. While the VA is not purposely limiting access to care, it does not have enough resources to accommodate its members. This results in the rationing of care. The VA’s rationing of care comes in the form of long wait times. Patients have died while waiting to receive care. In a 2018 report, it was revealed that patients at the Washington, D.C. VA Medical Center underwent prolonged anesthesia because the necessary surgical instruments for their procedures were not available. Doctors and nurses at that facility also admitted to borrowing supplies from a nearby hospital to try to overcome the shortages (Spradley, 2019). Due to being underfunded and over budget, the VA Health System is unable to manage its facilities to offer care to all its members in a timely manner.

Cheating Metrics

The VA hospital has a performance metric with the goal of seeing veterans for non-urgent appointments within 2 weeks. The VA offers financial incentives to hospitals that meet this metric. As a result of cheating metrics relating to the wait time, the VA hospital in Phoenix is responsible for 40 deaths (Klein, 2014). At the Phoenix location and others, administrators created secret waiting lists to hide the true wait times.

SUGGESTED POLICIES

As long as demand for medical care is greater than the supply of providers and facilities (it always will), rationing is inevitable. One suggestion to combat this, as this is the chief complaint of a single-payer system, is to enforce a policy of transparency. All payers must completely disclose levels of coverage and price, giving consumers the ability to choose. This aligns with the current policy in privatized health care, which exists alongside a single-payer system. In this way, no one is “forced” to accept the inherently long wait times associated with a single-payer system. Cost is the key factor with this suggestion. The VA offers low-cost care. This transparency plan would require all payers to price their policies competitively, otherwise many individuals will go uninsured.

Another approach would be to improve the existing single-payer system, extending coverage to all Americans. The current health care budget would be utilized. Infusing the total budget into one system as opposed to many would likely improve outcomes. Competition would exist among hospitals and providers, as each individual would have the liberty to choose where he or she wants to receive care. Choice appears to be a leading reason that people oppose a nationalized health care system. To address this, a more provider-friendly reimbursement system would be adopted. Emphasizing performance on key metrics, including wait time and patient satisfaction, could motivate providers to provide a higher quality of care and reward them for meeting these metrics. Thus, a more welcoming environment for patients would be created. Also, dollars from businesses could be used elsewhere. Perhaps to provide other benefits to their employees. This option would also call for transparency among hospitals and providers for billing, which would increase competition and incite competitive pricing for services. Finally, this option would offset the risk assumed by the government due to a larger number of members.

FUTURE EVIDENCE

The two main complaints about a single-payer system are lack of choice and long wait times. Evidence should be obtained that supports the claims that a single-payer system would increase choice and improve or leave wait times unchanged. Currently, there is no evidence that the VA’s wait times are any longer than non-VA wait times. The average wait time in major metropolitan areas for non-VA hospitals is 20 days (Klein, 2014). In areas like Boston and Los Angeles, wait times are about 60 days on average. Current and trending data on wait times needs to be obtained by both the VA and non-VA hospitals to determine how the single-payer system performs in this regard. Also, a common set of metrics should be developed to accurately compare the performance of the single-payer system to the multi-payer system in the U.S.

CONCLUSION

Based on the information provided, it can be concluded that the VA Health System is a model for a single-payer health system in the U.S. The VA Health System satisfies each of the criteria in Berwick, et. al’s Triple Aim. The VA Health System offers a high quality of care and improves on it, as evidenced by patient satisfaction surveys and self-reported metrics. The VA, although it is experiencing a shortage on the supply-side, is increasing population health among veterans by expanding access to care and carefully coordinating that care. Finally, the VA offers low to no-cost care to all its members. It meets the Triple Aim to the best of its ability and, therefore, serves as a model of what a single-payer system in the U.S. could be with more support, staff, and funding.

References

Berwick, D.M., Nolan, T.W., & Whittington, J. (2008, May 01). The Triple Aim: Care, Health, and Cost. Health Affairs, Vol. 27, No. 3: Health Reform Revisited. Retrieved from https://www.healthaffairs.org/doi/full/10.1377/hlthaff.27.3.759.
Kindig, D., & Stoddart, G. (2003). What is population health?. American journal of public health, 93(3), 380–383. https://doi.org/10.2105/ajph.93.3.380.
Klein, E. (2014, May 23). Veterans Aren’t the Only Ones Waiting for Health Care. Retrieved from https://pnhp.org/news/va-care-still-the-best-care-anywhere/.
LaForce, J. (2017, August 16). America Already Has a Single-Payer System, and It’s Killing Veterans Like Me. Retrieved from https://thefederalist.com/2017/08/16/america-already-single-payer-system-killing-veterans-like/.
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Singer, P. (2009, July 15). Why We Must Ration Health Care. The New York Times. Retrieved from https://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?pagewanted=all&_r=0.
Spradley, S. (2019). Single-Payer Health Care: What Does it Mean for You?. Retrieved from https://www.nfp.com/files/WhitePapers/Single_Payer_Definitions_Examples_NFP.pdf.
Stark, R. (2017, December 07). Single-Payer Would Devastate the Economy. Forbes. Retrieved from https://www.forbes.com/sites/realspin/2017/12/07/single-payer-would-devastate-the-economy/#392478e36442.
The Affordable Care Act, VA, and You. (2016). Retrieved from https://www.va.gov/health/aca/NonEnrolledVeterans.asp.
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VA Health Care Copay Rates. (2020, January 14). Retrieved from https://www.va.gov/health-care/copay-rates/.