Unveiling Truths, Connecting Communities

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A Middle Ground in American Healthcare: Dr. Jonathan Kenigson’s Reflections

The quality and accessibility of healthcare in the USA is a persistent and vitally important question in public policy. Uninsured and underinsured individuals are routinely subjected to astronomical unforeseen expenses stemming from routine and preventable illnesses. Hospitals and medical providers are compelled to satisfy the ethical standards and profit requirements while navigating a staggering litany of legislative mandates from federal, state, and local bodies. Political machinations, grandstanding, and ham-handed intransigence are the orders of the day. American healthcare has always been expensive and of a low quality for the price. Despite 50 years of accruing medical inflation and untold human suffering and anxiety stemming from inadequate access to care, the motley patchwork of poorly interdigitated systems that define American healthcare shows little sign of simplification or increased transparency. Liberals opine that a single-pay system is the only way to stabilize prices and improve healthcare outcomes. Conservatives take this Keynesian approach as an affront to free-market values and reject the discussion wholesale. What both camps gratuitously assume, however, is that Americans lack common sense and an ability to weigh evidence with sober judgment. This assumption dramatically underestimates the character and integrity of our country’s bent toward pragmatic, compromised decisions. 

None of the models for single-pay healthcare considered in recent CBO reports or considered in Congress or by the Executive consider use-stratified pricing models, rebates for low utilization, a transparent fee-for-service marketplace, or gradated copayment/deductible structures, all of which could contain costs through free-market mechanisms. It is both fair and prudent that greater use of a system should entail greater payment for the services that this use provides. The introduction of utilization-based Medicare premiums in a differential manner would offset some costs of higher utilization projected by all CBO reports issued to date. Premiums for individuals could be set by Bayesian mechanisms with an equitable differential cap. The introduction of use-adjusted stratified premiums would offset many of the costs outlined in the CBO reports cited herein. High-risk pools – mainstays of Conservative opposition to the Affordable Care Act (ACA) – used such stratification to contain costs, although the small risk pools made many of the premium differentials draconian and unaffordable. Additionally, no CBO-investigated plan has determined the possible effects of “low utilization” rebates on national health expenditures. Such rebates could be issued as tax credits if expenses incurred by Medicare were lower than anticipated for a given individual. This commonsense, free-market approach to cost containment would strongly incentivize use-reductions while ensuring adequate and prompt care for high-risk patients. Additionally, the establishment of a universal, fair deductible for health services throughout any universal Medicare system would reduce complexity and administrative overheads. Based upon existing CBO data, conservatives would be right to object that payment-free healthcare may increase wasteful utilization. Free-rider arguments aside, however, a uniform deductible and copayment structure would dramatically decrease the complexity of medical billing and place a downward pressure on the soaring administrative overheads of the astronomically more inefficient private markets and Affordable Care Act (ACA) exchanges. 

The American public may falsely assume that the lack of uniformity in prices levied by healthcare providers implies that healthcare in our country is a free-market enterprise. This assumption is dramatically false. In the current medical paradigm, prospective consumers cannot determine the prices of services before they are rendered. Service providers are at the mercy of constantly shifting reimbursement rates negotiated with hundreds of individual insurers. Providers are also at the mercy of astoundingly prohibitive costs for uncompensated care or patients’ impartial payments of deductible expenses due to the vicissitudes of housing, transportation, childcare, and other expenses. Despite the successes of the Affordable Care Act (ACA) in increasing the rate of uninsurance, these costs remain staggeringly high, and seem frankly unresolvable from within the paradigm of the legislative framework as written. Instead of state exchanges for health plans, medical providers could be granted incentives to post transparent, inclusive, price-per-procedure prospectuses that consumers could query on a national exchange. Consumers could receive premium reduction incentives for selecting more affordable providers via the national exchange. Prescription drugs are similarly mired in a welter of obscurity that does not even remotely approach a free market with adequate information for optimal consumer decisions. An open-bidding interface via a national exchange in which consumers could compare prices for prescriptions drugs from across state lines and secure generic and lower-priced alternatives would likely place a strong downward pressure on drug prices. Additionally, premium reduction incentives could be issued to consumers who were to opt for less expensive alternatives on the national exchange.

The model outlined above encapsulates the best aspects of a single-pay system while decreasing legislative burden and enhancing consumer information, freedom of action, and personal responsibility for healthcare choices. As such, it could be termed a pragmatic model rather than a partisan one. The best non-partisan evidence suggests that a single-pay healthcare model far less efficient than the above would increase American economic productivity while decreasing working hours and improving health outcomes overall. The decrease in working hours for employees no longer requiring full-time employment for healthcare coverage would be offset by a healthier and fitter workforce. Aggregate demand for consumer goods would increase by 11% over 10 years, and salaries for medical professionals would increase due to lower burdens of uncompensated care (https://www.cbo.gov/system/files?file=2022-02/57637-Single-Payer-Systems.pdf). Additionally, there is no reason to assume that wait times for medical procedures would dramatically increase. It is not in general true that countries with single-pay healthcare systems have longer wait-times to see specialists or access life-saving care. In fact, a complex multimodal distribution may be observed in the data, with the USA performing worse than virtually all OECD countries with respect to the percentage of patients waiting more than 1 day for care in the 2020 Waiting Times for Health Services: Next in Line study by the OECD. However nonpartisan CBO models indicate that increased wait times could arise if deductibles were lower and utilization rates were higher than at present. The measures outlined above could reduce unneeded utilization through free-market mechanisms, interstate exchanges, and rebates for affordable and sound judgments that conserve taxpayer funds. 

Fellow Americans, read and study available evidence and exercise your freedom of thought to ask sensible questions about your healthcare. Dare to think independently as scientists, philosophers, and stewards of the public purse. Read the best available evidence and take charge of your future. Demand that you have access to quality care and demand that care be equitable for all. You do not have to dispense with a free market in healthcare to make our system better. We do not have a free market to dispense with. I have great faith in our common ability to reason without slipping into egregious errors of judgment. Demand justice and honor for yourself, your family, and your neighbors without surrendering the advantages that free markets provide or falling foul of crass political sloganeering.

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