Does Single Payer Pay for Itself?

September 16, 2017
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Was this the message of the title of the latest from Dean Baker:

The economies of a single system can be viewed as analogous to the Social Security system, which has administrative costs that are less than 1/20th as much as privatized systems in places like Chile and the United Kingdom. The analogous institution in the health-care sector is of course Medicare, which has administrative costs of less than 2 percent of benefits in the traditional fee-for-service portion of the program, roughly a tenth the cost for private insurers.

I will agree that the 20% gross margins received by the health insurance companies are obscene. This margin breaks down into a 14% operating expense to premium revenue ratio and a 6% operating margin. I would imagine competition could cut the former in half and the latter by a factor of two-thirds. I’m suggesting a 2% operating margin is reasonable as the reserve to premium revenue ratio is close to 25% for health insurance and an 8% cost of capital is more than reasonable. But Dean is arguing that we can live on a 1% gross margin, which seems to be very ambitious. OK- governments might be able to lower the cost of capital but nearly eliminating administrative costs sounds incredible. But what do I know – so I did a Google search and came across this interesting discussion:

The correct way to estimate administrative savings is to use actual data from real world experience with single-payer systems such as that in Canada or Scotland, rather than using projections of costs in Vermont’s non-single-payer plan. In our study published in the New England Journal of Medicine we found that the administrative costs of insurers and providers accounted for 16.7 percent of total health care expenditures in Canada, versus. 31.0 percent in the U.S. – a difference of 14.3 percent. In subsequent studies, we have found that U.S. hospital administrative costs have continued to rise, while Canada’s have not. Moreover, hospital administrative costs in Scotland’s single-payer system were virtually identical those in Canada.

Their study is worth the read as it does show we can reduce administrative costs even if Dean’s claim still strikes me as an exaggeration. But the point of this discussion is to question the latest from Kenneth Thorpe:

Professor Kenneth Thorpe recently issued an analysis of Senator Bernie Sanders’ single-payer national health insurance proposal. Thorpe, an Emory University professor who served in the Clinton administration, claims the single-payer plan would break the bank. Thorpe’s analysis rests on several incorrect, and occasionally outlandish, assumptions. Moreover, it is at odds with analyses of the costs of single-payer programs that he produced in the past, which projected large savings from such reform

Back in 2005, Professor Thorpe was the darling of progressives as his analysis back then was used to promote Vermont’s proposal to go for single payer. Let me return to Dean’s discussion for a moment:

Per-person health-care costs in Canada are 47 percent of the costs in the United States. The per-person cost for the single-payer system in the United Kingdom, where health care is provided directly by the government, is 42 percent of the U.S. system.

That is accurate whereas promising administrative costs that are only 10% of what we currently see is not. I guess we are about to have a battle of the experts. My only plea is for the experts to inform us rather than push some particular agenda. Let me also note the portions of Dean’s latest that the proponents of this single payer should pay close attention to:

While a single-payer system is probably the most efficient way to provide universal coverage, it is not the only way. Most wealthy countries do not provide coverage to their population through single-payer systems. Many countries, including Germany, France, and the Netherlands, provide coverage through heavily regulated non-profit insurers. This is important to keep in mind, since it means we can have universal health-care coverage without single payer. It’s not clear that it is a good thing for progressives to gain power if they are committed to a program that really is unworkable policy… University of Massachusetts economist Gerald Friedman bravely picked up this job for the Sanders campaign, as he tried to design a plan to pay for the single-payer proposal Sanders put forward in his campaign. I think it’s fair to say the plan comes up somewhat short. Even with generous assumptions about potential revenue and savings, there would still be a substantial gap between the additional spending and the new revenue.

This discussion from Dean is an excellent one even as I picked on some of what he wrote on the alleged reductions in administrative costs. Yes – reducing administrative costs is a good thing but let’s be clear that single payer by itself does not pay for itself. Nor is it the only step we can take to reduce the per capita coverage of health care in the U.S. Going after the doctor’s cartel by letting more foreign trained doctors move here and reigning in the insane pharmaceutical patent system are likely even more important. And yes – Dean Baker has pushed both of these ideas quite admirably.

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