Medicare for All:
Single Payer Insurance Schemes as they apply to EMS
In the United States, money and profit are the driving forces behind all aspects of the healthcare system. There is a price tag on every item, every procedure and every level of medical intervention. Effective January 1st, 2021 a BLS Ambulance ride will cost $900 before millage and Oxygen. An ALS ride will cost $1,600. Although we think of ourselves as a real economic powerhouse, our medical system is ranked 27th on the planet. The Covid-19 Pandemic also exposed the full extent of the “two-Americas”; one with a set of marginal, broken public services for the poor and full speed, hyper modern and efficient services for those who pay.
Single-payer Healthcare is a type of universal healthcare in which the costs of essential healthcare for all residents are covered by a single public system through the tax base. Single-payer systems may contract for healthcare services from private organizations, as is the case in Canada, or may own and employ healthcare resources and personnel directly, as is the case in the United Kingdom. “Single-payer” describes the mechanism by which healthcare is paid for by a single public authority, not a private authority, nor a mix of both.
There are generally five primary methods of funding health care systems:
- General taxation to the state, county or municipality.
- Social health insurance.
- Voluntary or private health insurance.
- Out-of-pocket payments.
- Donations to health charities/ Non-Governmental Organizations.
In most countries there is a mix of all five models. This varies across countries and over time within countries. Aside from financing mechanisms, an important question should always be how much to spend on healthcare. For the purposes of comparison, this is often expressed as the percentage of Gross Domestic Product spent on healthcare. In OECD ( Organisation for Economic Co-operation and Development ) countries for every extra $1000 spent on healthcare, life expectancy falls by 0.4 years. A similar correlation is seen from the analysis carried out each year by the Bloomberg Group. Life expectancy is only one measure of a health system’s performance, but there is direct causality found between investments in healthcare in relation to life expectancy and infant mortality rates.
In 2011, the healthcare industry consumed an average of 9.3 percent of the GDP or US$ 3,322 (PPP-adjusted) per capita across the 34 members of OECD countries. The U.S. (17.7%, or US$ PPP 8,508), the Netherlands (11.9%, 5,099), France (11.6%, 4,118), Germany (11.3%, 4,495), Canada (11.2%, 5669), and Switzerland (11%, 5,634) were the top spenders, however life expectancy in total population at birth was highest in Switzerland (82.8 years), Japan and Italy (82.7), Spain and Iceland (82.4), France (82.2) and Australia (82.0), while OECD’s average exceeds 80 years for the first time ever in 2011: 80.1 years, a gain of 10 years since 1970. The US (78.7 years) ranges only in place 27 among the 34 OECD member countries, but has the highest costs by far. All OECD countries have achieved universal (or almost universal) health coverage, except the US and Mexico. In the United States, where around 18% of GDP is spent on health care has been one of the least efficient among developed nations in distributing it.
The Nordic countries are sometimes considered to have single-payer health care services, as opposed to single-payer national health care insurance like Taiwan or Canada. This is a form of the ‘Beveridge Model‘ of health care systems that features public health providers in addition to public health insurance.
The term ‘Scandinavian model’ or ‘Nordic model’ of health care systems has a few common features: largely public providers, limited private health coverage, and regionally-run, devolved systems with limited involvement from the central government. Due to this third characteristic, they can also be argued to be single-payer only on a regional level, or to be multi-payer systems, as opposed to the nationally run health coverage found in Taiwan and South Korea.
Healthcare in the United Kingdom is a “devolved matter”, meaning that England, Scotland, Wales, and Northern Ireland all have their own system of private and publicly funded healthcare, generally referred to as the National Health Service (NHS). With largely public or government owned providers, this also fits into the ‘Beveridge Model’ of health care systems, sometimes considered to be single-payer, with relatively little private involvement compared to other universal systems. Each country’s having different policies and priorities has resulted in a variety of differences existing between the systems. That said, each country provides public healthcare to all UK permanent residents that is free at the point of use, being paid for from general taxation. In addition, each also has a private sector which is considerably smaller than its public equivalent, with provision of private healthcare acquired by means of private health insurance, funded as part of an employer funded healthcare scheme or paid directly by the customer.
In England, funding from general taxation is channeled through NHS England, which is responsible for commissioning mainly specialist services and primary care, and Clinical Commissioning Groups (CCGs), which manage 60% of the budget and are responsible for commissioning health services for their local populations. These commissioning bodies do not provide services themselves directly, but procure these from NHS Trusts and Foundation Trusts, as well as private, voluntary, and social enterprise sector providers.
Since 1935 there have been several attempts by U.S. politicians to implement some form of universal healthcare for the American people. President Franklin Delano Roosevelt planned to include federally sponsored health insurance to be part of the Social Security Act of 1935, but it was thrown out to speed the bill through Congress. President Lyndon Jonson tried to pass a similar universal healthcare bill in 1965, the power of the health insurance industry was so entrenched that he met too much resistance to get it passed. As this was happening in the U.S. The rest of the developed world was passing their own versions of Universal Healthcare. Mitt Romney while governor of Massachusetts and President Barack Obama both established a wide range of legislation to advance hybrid versions of single-payer/ private payer Health care.
Supporters of single-payer or Medicare for All note that minorities and the poor, as well as rural residents in general, are less able to afford private health insurance, and that those who can must pay high deductibles and copayments that threaten families with financial ruin. Advocates also argue that single-payer could benefit from a more fluid economy with increasing economic growth, aggregate demand, corporate profit, and quality of life. Others have estimated a long-term savings amounting to 40% of all national health expenditures due to the extended preventive health care, although estimates from the Congressional Budget Office and the New England Journal of Medicine have found that preventive care is more expensive due to increased utilization.
Any national system would be paid for in part through taxes replacing insurance premiums, but advocates also believe savings would be realized through preventive care and the elimination of insurance company overhead and hospital billing costs. A 2008 analysis of a single-payer bill by Physicians for a National Health Program estimated the immediate savings at $350 billion per year. The Commonwealth Fund believes that, if the United States adopted a universal health care system, the mortality rate would improve and the country would save approximately $570 billion a year.
Opponents argue that access to health care diminishes under single-payer systems, and that the overall quality of care suffers. Opponents also claim that single-payer systems cause shortages of general physicians and specialists and reduce access to medical technology. However, a wide international consensus is shareds that Healthcare is both a Human Right and a national priority. Obtaining Universal Healthcare for the member states in part of the United Nations sustainable development plan.
Universal healthcare (also called universal health coverage, universal coverage, or universal care) is a health care system in which all residents of a particular country or region are assured access to health care. It is generally organized around providing either all residents or only those who cannot afford on their own, with either health services or the means to acquire them, with the end goal of improving health outcomes.
Some universal healthcare systems are government-funded, while others are based on a requirement that all citizens purchase private health insurance. Universal healthcare can be determined by three critical dimensions: who is covered, what services are covered, and how much of the cost is covered. It is described by the World Health Organization as a situation where citizens can access health services without incurring financial hardship. The Director General of WHO describes universal health coverage as the “single most powerful concept that public health has to offer” since it unifies “services and delivers them in a comprehensive and integrated way”. One of the goals with universal healthcare is to create a system of protection which provides equality of opportunity for people to enjoy the highest possible level of health. As part of Sustainable Development Goals, United Nations member states have agreed to work toward worldwide universal health coverage by 2030.
Single-payer healthcare is a system in which the government, rather than private insurers, pays for all health care costs. Single-payer systems may contract for healthcare services from private organizations (as in Canada) or own and employ healthcare resources and personnel (as was the case in England before the introduction of the Health and Social Care Act). In some instances, such as Italy and Spain, both these realities may exist at the same time . “Single-payer” describes only the funding mechanism and refers to health care financed by a single public body from a single fund and does not specify the type of delivery or for whom doctors work. Although the fund holder is usually the state, some forms of single-payer use a mixed public-private system.
In Fax-Based Financing, individuals contribute to the provision of health services through various taxes. These are typically pooled across the whole population unless local governments raise and retain tax revenues. Some countries (notably the United Kingdom, Canada, Ireland, New Zealand, Italy, Spain, Brazil, Portugal, India and the Nordic countries) choose to fund public health care directly from taxation alone. Other countries with insurance-based systems effectively meet the cost of insuring those unable to insure themselves via social security arrangements funded from taxation, either by directly paying their medical bills or by paying for insurance premiums for those affected.
In a Social Health Insurance system, contributions from workers, the self-employed, enterprises and governments are pooled into single or multiple funds on a compulsory basis. This is based on risk pooling. The social health insurance model is also referred to as the Bismarck Model, after Chancellor Otto von Bismarck, who introduced the first universal health care system in Germany in the 19th century. The funds typically contract with a mix of public and private providers for the provision of a specified benefit package. Preventive and public health care may be provided by these funds or responsibility kept solely by the Ministry of Health. Within social health insurance, a number of functions may be executed by parastatal or non-governmental sickness funds, or in a few cases, by private health insurance companies. Social health insurance is used in a number of Western European countries and increasingly in Eastern Europe as well as in Israel and Japan.
In Private Health Insurance, premiums are paid directly from employers, associations, individuals and families to insurance companies, which pool risks across their membership base. Private insurance includes policies sold by commercial for-profit firms, non-profit companies and community health insurers. Generally, private insurance is voluntary in contrast to social insurance programs, which tend to be compulsory. In some countries with universal coverage, private insurance often excludes certain health conditions that are expensive and the state health care system can provide coverage. For example, in the United Kingdom, one of the largest private health care providers is BUPA, which has a long list of general exclusions even in its highest coverage policy, most of which are routinely provided by the National Health Service. In the United States, dialysis treatment for end stage renal failure is generally paid for by the government and not by the insurance industry. Those with privatized Medicare (Medicare Advantage) are the exception and must get their dialysis paid for through their insurance company. However, those with end-stage kidney failure generally cannot buy Medicare Advantage plans. In the Netherlands, which has regulated competition for its main insurance system (but is subject to a budget cap), insurers must cover a basic package for all enrollees, but may choose which additional services they offer in supplementary plans (which most people possess).
Community-based health Insurance is a particular form of private health insurance that has often emerged, if financial risk protection mechanisms have only a limited impact, is community-based health insurance. Individual members of a specific community pay to a collective health fund which they can draw from when they need medical care. Contributions are not risk-related and there is generally a high level of community involvement in the running of these plans.
Fast forward to today, the U.S. is now ranked 27th in healthcare behind Costa Rica, Canada and Colombia. New Zealand which has a full coverage tax payer healthcare being ranked number 1 according to Cigna Global. The body count in the Covid-19 Pandemic has so far gone above 290,000 deaths and the number is only growing.
So what does all this mean for EMTs and Paramedics? Well, there are some positive effects and some challenges we could expect. With a growing segment of the U.S. population uninsured and underinsured, we will see a more healthy population under universal healthcare. Instead of people going to the hospital when they’re absolutely dying because they didn’t want to go when they were a little bit sick, we will see more people going to doctors offices and clinics for preventative reasons or to treat their illnesses before they get out of hand. We will see less people going to the hospital instead of using the ER as their doctors office. We will see the continued rise and importance of Community Paramedicine as well as more “treat in place” protocols. Inability to pay for healthcare costs is the #1 cause of bankruptcy in the United States, according to a 2019 by the American journal of public health, and when these uninsured people finally go to the hospital, they’re very sick, They’re also unable to pay for their ambulance rides. This puts more pressure on the need for funding from private insurance companies, medicare and medicaid payment. If ambulance services were able to be fully paid for every ambulance trip, municipal budgets would experience much relief from the pressure to close deficits due to the mandate to offer care to everyone despite the patient’s insurance situation. There would be a balancing effect. Another structural aspect is the separation of our service based on who is paid by whom, which is to say FDNY Municipal being paid by tax revenue, Voluntary Hospital units paid by Hospital Groups and the Privates paid by commercial firms. With single payer we will all be absorbed into a singular EMS service. There will no longer be pressures to collect billing information as it will all be one unified insurance system.
Medicare and Medicaid are federal programs that get distributed to the states and then to the municipalities. Medicare is public healthcare for the elderly over 65 and the disabled, while Medicaid is health care for the poor. When asking how we would pay for a universal healthcare program, many Americans are not aware of the use of American modern Monetary Theory (MMT). Since the U.S. went off the gold standard in 1971, we have used what is called a “fiat currency”. That means that the dollar is not tied to any commodity to give it value except for taxation itself. When federal taxes are received by the federal government, they are immediately deleted and all federal spending is done with new money. So when we want to give billions in subsidies to foreign dictatorships who are also our allies, we use MMT. When we want to pay for a permanent state of war, we use MMT. When we want a system of single payer-universal healthcare, we’re asked, “How are we going to pay for it?” With new money! Just like we pay for everything else.
What we would ultimately see is a population that will become less chronically ill, diabetics who can receive insulin at no cost, cardiac and hypertension patients who can see specialists instead of going months or more without medication because they can’t afford it. We will see overweight people lose weight due to better overall preventative health. On our part, we might see an actual drop in call volume. France, which is usually in the top five countries in worldwide healthcare requires a copay for all ambulance rides. Since implementing this co-pay, they’ve seen a steep drop in abuse of the Emergency Medical System. The burden on towns and cities would be relieved greatly due to no more treatment of uninsured patients and the end of bankruptcy due to unavoidable illnesses.
Medicare in the United States is a public healthcare system, but is restricted to persons over the age of 65, people under 65 who have specific disabilities, and anyone with end-stage renal disease. A number of proposals have been made for a universal single-payer healthcare system in the United States, among them the United States National Health Care Act (popularly known as H.R. 676 or “Medicare for All”) originally introduced in the House in February 2003 and repeatedly since. On July 18, 2018, it was announced that over 60 House Democrats would be forming a Medicare for All Caucus.
Advocates argue that preventive healthcare expenditures can save several hundreds of billions of dollars per year because publicly funded universal health care would benefit employers and consumers, that employers would benefit from a bigger pool of potential customers and that employers would likely pay less, would be spared administrative costs, and inequities between employers would be reduced. Prohibitively high cost is the primary reason Americans give for problems accessing health care. At over 27 million, the number of people without health insurance coverage in the United States is one of the primary concerns raised by advocates of health care reform. Lack of health insurance is associated with increased mortality – about sixty thousand preventable deaths per year, depending on the study. Harvard Medical School conducted a study with Cambridge Health Alliance showed that nearly 45,000 annual deaths are associated with a lack of patient health insurance. The study also found that uninsured, working Americans have a risk of death about 40% higher compared to privately insured working Americans.
It is almost criminal the situation we are in today where a global pandemic has exposed that in our nation there are vastly different results for the rich and poor in health and social well being. In true matters of access to care and the results being life and death. Rebuilding our nation and healing the wounds inflicted by our outgoing President Trump should begin by the reconstruction of our healthcare system and the endorsement of every American for the concept of health equality and Medicare for All.
Chris Jacobs, FDNY Paramedic