- A Path to Universal Access
What should health care reform look like, and how do we get it under way? Three commentators respond to DeGrazia.
What balance of government and private institution activity might stand a reasonable chance of achieving universal access to basic health care in the United States? David De Grazia makes a strong case that single-payer national health insurance with managed competition in delivery is morally the preferred structure for universal access: it best achieves the combination of universal access, cost control, freedom of patient choice, and quality of care. If we account for the realities of American political and moral culture, however, is this the model for reform that people seriously committed to actually achieving universal access should be pushing?
An example of the approach DeGrazia favors is Medicare. A single governmental entity pays for the care to which all persons within the program's scope are assured access, but the care is delivered by competing private providers, for-profit ones included.
The international health care landscape, and even the United States itself, provides other models of the public-private mix. In Switzerland and the Netherlands, not only the providing organizations but also the "health plans"—the insurers—are competing, privately owned entities.1 The government, to be sure, sets the framework for the competition: it controls the cost and content of the basic benefits package, enforces the mandate that everyone have insurance, and funnels significant resources to help people obtain it. In the United States, this model is represented by the Federal Employees Health Benefits plan (FEHB). The government organizes and manages the structure within which insurance plans compete and largely finances that insurance, but competing private companies offer the insurance.
Can such a variant fit within the model that "single-payer" proponents like DeGrazia defend? It is not clear. DeGrazia opens the door to mixes of public and private insurers within his framework, noting that a sizable but not dominant role will be left for private insurance: insurance for whole categories of services not included in the publicly provided coverage, as well as insurance for services that fall within a public coverage category but outside the scope of services covered within the category. He also acknowledges a more debatable possible role: private insurance that duplicates the public plan's coverage.
Terminologically, one might claim that "single-payer" still applies to a system that harbors private insurance of all these sorts, for a single insurer or payer is still used to assure universal access to basic care. The model of the Dutch and Swiss systems and our FEHB uses even more private insurance, yet it might also seem to qualify for the single-payer label because the government is still the single, dominant payer for the insurance. That would introduce a different sense of "payer" than proponents of single-payer national health insurance (SPNHI) have in mind: instead of paying providers to deliver the care, it would finance the insurance.
This second single-payer model would seem to lose a good bit of what makes the SPNHI model morally attractive: the huge efficiency of a single insurance [End Page 34] plan that, among other things, avoids private insurers' high spending on promotion and advertising. It is this efficiency, in turn, that allows the system to control costs, support enough services to allow patients real freedom of choice, and ultimately deliver on quality of care and patient satisfaction.
Nonetheless, any astute observer can see why the Dutch-Swiss-FEHB model is enticing within the U.S. political and moral landscape. First and foremost, people get to choose their insurer, thereby preserving their perceived independence. Second, private insurance companies stay in business (and in the primary business of covering basic care). Third, a significant portion of SPNHI's efficiency advantage is retained. As long as insurance companies are all offering, at a minimum, a basic package of benefits stipulated as common to all qualified plans, insurers will be competing within a much more defined arena. Since insurance would be mandatory, they will not need to insist on the prerogative of denying coverage to new applicants to avoid the "adverse selection" that is...