We often look to Canada as an example of how Single Payer Medicare for All (SP) could function in the United States. Like Medicare for people over 65 and people with disabilities, Canadian Medicare is federally funded. Unlike U.S. Medicare, each Canadian province or territory manages its own program.
But there is another model we look at less frequently: SP in Taiwan. There, the Ministry of Health and Welfare determines the global budget and negotiates fees for medical services and supplies and keeps administrative costs low for the National Health Insurance (NHI). Stakeholders are involved in the budget process. The NHI speaks with one voice. Everyone is covered, either through premiums paid at the workplace or via government subsidies for poor individuals and families. Everyone has a healthcare card that carries their health history so that as they go from one place to another, their records move with them. Each provider is able to easily and speedily access the records.
Patients can choose their own doctor and hospital, and if they are willing to pay a small extra fee, they do not have to wait for a referral from a primary physician. The bulk of NHI-covered services are delivered through a predominantly private delivery system although local governments own and manage some hospitals.
One huge difference in the Canadian and the Taiwanese systems is that with global budgeting, administrative costs are exceedingly low. Here in the United States billing and insurance related costs for traditional Medicare hover around 2 to 5 percent, but health administration costs were more than four times higher per capita in the United States in 2017 as compared to costs in Canada ($2,479 vs. $551 per person). Looking to Taiwan, Tsung-Mei Cheng notes in her personal communication with an official in the Taiwanese NHI that the 2019 administrative budget was 0.77 percent of the total NHI budget.
Taiwan spends approximately 6.5 percent of its gross domestic product on health care. The United States spends more than 17 percent of its gross domestic product on health care. You would think that people in the United States would be super healthy. Not so. Death rates from major causes are higher in the United States in most cases, and people in Taiwan live slightly longer than those in the United States. The average life expectancy is 80.7 compared to 78.7 years in the United States.
Taiwanese express satisfaction with the NHI. The 2019 NHI survey showed that 90 percent of the Taiwanese were happy with the care they received. The Taiwanese give the NHI a very high approval rate. In the poll conducted by the National Yang-Ming University, 89.7 percent of the respondents said they were satisfied with the system, while 8.1 percent were not.
Implementing SP in the United States
A number of approaches to implementing SP in the United States are possible. Four bills were proposed in the last session of Congress. Each needs to be reintroduced in both houses in the 2021-2022 session.
HR 6906, Health Care Emergency Guarantee Act requires the Department of Health and Human Services to pay the expenses for those individuals receiving medical care and services during the pandemic. This bill does not lead directly to SP but is a step in that direction
HR 5010, State-Based Universal Health Care Act of 2019 would provide for federal waivers to facilitate individual states or several states working together to continue moving forward on SP. Each state or group of states would submit their plan that would cover at least 95 percent of their population within five years and the remaining uninsured population within ten years. California governor Gavin Newsom has noted the inflexibility of the federal government as the number one obstacle working against SP in California. Newsom ran on a SP platform. On day one as governor, he wrote to the Trump administration and congressional leaders:
However, to address this ongoing cost crisis in health care in the most effective way, we must have the federal tools to support California’s ability to provide quality healthcare for everyone, financed through a single-payer model like Medicare. We must have the tools to innovate and expand on the Affordable Care Act, even as we build towards a more comprehensive, universal system that works for patients, providers, and taxpayers alike.
The letter was never answered.
Although polls show that a majority of Democrats and some Republicans and Independents say they support SP, the primary problem is political will. Elected officials do not hear their constituents. Recently, my inbox included a survey from Mike Thompson, who represents my congressional district in California. The survey asked for my priorities. SP, which is my highest priority, was not even listed for me to check.
Along with continuing to pressure elected officials, we need to emphasize that the money is there. The issue is reallocating resources. Funds that go to private for profit insurance need to be shifted to SP. If corporations actually paid what they owed in taxes, the money would be available. Our coffers are empty because of a bizarre tax system that allows corporations to avoid paying taxes.
The good news
Joseph Biden has picked Xavier Becerra, a longtime SP advocate, to head Health and Human Services. For the first time in years, we have an opening to push for SP.
We need to form stronger coalitions. We need to educate unions and other groups about SP. We need to listen to those against SP with openness and try to shift their thinking. We need to listen to those who are undecided with openness and try to shift their thinking. We need to revise the false narratives about skin in the game and overusing the medical system. In particular, we need to avoid the tainted rhetoric that those opposed to SP use. We do not repeat their words because if we do so the words are cemented into the ideas of other people. We need to use our own terms. None of the work will not be easy, but we must continue.