Thursday, September 17, 2009

The "single payer" should be you

When some people say that the U.S. should have a "single payer" health care system, they're generally talking about a system in which government is the exclusive payer of all health care bills. It's tempting to think that in such a system, the money comes from some magic place in the sky, but of course, it ultimately would come from higher payroll or other taxes.

If you take a broad perspective, though the U.S. already has multiple forms of single payer systems. Medicare and Medicaid and the Veterans' Health Administration provide health services that are directly funded by taxpayers. Employer-based and individual health insurers collect premiums from employers, employees, and individuals to create large pools of money that pay the health care bills of their members. In all of these cases, the "single payer" is, ultimately, you.

The trouble with all of these systems is that much of your payments (up to 40 percent in some cases) pay for administrative costs rather than actual health care services. But what if there was a way to cut out the middle men? The Seattle-based practice Qliance Primary Care has developed one innovative solution - charging a flat monthly fee for the full spectrum of primary care services. The practice offers "same or next-day appointments for urgent care, unhurried 30 to 60 minute office visits, 24 hour phone and email access to a physician and the convenience and cost savings of an on-site x-ray, laboratory and 'first-fill' prescription drug dispensary."

Previous medical groups that utilized this business model often charged exorbitant fees, leading critics to label them "boutique" or "concierge" medicine, available only to the wealthy. In contrast, Qliance's fees are quite affordable: from $49 to $79 per month. This fee, combined with a catastrophic health insurance policy to protect against unexpected ER visits or hospitalizations, is significantly less expensive than traditional insurance policies - which makes sense, since 100 percent of payments go directly to the practice rather than being filtered through insurance bureaucrats.

So why aren't there more advocates for a "single payer" health system in which the single payer is you?


  1. Hi Kenny,

    Wouldn't a person still need full-coverage insurance to ensure they could receive complete care without going bankrupt? It seems like this office, and other physician practices like it that have done away with insurance, can only provide a limited array of services and care. How would necessary surgeries be paid for (I assume non-urgent ones aren't covered by most catastrophic plans), or the referral appointments to specialists?

    I also think a lot of people that advocate single payer do understand it comes at a high tax cost and isn't free, but still feel like it's the more efficient, fair way to see American's cared for.

    Interesting post.


    P.S. I didn't realize this post was from 2009 (saw it linked to on Twitter and clicked) - it does seem like a really popular topic now though.

  2. Hi Marselle - great questions. Yes, anyone who contracts directly with a primary care practice to receive care would still need to buy some sort of catastrophic insurance policy for, well, catastrophic medical expenses. Those health premiums are considerably lower than "full coverage" premiums (my wife had one before we were married), so a lot more people could afford them without assistance. Sure, some poor persons would still need subsidized insurance, but not nearly as many as the millions who will be receiving billions of dollars in tax credits through the ACA's health insurance exchanges next year.

    Let me put this argument a different way: if your car insurance covered your oil changes, tire changes, and other routine maintenance, how much do you think it would cost? If your home insurance covered the costs of new appliances and furniture, how much do you think it would cost? Compared to single-payer or the patchwork solutions of the ACA, I think that a regulated system of direct-pay primary care with insurance reserved for expensive specialist procedures and hospitalizations could be an efficient way to care for the most people at the lowest cost.

  3. Consider, also, that since the average health insurance premium for an American family of 4 is currently >$15,000, that thousands of dollars of reduced premium costs could pay for needed visits to specialists or minor procedures (major procedures, "elective" or not, could still be covered by a high-deductible plan).

  4. I have always been under the impression that catastrophic coverage is what you buy if you essentially have no other choice, and that you hope it's only a temporary fix until better coverage is available to you.

    Wouldn't this model, if implemented on a large scale, make full insurance coverage more expensive and inaccessible, as mostly people needing specialist/expensive care would purchase and need to use it?

    The analogies you used are really easy to understand, but I don't quite feel they can be extrapolated to explain the problems with health care coverage costs. I think a lot of people don't realize or feel they need routine visits for things like vaccines, weight management, skin checks (for melanoma), etc. By providing a no co-pay preventive check up, it seems like (fingers crossed) more people would go to their primary care physician annually or every couple of years, and that these check ups overall would end up benefiting public health. Whereas, if you don't keep your oil changed and your car dies, it has neither a negative affect on my health nor an impact on the economy.

    I do really hope that a practical & just system comes to take the place of the way things currently are! Thanks for your response. - Marselle