Dori I understand your beef with insurance but you are not acknowledging that it is a solution of sorts to a fundamental problem - the disconnect in healthcare between the supply and demand curve.
Normally supply and demand are controlled by price - if we want more of something (demand) we’ll pay more and in response more will be made (supply). This is not what happens in healthcare - we all want optimal care - MRIs for headaches - but we can’t afford that level of care. The value provided by insurance is that it connects the supply and demand curves. Insurance decides if something is a good value. The obvious problem with this approach is that the insurer values all sorts of things that the person who needs medical care does not value or values less.
A single payer system has the same problem - supply/demand curve disconnect - but responds differently. I’d call it rationing but that word carries baggage … making societal value decisions. Take dialysis the closest thing to single payer in the US. MSP rations program access and the three day a week standard rations dialysis dose and resources used. Fundamentally reimbursement determines what is supplied and therefor, rations what is delivered. Again think of the dialysis unit - at the start of the year the renal administrator (RA) knows or is given the average revenue per treatment, from that number it is the RA’s job is to figure out how use that money - staff ratios, consumable choices, etc. if reimbursement goes up or down it will change what is possible. (note - whether the provider is for or non-profit does not matter. Profit is a cost of doing business all business have, it’s an expense, an overhead expense that varies between organizations. It is typically less of an expense in non-profit organizations.)
If cost was not a constraint would incenter dialysis look the same? Why not use ultra-pure dialysate, silicon instead of PVC, more staff per dialyzor, high end artificial kidneys, unlimited frequency? Reimbursement implies the answer - they are not worth the price. Who decides what is worth the price in ESRD? I don’t know or no one does in the US and in other countries? I don’t know - isn’t it true that in the existing single payer systems it is hard to do more than the US standard unless there is a clear financial advantage from a global cost perspective? Does that by itself lead to clinical progress?
The problem is the goal. Our goal is not to save money, it is to save human potential. We want people (ourselves) to not only exist we want to live the lives we were meant to live. That is a big harry audacious goal, something we can strive for but realistically it’s not achievable in the near term. But we can work towards our goal.
Break medical care into three buckets - acute, chronic and preventative - and cover them in different ways. Preventative (and what use to be called public health: disease education and surveillance) fits with the single payer model, all services are free to the consumer - in fact you might be rewarded for healthy lifestyle habits. Preventative costs money but it delivers value to the entire system and moves us in the direction of the goal. The government does a lot in the name of protecting us - encouraging the development of healthy habits and looking for early signs of disease would do more then many of the government’s other efforts.
Chronic conditions could be covered by Medicare Plus (Medicare for all with no MSP). The difficulty in setting a reimbursement rate that does what you want it to do and the difficulty of monitoring the quality of care has to be understood when designing the system. I don’t think we want to enact a system that freezes medical care at the level of 2007, just as dialysis care seems to have been frozen in 1972. And I don’t think we want to monitor care through unfunded mandates to the states. If we could do a good job with this piece it would make everything else easier. I think this piece of the healthcare system is where the federal government should focus in the near term. This is the area of healthcare most ripe for reform.
This leaves acute and my personal heterodoxy. I’d favor a high deductible health savings account insurance scheme tied to FICA and/or access to federal benefits besides a pension. If the other pieces worked then this piece would be a smaller problem each year making insurance a smaller part of the system over time. Making some future reform easier to enact.