Does single payer save money? Matt Yglesias had a piece in Vox today headlined “The single-payer debate we should be having,” in which he admits that Hillary Clinton’s recent anti-single payer (SP) attack is “questionable,” but contends that we’re missing the main point about SP: namely, that it saves money by reducing reimbursement to health care providers like physicians.
Such a move would be politically very difficult, he argues, and in any event we could very well cut payments without moving to SP – and save money all the same. It’s best to quote him at length:
Single-payer systems save money by squeezing health care providers — doctors, hospitals, and ultimately everyone who works for them — which would be very difficult to accomplish ex post facto. If the political consensus did exist for enacting large, across-the-board cuts in doctors’ fees and hospital charges, then there would be no need to shift to a single-payer system in order to accomplish the cuts. In the absence of such a consensus, the switch to single-payer actually wouldn’t save money, and the costs would become exorbitant.
Thus, he contends that “a single-payer structure is neither necessary nor sufficient” to reduce health expenditures in this fashion. He says a lot in this article, some of which is fair, but this specific point is incorrect.
In passing, Yglesias briefly mentions that SP would be administratively simpler, yielding some increased efficiencies. But this is entirely inadequate: reduced administrative expenditures would be a primary source of potential savings under SP. This may sound wonkish, but it’s a point of great importance in this very high-stakes debate.
There’s a whole literature about administrative inefficiencies of the US health care system, but I’d ask Yglesias to have a look at this paper by Jiwani et al., Billing and insurance-related administrative costs in United States’ health care: synthesis of micro-costing evidence, published in BMC Health Services Research in 2014 (note: two of the co-authors [DS and SW] are colleagues/collaborators on other projects). The paper provides an estimate for “billing and insurance-related” (BIR) costs for the US health care system, and compares it to Canada, which has a single-payer system.
The potential estimated efficiency savings are enormous. In comparison to the SP system in Canada, “added BIR costs” were estimated at $49 billion/year for physician practices, $54 billion/year for hospitals, and $69 billion/year for “other health service and supplies.” Using US Medicare as a benchmark, added BIR costs were estimated at $185 billion/year for private insurers and $18 billion/year for public insurers. Depending on the exact assumptions used, the investigators produced a “plausible range for overall added BIR costs in the US of $254 – $507 billion in 2012…”
The implications of this are clear: the efficiencies of a SP system – which could reduce or eliminate the need for a whole range of administrative and billing activities at the level of insurance companies, hospitals, and doctors’ offices – could be a substantial contribution towards expanding coverage under SP. To quote the investigators:
Implementation of a simplified financing system offers the potential for substantial administrative savings, on the order of $375 billion annually, which could cover all of the uninsured and upgrade coverage for the tens of millions who are under-insured.
This might sound farfetched for those who are unfamiliar with the enormous administrative inefficiency of the US health care system. Hospitals, for example, currently tabulate complex patient-by-patient bills, sometimes for every service or supply utilized (and often chase down those with unpaid bills using debt collection agencies). Under SP, they could instead be paid “global budgets” to cover all operating expenses and all patients; the need for hospital billing departments would thereby shrivel. Physicians practices’ likewise must bill (and jostle with) an ever-changing roster of insurance plans, requiring significant staff and/or time.
In short, Yglesias’ analysis of the current SP debate almost entirely neglects how increased administrative simplicity could pay for a SP system that eliminated both uninsurance and underinsurance. Even if overall health care expenditures were unchanged at the end of the day, this would be quite a bargain.
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