Key Design Components and Considerations for Establishing a Single-Payer Health Care System

In anticipation of House committee hearings on single-payer (in the Rules Committee last week, and in the Budget Committee soon), the CBO released a report last week on the concept. It's not a score or any sort of financial analysis, but rather is a primer on some of the key decisions that would need to be made in putting together such a model.

It's a good overview, particularly as the single-payer discussion drifts toward entering a more nuanced phase.

Key Design Components and Considerations for Establishing a Single-Payer Health Care System

Some Members of Congress have proposed establishing a single-payer health care system in the United States to ensure that virtually everyone has health insurance. In a typical single-payer system, people enroll in a health plan operated by the government, and the receipts and expenditures associated with the plan appear in the government’s budget.

This report describes the primary features of single-payer systems, and it discusses some of the design considerations and choices that policymakers will face as they develop proposals for establishing such a system in the United States. The report does not address all of the issues involved in designing, implementing, and transitioning to a single-payer system, nor does it analyze the budgetary effects of any specific proposal.

Some of the key design considerations for policymakers interested in establishing a single-payer system include the following:

• How would the government administer a single-payer health plan?
• Who would be eligible for the plan, and what benefits would it cover?
• What cost sharing, if any, would the plan require?
• What role, if any, would private insurance and other public programs have?
• Which providers would be allowed to participate, and who would own the hospitals and employ the providers?
• How would the single-payer system set provider payment rates and purchase prescription drugs?
• How would the single-payer system contain health care costs?
• How would the system be financed?

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Nice job. IMO, it's a bridge too far because we have unenforced borders on our "poverty" border. So if anything, it will be an "averaging" of care, with people like me buying a supplemental, like the Advantage Plan as it's called here in California for Medicare. But even with secure borders, we have too many people not contributing to the system to not bankrupt the nation.

Did they include a "how to pay for it" chart? They always forget that part.

Greenbeard said:

In anticipation of House committee hearings on single-payer (in the Rules Committee last week, and in the Budget Committee soon), the CBO released a report last week on the concept. It's not a score or any sort of financial analysis, but rather is a primer on some of the key decisions that would need to be made in putting together such a model.

It's a good overview, particularly as the single-payer discussion drifts toward entering a more nuanced phase.

Key Design Components and Considerations for Establishing a Single-Payer Health Care System

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Decent outline, not exactly rocket science. Hope we didn't pay $10 million for it.

Of course CBO would acknowledge the issue is much more detailed than this. So yes health care is complicated. Adding to the complexity is that most Americans not covered by the government are covered by their employer. So the trick (one of them at least) is how do you do this without making it a materially bigger giveaway to corporate America than the recent tax cuts many were so concerned about.

Very cool, that means that people are really taking it seriously for once. A lot of those questions are answered in Bernie's plan, but I get that there may need to be some tweaks in order to get it done - although I do not support compromising on the basic premise - healthcare for every man, woman, and child at little to no upfront cost.

nekrodev said:

Very cool, that means that people are really taking it seriously for once. A lot of those questions are answered in Bernie's plan, but I get that there may need to be some tweaks in order to get it done - although I do not support compromising on the basic premise - healthcare for every man, woman, and child at little to no upfront cost.

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The problem is..what constitutes healthcare for everyman woman and child.

A single payer like in Canada? That doesn't pay for outpatient drugs, outpatient services like physical therapy etc?

That means 90% of americans would have worse coverage than they do now.

I haven't seen where "Bernie's plan"...answers pretty much any of it.

jaeger19 said:

The problem is..what constitutes healthcare for everyman woman and child.

A single payer like in Canada? That doesn't pay for outpatient drugs, outpatient services like physical therapy etc?

That means 90% of americans would have worse coverage than they do now.

I haven't seen where "Bernie's plan"...answers pretty much any of it.

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If you don't understand, or haven't read, Bernie's plan, Vox did a pretty good rundown on it - Bernie Sanders’s Medicare-for-all plan, explained - Vox

nekrodev said:

If you don't understand, or haven't read, Bernie's plan, Vox did a pretty good rundown on it - Bernie Sanders’s Medicare-for-all plan, explained - Vox

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Exactly. So.. he barely lays out a plan of what it may cover.. and there is a lot of questions there. What about rehabilitation inpatient and outpatient. Mental health services. Will there be preauthorization? so on and so forth.

What about providers? What happens with providers that don't want to accept the system? If they retire.. or go concierge.. what happens? Bernie is suggesting that they can force providers to accept government payment rates like medicare… but private insurance generally pays more.. sooo it somewhat subsidizes medicare patients. Payer mix means everything.

Then how is it administered? Bernie seems to forget that currently 60% of the revenue of private insurance industry comes from administering public insurance...like medicare. Does that continue.. or is their a separate organization that takes over the administration.

And the big question.. as your link alludes to.. how does it get paid for.?

Basically.. Bernie's plan has little behind it

jaeger19 said:

Exactly. So.. he barely lays out a plan of what it may cover.. and there is a lot of questions there. What about rehabilitation inpatient and outpatient. Mental health services. Will there be preauthorization? so on and so forth.

What about providers? What happens with providers that don't want to accept the system? If they retire.. or go concierge.. what happens? Bernie is suggesting that they can force providers to accept government payment rates like medicare… but private insurance generally pays more.. sooo it somewhat subsidizes medicare patients. Payer mix means everything.

Then how is it administered? Bernie seems to forget that currently 60% of the revenue of private insurance industry comes from administering public insurance...like medicare. Does that continue.. or is their a separate organization that takes over the administration.

And the big question.. as your link alludes to.. how does it get paid for.?

Basically.. Bernie's plan has little behind it

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Again, if you actually read the thing, many of your questions would be answered. The only thing I think that isn't addressed is non-healthcare related stuff, like how it may affect jobs in the insurance industry and the plan to fund the system, but he's spoken at length about those in various town halls and television interviews.

According to the two major studies done looking at Bernie's proposal, we should save between $2-5 trillion as a nation. Rather than paying your premiums currently, you'd pay additional taxes (probably less than you pay now to your private healthcare). This, along with higher taxes on the wealthy and corporations, or cuts to existing spending on things like the military would easily cover the rest. They haven't worked out specifics on this yet, as it's not really possible since the Senate and Trump would never allow it to pass anyway.

nekrodev said:

Again, if you actually read the thing, many of your questions would be answered. .

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I did read it.. I read it before you posted your article. And as I point out.. IT DOES NOT.. answer my questions... but if its there.. feel free to point out in your article exactly where it lays out exactly how its going to be administered. What happens with rehabilitation. What happens with durable medical equipment... is there preauthorization.. etc.

then point out where exactly it states what happens when providers can't make it on medicare rates alone. ETc.

According to the two major studies done looking at Bernie's proposal, we should save between $2-5 trillion as a nation.

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That's complete BS.. because without answering the questions about how its administered.. and whats covered, and whether providers will accept such a decrease.. then there is no way to say.. "it will save us x".

In fact your own article points that out. Especially when you consider that Bernies study says.. "you will get these savings"...but there is no model in the world that pays for as much in single payer as bernies plan.

Rather than paying your premiums currently, you'd pay additional taxes (probably less than you pay now to your private healthcare).

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those taxes on the wealthy and on corporations.. are going to have an impact somewhere.. either on higher prices,, or lower salaries.

And they could easily work out the specifics and have the CBO grade them. But Bernie doesn't want that.. because he thinks there is some free lunch somewhere...that you can cover everyone with "medicare"...which is better than any other countries single payer...

And yet..get all the cost savings that other countries.. with less coverage..get.

jaeger19 said:

The problem is..what constitutes healthcare for everyman woman and child.

A single payer like in Canada? That doesn't pay for outpatient drugs, outpatient services like physical therapy etc?

That means 90% of americans would have worse coverage than they do now.

I haven't seen where "Bernie's plan"...answers pretty much any of it.

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Yes, aside from saying that his plan would cover all prescription drugs and rehabilitative treatment, it answers nothing about whether it would cover prescription drugs or rehabilitative treatment

So it MUST be just like Canada's single payer system!!

jaeger19 said:

I did read it.. I read it before you posted your article. And as I point out.. IT DOES NOT.. answer my questions... but if its there.. feel free to point out in your article exactly where it lays out exactly how its going to be administered. What happens with rehabilitation. What happens with durable medical equipment... is there preauthorization.. etc.

then point out where exactly it states what happens when providers can't make it on medicare rates alone. ETc.

That's complete BS.. because without answering the questions about how its administered.. and whats covered, and whether providers will accept such a decrease.. then there is no way to say.. "it will save us x".

In fact your own article points that out. Especially when you consider that Bernies study says.. "you will get these savings"...but there is no model in the world that pays for as much in single payer as bernies plan.



those taxes on the wealthy and on corporations.. are going to have an impact somewhere.. either on higher prices,, or lower salaries.

And they could easily work out the specifics and have the CBO grade them. But Bernie doesn't want that.. because he thinks there is some free lunch somewhere...that you can cover everyone with "medicare"...which is better than any other countries single payer...

And yet..get all the cost savings that other countries.. with less coverage..get.

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Your posts are BS. For example, Sec 201(10)(b) details coverage for durable medical equipment

You either lied when you said you read it, or you didn't understand what you read

sangha said:

Your posts are BS. For example, Sec 201(10)(b) details coverage for durable medical equipment

You either lied when you said you read it, or you didn't understand what you read

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I read the article that the fellow presented. But feel free to post a link to sec 201 (10)(b).

sangha said:

Yes, aside from saying that his plan would cover all prescription drugs and rehabilitative treatment, it answers nothing about whether it would cover prescription drugs or rehabilitative treatment

So it MUST be just like Canada's single payer system!!

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Please provide links to all these details please.


The problem is.. I have heard Bernie say that he plans to get the savings like Canada.. but as you just point out..and so does the article..his plan pays for more than Canada.


So.... there is a disconnect by Bernie.

jaeger19 said:

Please provide links to all these details please.


The problem is.. I have heard Bernie say that he plans to get the savings like Canada.. but as you just point out..and so does the article..his plan pays for more than Canada.


So.... there is a disconnect by Bernie.

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If you haven't read the bill, you shouldn't make up lies about what it doesn't say

And since you have been proven to have lied about Sanders, please post a link to Sanders saying what you claim he has said. Your words cannot be trusted

sangha said:

If you haven't read the bill, you shouldn't make up lies about what it doesn't say

And since you have been proven to have lied about Sanders, please post a link to Sanders saying what you claim he has said. Your words cannot be trusted

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Yawn...nice try..

Nope..I was not proven to "have lied"... I have brought out salient points that even the article that was presented pointed out as well.

But I certainly love a debate.. so how about you provide those links to descriptions of exactly what is paid for and what is not. You know.. the links I asked for.

Single-payer does not cost more than the private insurance system we already pay for. Current Medicare is funded from a payroll tax plus premiums paid. There is no reason for that to change, just the amount assessed as a premium. That would be based on income.

If your paying for insurance premiums your paying for the same thing Medicare pays for now and with single-payer. It covers about 70% of medical costs. If you want more, you purchase a supplemental plan to fill in the gaps.

Benefits for Single-payer include; everyone is covered, No more need for Medicaid, no unreimbursed care, no provider networks, consistent and justifiable pricing, lower operating and hiring costs for employers, health insurance independent from job enables more flexibility for employment mobility, higher wages or entrepreneurship.

CMS would still administer it.

manofknowledge said:

Single-payer does not cost more than the private insurance system we already pay for.

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That depends, primarily on what it pays for and how much it pays for it.

If it's more generous than coverage today in terms of covered benefits and benefit design (e.g., if it had zero cost-sharing), it would tend to cost more. If it eliminates utilization management across the system, it would tend to cost more.

Making reimbursement-setting into a political exercise (i.e., an exercise in lobbying) could go either way. It could push payments down if the politicians and their designees are disciplined, although it's not really clear who the constituency for lower spending is. It could push payments up if the constituencies for higher spending get ahold of the political machinery behind the rate-setting process, or if the politicians see rate-setting as Christmastime for their districts and stakeholders--which is presumably a bigger danger if SP is at least partially deficit-financed.

Current Medicare is funded from a payroll tax plus premiums paid.

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Well, that and about $300 billion in general revenue.

manofknowledge said:

Single-payer does not cost more than the private insurance system we already pay for. Current Medicare is funded from a payroll tax plus premiums paid. There is no reason for that to change, just the amount assessed as a premium. That would be based on income.

If your paying for insurance premiums your paying for the same thing Medicare pays for now and with single-payer. It covers about 70% of medical costs. If you want more, you purchase a supplemental plan to fill in the gaps.

Benefits for Single-payer include; everyone is covered, No more need for Medicaid, no unreimbursed care, no provider networks, consistent and justifiable pricing, lower operating and hiring costs for employers, health insurance independent from job enables more flexibility for employment mobility, higher wages or entrepreneurship.

CMS would still administer it.

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Well.. a few corrections.

1. Current medicare is not funded from a payroll tax plus premiums paid. Medicare currently is running a deficit.. I believe somewhere in 2005 is where it flipped from running a surplus to running a deficit.
And current medicare relies on people who are not eligible for benefits funding it. In other words.. I will pay into medicare my whole working life.. and then only near the end.. do I become eligible for benefits.

That's a far cry from whats being proposed.. which is that suddenly people will be able to be eligible for benefits.. without having put decades worth of funding into it.

2. By and large your insurance premiums are not paying for the same thing medicare pays for. Medicare is actually made up of several parts. Medicare Part B..Medicare PArt A and medicare part D the most notable. Most single payer plans in other countries... like Canada... actually only cover things comparable to our Medicare part A. (and in fact our medicare partA..even then covers more)…
So there is real question..just how single payer "medicare for all"... is going to work. Medicare for all proponents... talk about the savings it will have just like other countries like Canada. Well then.. does that mean it will cover the same things? Because generally that's a lot less than our medicare part A, part B and part D.

Bernie in fact has proposed a medicare for all program that he states will give us savings like other countries... but the benefits he covers appear to be well beyond other single payer countries benefits.

3. There will still be unreimbursed care. That happens with our current government systems now.. not sure why you would think it will magically end.
The same with consistent and justifiable pricing. The medicare system certainly does not have consistent nor justifiable pricing.

4. Not necessarily lower operating and hiring costs for employers. In fact there may be increased costs in the form of payroll taxes.

5. CMS does not administer medicare currently.. its administered by private insurance contractors.

Greenbeard said:

That depends, primarily on what it pays for and how much it pays for it.

If it's more generous than coverage today in terms of covered benefits and benefit design (e.g., if it had zero cost-sharing), it would tend to cost more. If it eliminates utilization management across the system, it would tend to cost more.

Making reimbursement-setting into a political exercise (i.e., an exercise in lobbying) could go either way. It could push payments down if the politicians and their designees are disciplined, although it's not really clear who the constituency for lower spending is. It could push payments up if the constituencies for higher spending get ahold of the political machinery behind the rate-setting process, or if the politicians see rate-setting as Christmastime for their districts and stakeholders--which is presumably a bigger danger if SP is at least partially deficit-financed.

Well, that and about $300 billion in general revenue.

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Medicare already defines what is covered and what it pays. None of that has to change to implement Medicare for All. Now if the legislation addressed more comprehensive coverage then that will be part of the debate. It is currently equivalent to a Silver level plan on the Insurance Exchanges.

Currently the Medicare premium is $125/mo. The average cost of a Silver health insurance plan is $500 for an individual and $1200 for a family. If a similar premium were assessed for Medicare for All based on incomeit would cover the added cost. Taxes would go up significantly but there would be no need to buy insurance or depend on your employer for it which would offset the tax increase.

manofknowledge said:

Medicare already defines what is covered and what it pays. None of that has to change to implement Medicare for All. Now if the legislation addressed more comprehensive coverage then that will be part of the debate. It is currently equivalent to a Silver level plan on the Insurance Exchanges.

Currently the Medicare premium is $125/mo. The average cost of a Silver health insurance plan is $500 for an individual and $1200 for a family. If a similar premium were assessed for Medicare for All based on incomeit would cover the added cost. Taxes would go up significantly but there would be no need to buy insurance or depend on your employer for it which would offset the tax increase.

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How, exactly, is freeing your employer from providing an employee benefit going to offset a federal tax increase?

manofknowledge said:

Medicare already defines what is covered and what it pays. .

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And start with which medicare you are talking about. Medicare Part A..Medicare Part B..or Medicare Part D.

Because.. if you plan on getting the savings like Canada.. or other countries..their single payer is NOT like all three medicares put together...

They are like Medicare Part A.. and actually usually less comprehensive than our medicare part A.

Currently the Medicare premium is $125/mo

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Nope..not true. Sorry but that's just one part of Medicare.. not all Medicare.

jaeger19 said:

And start with which medicare you are talking about. Medicare Part A..Medicare Part B..or Medicare Part D.

Because.. if you plan on getting the savings like Canada.. or other countries..their single payer is NOT like all three medicares put together...

They are like Medicare Part A.. and actually usually less comprehensive than our medicare part A.



Nope..not true. Sorry but that's just one part of Medicare.. not all Medicare.

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So what?

Per capita medical spending is lower in Canada than the U.S. That includes care that is covered and that is not

sangha said:

So what?

Per capita medical spending is lower in Canada than the U.S. That includes care that is covered and that is not

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Right. Which means that people are going to find out that some of their care that is covered now..is not covered.

That will mean that per capita.. I .. who am not currently using healthcare.. might cost me less...

but it means that someone who was getting care.. is now having to pay.. much more than they were before.


Let me help you out..

Lets say that I am paying 5000 in healthcare coverage per year.. when it comes to taxes and what I pay in coverage for healthcare.

With that.. another person is paying nothing.. because their Medicaid.. (which I basically am subsidizing).. covers their healthcare their medications.

Now.. under a Canada system.. their Medicaid is switched a Canadian government type insurance... so they don't have medication coverage anymore.

I now pay 4000 per year in taxes and healthcare coverage (for my supplement).

Per capita? PEr capita in the first example is 2500 a year.

Per capital in the second example is 2000 per year.

Awesome right.. its a savings...unless you are that fellow on Medicaid who now doesn't have coverage for his medications....

There is no free lunch here.

jaeger19 said:

Right. Which means that people are going to find out that some of their care that is covered now..is not covered.

That will mean that per capita.. I .. who am not currently using healthcare.. might cost me less...

but it means that someone who was getting care.. is now having to pay.. much more than they were before.


Let me help you out..

Lets say that I am paying 5000 in healthcare coverage per year.. when it comes to taxes and what I pay in coverage for healthcare.

With that.. another person is paying nothing.. because their Medicaid.. (which I basically am subsidizing).. covers their healthcare their medications.

Now.. under a Canada system.. their Medicaid is switched a Canadian government type insurance... so they don't have medication coverage anymore.

I now pay 4000 per year in taxes and healthcare coverage (for my supplement).

Per capita? PEr capita in the first example is 2500 a year.

Per capital in the second example is 2000 per year.

Awesome right.. its a savings...unless you are that fellow on Medicaid who now doesn't have coverage for his medications....

There is no free lunch here.

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What care that is currently covered will not be covered under single payer?

sangha said:

What care that is currently covered will not be covered under single payer?

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We don't know yet.

That's the point of the OP. We know that you cannot get the savings that are being claimed.. and savings that are being compared to other countries like Canada.. without having insurance that's like those countries. I mean.. you can't go "we are going to get savings from our single payer like Canada and other countries do"... then design a single payer that pays for way more than these countries do.. that doesn't cut reimbursements to providers like these other countries do, that doesn't put in controls like pre authorizations like these countries do, that doesn't decrease access to hospital beds and equipment that these other countries do. Its just not logical.

There is no free lunch with single payer.

Now.. I get that you will never listen to me.. because I have conservative in my lean... but Greenbeard here has done an excellent job on multiple threads of pointing out these various facts and why our system costs more.