When will we get single payer health insurance in the United States?

Not anytime soon.

That’s according to Arnold Relman writing in the current issue of the New York Review of Books.

(The title of the article — Obamacare: How It Should be Fixed — could not have been Relman’s. It’s clear Relman doesn’t believe Obamacare can be fixed, but instead must be replaced by a single payer system.)

“The political gridlock in Washington, the financial interests of the health insurance industry, and the concerns of the physicians, clinical facilities, and businesses that are threatened by reform all make any significant change in the status quo unlikely — at least anytime soon,” Relman writes. “Probably nothing will happen until the public and the medical profession become sufficiently aroused by the growing failure of the system to provide the affordable care we need. At that point, the possibility of a single-payer system will be seriously considered because it is arguably the simplest and most logical solution — the best, and probably the only, way to ensure a universal right to affordable access to care.”

But Relman’s says single payer is not enough.

As he lays out in the article and in more detail in his book — A Second Opinion: Rescuing America’s Health Care — A Plan for Universal Coverage Serving Patients Over Profits (Century Foundation, 2007) — Relman would get rid of fee for service medicine as a way to control costs.

“The question will become: What kind of single-payer system will work best? Medicare is an example of a single-payer system that benefits those over age sixty-five and others with some types of disability (for example, end-stage kidney disease),” Relman writes. “It pays for care largely on a fee-for-service basis, and care is delivered by a mélange of independent physicians and facilities that compete for patients and income. Although Medicare forces large discounts on prices, it cannot control the volume or, with few exceptions, the choice of services. As a result, fee-for-service payments in such a system are an incentive to maximize services that can be billed separately, and Medicare’s costs have risen almost as rapidly as those in the private sector. Despite the cost-containing initiatives of the ACA, Medicare’s costs on a per capita basis are projected by the Congressional Budget Office to nearly double over the next decade, with unsustainable consequences for the federal budget.”

“‘Medicare for all’ is a policy favored by many advocates of single-payer reform. By replacing all private insurance plans, it would save a lot of money, but it would not solve most of Medicare’s problems. It would not address the rising costs that are generated by the various income-seeking medical care businesses; nor would it reduce the huge costs of the unnecessary and duplicated services delivered by the present fragmented and disorganized system. Neither would it prevent the fraudulent abuse of the billing system by physicians and health facilities that currently adds at least 5 percent to the total cost of health care. To avoid all these problems, ‘Medicare for all’ would have to go beyond simply reforming the insurance system. It would have to change the method by which the single payer reimburses doctors and clinical facilities, and it would also have to change the way medical care is delivered.”

“Most experts agree that cost containment will require replacement of fee-for-service payment with some method that encourages quality of care rather than an increasing volume of services. The ACA provides for experiments with “pay for performance” to reward quality, and private insurers are already exploring this approach. But quality in medical care is hard to define, and most of the guidelines suggested so far have been controversial. Moreover, such an approach invites providers to avoid high-risk patients. ‘Risk adjustment,’ in which payment is varied according to the severity and complexity of a given condition, is equally controversial. I doubt that initiatives based on any of these new payment ideas will prove practical enough to be widely adopted.”

In his book — A Second Opinion — Relman describes in detail “how a single-payer system sponsored by the federal government would function when coupled with a reorganized medical care system based on independent multispecialty group practices with salaried physicians.”

“Replacement of all public and private insurance and elimination of itemized bills with a public tax-funded system that simply paid medical groups per capita for comprehensive care would avoid much of the expense and many of the other problems with the current system,” Relman writes. “The enormous savings could ensure adequate compensation for all the facilities and physicians needed for universal care.”

“The loss of jobs in the eliminated private insurance industry would probably be more than compensated by increased employment in a greatly expanded public-payer system, and by the new jobs created by the emerging business opportunities created when employers no longer need to pay the health costs of their employees. Government would be able to contain the rise in total health expenditures by its power to set prices and determine the level of taxation required to fund the system, but it need not micromanage medical care. Medical decisions should remain in the hands of physicians and their patients, where they belong.”

“Most important, this revolution in our health care system would make universal access to good care affordable. It is a revolution that seems inevitable, even though it is not yet on the political horizon.”