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'Single-Payer' Healthcare Isn't Necessary -- But Single Pricing Is… and the delivery mechanism for single-pricing is Universal Health Coverage (UHC).With UHC, employer sponsored insurance (ESI) goes away — yes — as it logically should. In fact, I don’t think we’ll make much progress on systemic healthcare reform until we end ESI. Here are …10 Reasons Why Employers -- And New Ventures -- Won't 'Disrupt' U.S. Healthcare

All industrialized countries have universal health coverage (UHC).BUT - that’s also a really important distinction because how UHC is paid for is highly variable - including single and multi-payer models (and hybrids of both).The good news is that the U.S. can easily afford UHC using any payment model it chooses. The only model we can’t afford is the system we have of selective health coverage - SHC. We sort coverage by:Age (twice - 26 & 65)Income (poverty = Medicaid)EmploymentHeritage (Indian Health Services)Military Service (VA)Uninsured (~25 million)And just how does UHC compare to SHC?

Absolutely — and here’s why.Almost every OTHER industrialized country has a better healthcare system than the one we have. The proof is this chart (with emphasis on the ‘x-axis’ not the ‘y-axis’):This isn’t the only example. The Commonwealth Fund runs a study with some regularity — and they always find the same result. Comparing 11 countries across 10 or so different metrics, the U.S. always ends up dead last.Now, we can argue, fuss, and fight over how these studies are wrong — or how the U.S. is exceptional and different, or we can ask the really hard question — just what variables are so different about the American system compared to these other countries? Forget population size because every study can (and is) reduced to per-capita outcome and cost.It turns out, there are 2 big systemic flaws in our system that are unique to America. Two very large variables in our system — that aren’t found in any of the other healthcare systems. These are:Selective Health Coverage (SHC)Employer Sponsored Insurance (ESI)The first one (SHC) is interesting because every other industrialized country is built on the opposite of SHC — Universal Health Coverage (or UHC). Footnote: UHC doesn’t require single-payer healthcare, but single-payer healthcare is (by definition) UHC. Ergo, UHC is possible (even desirable) without being a single-payer healthcare system (Germany is a good example of this — and there are others).So just how is SHC different from UHC? In SHC, we select (or sort) coverage in ways that defy the logic of actuarial math. In UHC, everyone is part of one actuarial pool — and pricing is basically uniform to all patients. Let’s oversimplify the math to that so we can see the effect. Take a surgical procedure that costs $10,000.Actuarial pool of N=1 = $10,000Actuarial pool of N=320M = $0.00003125The point here is that the larger the pool, the lower the cost of that $10,000 procedure — FOR EVERYONE!Obviously, we aren’t N=1, but unlike other industrialized countries, we aren’t UHC — and here’s (roughly) how we sort health coverage in the U.S.:As we can see, Obamacare insurance represents a relatively small percentage of Americans overall — but it has definitely captured a seriously disproportionate part of the debate.Unlike UHC, SHC is designed to support a system of “variable” pricing as a way to maximize revenue and profits — not safety or quality (let alone equality). We do this, of course, for many other aspects of our consumer life (ride-sharing, room rentals, airfare, fast food, etc…), but healthcare isn’t a consumer product. We rarely know how much healthcare we’ll need or when we’ll need it — and when we do need expensive healthcare — we’ll pretty much spend every dime we have (including dimes we don’t have) to continue living. Our fight to live is literally built into our DNA. Often, we arrive at the doorstep of expensive healthcare (the ER) unconscious — on a gurney. That’s no time as “consumers” to say “let’s compare pricing before you patch me up.”The second systemic flaw is Employer Sponsored Insurance — or ESI. Here again, the U.S. is unique in that the largest single pool of insured Americans (~153M) get their health insurance through their employer. No other country does this — largely because it sets the stage for two other big problems:Extra administration costs around a 4-party system — employer, employee, provider, and payer. Totally unnecessary — and not used by any other industrialized country.Once again — ESI defies the logic of actuarial math because there are as many size “pools” of covered lives as their are employers. There may be 154 million Americans who get their insurance through their employer, but that doesn’t mean they’re part of one pool. Pricing here is wildly variable (based on — of course — the size of the pool/employer).The history here is mildly interesting — because ESI is an accident of World War II and we just never challenged the logic of its flawed design. We needed it to work for awhile and we’ve lived with ESI for so long now, it’s considered valid simply by longevity. But there’s another really ugly truth to ESI — and it’s the tax consequence of this design:That’s right — this “accident of history” is now the “nation’s second largest entitlement.” For the tax implications alone — we should absolutely review our commitment to this fatally flawed aberration of actuarial math. Here’s how a worker's contribution to family health premiums has has grown compared to workers earnings:Now, with all this as a backdrop, the answer to the original question is crystal clear.YES — either a public option OR single-payer would work better than Obamacare or the Republican healthcare plan. Why? Because it would tilt us (as does Obamacare) closer toward UHC! Even if we didn’t opt for full UHC, it would improve our actuarial calculus.So, the natural follow on question is, why don’t we?Here I’m reminded of two quotes that are directly relevant and applicable. The first was something that Lawrence Lessig said during the 2016 election cycle (just prior to the 1st Presidential debate between Trump and Clinton):You know, when Bernie was talking about single-payer healthcare people rolled their eyes. Not because it was a bad idea, but because there’s no chance to get single-payer healthcare in a world where money dominates the influence of how politicians think about these issues.The second was one I included in my annual list of Top Ten Healthcare Quotes for 2012 on Forbes:How many businesses do you know that want to cut their revenue in half? That's why the healthcare system won’t change the healthcare system. Rick Scott — Governor of Florida — as quoted by Vinod KhoslaOur healthcare system has been optimized (some would argue hijacked) for revenue and profits — not safety or quality (let alone equality). We can change this, of course. We should change this, of course, but to do that, we have to get the monied interests (including employers) out of the for-profit business of healthcare.Will this happen? Absolutely — for two related reasons. The first is that it’s (ultimately) in our economic and societal best interest to do this, and secondly because …American’s can always be counted on to do the right thing — after they’ve tried everything else. Abba Eban — Israeli politician and diplomatSimply put, Obamacare is just another example (of many) attempts at “trying everything else.” As evidenced by that very first chart, our decades long battle with actuarial math has been epic — but it’s unwinnable — and it’s now a global embarrassment. At 18% of GDP (growing by about 5% every year), it’s also a perpetual national crisis.