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Oliver Fein, M.D., is a Professor of Clinical Public Health in the Department of Public Health at the Weill Medical College of Cornell University. His research and policy interests include[…]

Publicly financed, privately delivered: Dr. Oliver Fein explains how healthcare financing reform is a pre-condition for delivery-system reform.

Question: What are some of the common arguments forwarded by opponents of a single-payer healthcare system?


Fein: Number one, that this is in some ways contrary to American culture that, you know, we are free and independent nation. Secondly that free markets which is what they usually are advocating are the best way to distribute resources within an economy and they argued that that would be best for health care. And thirdly, I think the problem is that they often represent those entities which indeed get the benefit from having our present system. Namely they are insurance companies, private health insurance companies, the pharmaceutical industry, those are the most common folks who speak against a Single-Payer National Health Insurance Program.


Question: What healthcare system do you propose?


Fein:Okay, let’s start with what we’re calling a single-payer National Health Insurance Program and let me be very clear that that’s confusing to people. I’ve had people come up and tell me you mean I have to be single to qualify for your health plan? No.


What we are talking about is a program that essentially provides automatic enrollment for anyone who lives in the United States, that’s what real universal coverage is. Somebody presents to an emergency room they don’t have health insurance, let’s take the opportunity and sign you up right there because you should be automatically enrolled. There is no private health insurance company in the United States that would enroll you when you came to the emergency room.


The second principle is that the coverage should be really comprehensive. Everything from preventive care, through doctor, hospital, mental health, dental, to nursing home care all medically necessary services.


The third principal is that it should be financed by a public system in essence. The way in which we finance private health insurance today is using premiums. And premiums are really relatively unfair. The president of the company pays the same premium as the secretary yet their incomes are so widely different. Public financing means that it would be scaled according to income.


And, the fourth principle is that all of this should be done through a much more simple administration and that’s what single payer is. For instance, the Medicare program, which is our one example of a single payer program in the United States, has a 4% overhead, 3 to 4%, whereas private health insurance can be anywhere from 20 to 30%.


And finally, all of these should be delivered essentially through a, how to describe it, a private delivery system. It’s public financing, private delivery.


Let me say that in addition to that there should be free choice of doctor and hospital and really that’s what a single-payer program would offer. That, right now in private health insurance you are limited to a network of doctors and a network of hospitals. You have to pay, frequently, substantially more if you want to go outside that network, whereas in single payer you can go to any doctor and hospital.


So you might ask the question, “Is there any health insurance program in the United States that resembles what we are talking about?” And I would like to say, “Yes. It’s the traditional Medicare program.” It’s essentially a program that is publicly financed but privately delivered and that’s what we are talking about.


Topic: White House Summit on Healthcare and healthcare reform


Fein:Okay, well let me start with the White House conference. We were invited largely because initially someone representing the single-payer position had not been invited including Representative Conyers who was the major sponsor of H.R. 676, the bill that in the last congress had 93 co-sponsors in the house, it had the most co-sponsors that any healthcare bill but he wasn’t invited, and then no one was invited from our organization, Physicians for National Health Program. So we, you know, call the White House, we had people from around the country get involved, we actually even threaten to do a white coat demonstration outside the White House and we were finally invited, literally, myself the day before the conference itself. So that was how we got there.


When we were there, we were able to be full participants and the essential agenda of the White House Summit on Healthcare I think was three things.


One was it was all broadcast on C-Span so the president was saying, “I am being transparent. I want you to see what’s happening in healthcare reform.”


Secondly, he invited quite a few Congress people, probably 52 if I count correctly, senators and representatives from the house but from both parties. So the second message was, I’m going to try to be bipartisan from the beginning.


And then the third message of the Summit was I am not going to dictate to Congress what they come out with. I’m handing all the significant issues over to Congress.


So, the overall message I think was I’m doing this different from Hilary Clinton and the Clinton’s in general. I’m trying to approach this with transparency, bipartisanship, and letting Congress take the initiative.


Now, the problem with that is that I think the president is going to have to take leadership here particularly if we’re going to get a significant reform and so far the notion that you can include the private health insurance industry and maintain a multi-payer system essentially I think really flies in the face of the evidence that it’s possible to do this.


First, you know, there isn’t going to be the dollars to grant access to all those who are uninsured nor to improve the policies for people who are under insured. The way single payer does that is that it removes a lot of the administrative cost of private health insurance but even more importantly, the administrative cost in my office of having to have an extra person to deal with all the multiple insurance companies each of whom have their own rules. In fact, hospitals will have smaller administrative cost.


We compare Toronto General with a similarly sized hospital in the United States. Toronto General has 3 billers. It is in the single payer system in Canada. We had over 300 billers in the comparable sized, US hospital. So if we convert it to a single-payer program, there would be the funds there without increasing the overall cost to the system. There would be the funds there to grant universal coverage automatic enrollment and to improve the kinds of policies that people have, that they are now getting from private health insurance companies.