Single-Payer Health Care Is Not the Answer
Fellow Canadian F.H. Buckley caused a maelstrom in conservative circles last week when he called on President Trump to advance a single-payer model for U.S. health care. A chorus of conservatives were quick to condemn this marked departure from long-time right-wing orthodoxy. While the critics are correct that single payer is not the answer, Mr. Buckley is nevertheless posing the right question to guide meaningful and durable health-care reform.
This intellectual and political debate highlights the competing priorities and inherent trade-offs in health-care policy and the attendant challenge of reaching a legislative outcome with broad-based political support. The failure of the American Health Care Act (AHCA) has left a gaping wound in the Republican agenda — and, apparently, a schism among some conservative policy thinkers and pundits on how best to improve the American health-care system.
One of the ill-fated bill’s greatest weaknesses was that it did not have a unifying purpose or goal. Was it about access or coverage? Cost or quality? Individual choice or collective responsibility? The answer was, effectively, a bit of each, due to congressional negotiations and the president’s pre-inauguration pronouncements. The resulting bill was an amalgam of different ideas and policy reforms that lacked overall coherence.
Reports that there are nascent efforts to revive health-care reform is encouraging, and not only because it was a major campaign promise on the part of both the administration and the Republican-controlled Congress. Health-care reform is also needed because the Affordable Care Act continues to face serious challenges.
But if a second attempt at reform is to be more successful, Republicans must clarify their overarching goals and explain how their new bill will achieve them. Enter Buckley’s recent call for a single-payer model and the considerable criticism that it has engendered.
Buckley is dismissive of what he might characterize as Republican doctrinarism, which places market freedom over universal coverage. He argues, instead, that the president and his allies should shed “RyanCare” and prioritize universality.
His principal argument is that a single-payer regime — what he calls the “Canadian model” — would best serve the “people who elected Trump in 2016.” It would be an act of “solidarity” to ensure that low-income or unemployed workers would have guaranteed basic health-care coverage. The result would be to wedge congressional Democrats and reinvent the Republican Party “as a party of working Americans of all races and ethnicities.”
Buckley’s proposal has been panned by prominent conservatives, who rightly respond that the single-payer model is an anathema to long-standing conservative orthodoxy. They have a point. It would certainly be a major shift to go from describing Obamacare’s combination of mandates and subsidies as “a government takeover” to adopting state-financed health care.
Canada’s model of fiscal federalism with regards to health care does offer some useful, positive lessons for U.S. policymakers, as I recently argued in these pages. But other key parts of Canada’s health-care system — in particular, its single-payer insurance — offer salutary lessons about the negative consequences of government monopoly.
The “Canadian model” of single-payer insurance is deeply flawed. It is highly costly and increasingly unsustainable from a fiscal perspective. It performs poorly with regards to wait times and access to physicians and medical technologies. And, perhaps most surprisingly, it is inegalitarian: While the Canadian state-provided model covers everyone’s hospital and doctor costs irrespective of income, it offers little to no support for non-insured services, including drugs, dental, vision, and long-term care — even for low-income citizens.
This latter point is important because hospital and doctor services represent less than half of overall health-care expenditures, and that number is shrinking. The result? The single-payer model with its attendant prohibitions on patient cost-sharing means effectively fully subsidizing hospital and doctor services for wealthy Clinton voters and providing no support for drug costs to poor Trump voters.
That is hardly the paragon of “economic nationalism” that Buckley envisions. Canada, in short, is a poor example of universal health care.
But this does not mean that he is wrong that basic universal coverage ought to be a goal. There is a good policy and political case for such an objective, as the American Enterprise Institute’s Michael Strain and others have argued.
It is important to recognize, however, that a single-payer model is not a necessary condition for universal coverage. There are ample examples from OECD countries where universal health care is guaranteed without the single-payer model. These countries are able to achieve universal coverage through a combination of mixed insurance with catastrophic coverage, direct subsidies, tax preferences, cost-sharing and user fees, and regulations and mandates. The result is the upsides of universality without the downsides of Canada’s single-payer model.
A second attempt at repealing and replacing the Affordable Care Act should draw on these models. It would be wise, for instance, to start with universal coverage for catastrophic expenses associated with serious illnesses or injuries. This would narrow the scope of Obamacare’s overreach without abandoning the idea that Americans should not be put into financial dire straits if they get sick or hurt.
The first step in any renewed effort to reform American health care is to define the objectives. Frank Buckley’s emphasis on universality is a useful contribution to this real-time debate, even if his focus on the Canadian model is misguided. There are plenty of better examples out there. Republican legislators should draw on those, instead.
Sean Speer is a Munk Senior Fellow at the Macdonald-Laurier Institute, a public policy think-tank based in Ottawa, Canada.