RATIONALE

The American Public Health Association (APHA) has a long history of support for a single-payer (SP) universal health care system. In both policies and practice, its members, leaders, and statements have recognized this approach as the best model for advancing public health principles. This policy aims to reinforce that position with up-to-date context and an urgent call to action. The passing of the Patient Protection and Affordable Care Act (ACA) in 2010 represented a critical step toward increasing insurance coverage, particularly in states that agreed to expand Medicaid coverage. However, opportunities remain to integrate payment mechanisms or rein in administrative waste, instead of offering incentives for private payers to provide eligible low-cost plans through state-level marketplaces.

Now, the need for a SP system is more relevant and pressing than ever. The proportion of those without health insurance spiked during the economic hardship associated with the SARS-CoV-2 pandemic and the degree of health disparities and the income gap continue to widen further in the United States.1 Our reliance on an employer-based coverage strategy must be seriously reconsidered, in light of the economic and demographic disparities in coverage that result.2 Private payer employment-based insurance and private for-profit insurance must be abandoned, given the inefficient scale of administrative costs and wasted health care expenditures associated with the current system.3 SP finance reform is the single best approach to address the problems in the US health care industry. Therefore, the adopted statement reaffirms the unity of the APHA members and leadership around the principals of universal coverage and SP payment reform.

PROBLEM STATEMENT

National Health Expenditure (NHE) in the US grew by 9.7% in 2020, to US$ 4.1 trillion, or US$ 12,530 per capita.4 This accounted for 19.7% of the Gross Domestic Product (GDP) at the time.4,5 The US spends the most by far on health care among all 36 countries in the Organization for Economic Cooperation and Development (OECD), both as a proportion of GDP and per capita.6,7 Despite using fewer health care resources, the US spends US$ 2000 more per person than the next highest-spending country, Switzerland, and nearly twice as much per capita on health care as the median for OECD countries.6,8

The pricing system is inherently the single greatest driver of health care costs, while providing fewer key health resources.6 There is also a large and widening gap in the prices which public and private payers are charged for identical services, which indicates that the rising total NHE is primarily driven by private health care insurers and pharmaceutical companies.6,9

US prescription drug expenditures reached US$ 335 billion in 2018, a 28% increase in a decade.9 The growth is expected to continue and is projected to increase 67.3% to US$ 560 billion by 2028, representing 19.7% of US GDP.9 In 2018, annual per capita US prescription drug spending was US$ 1221, well above that of the United Kingdom (US$ 526), Sweden (US$ 534), and Germany (US$ 884), largely because of higher drug prices in the United States than in any other country.10 One of the distinctions in US prescription policy is the burden of drug costs borne by patients as out-of-pocket costs. For instance, Medicare Part D prescription drug benefit has no cap on out-of-pocket costs for beneficiaries.11

While the US spends more per capita on health care than any other OECD country, the additional spending contributes little value from either an economic or a health outcomes perspective.6,8,12 Countries with SP spend less while their populations live longer, healthier lives.3 The average life expectancy and burden of adverse health outcomes for almost all major chronic illnesses, apart from cancer treatments, in the United States also falls short of the OECD median.10,12,13

As far back as 2003, administrative costs of health care (including insurance, reimbursement, and other administrative tasks) accounted for nearly a third (31%) of the US NHE.3,14 By 2011, the United States still spent more of its NHE on the administrative costs of the reimbursement system than any other country, 8%–18% of health care spending.7,8,15 By one analysis updated through 2017, excess administrative costs in the United States compared with Canada (SP) have persisted and still account for 17% of NHE.16 Analysis between countries with a variety of health insurance systems showed that both SP and “two-tiered” systems, such as those in France and Japan, operated with lower administrative costs than the insurance-mandated systems of the United States or Switzerland.8

Excess US spending is driven by the availability, not utilization, of medical technology and broad service pricing, as opposed to a higher rate of health care consumption or better outcomes.6 Health care services are provided at a less efficient cost for equivalent levels of care.6 Neither the quantity nor quality of care is improved by the increase in US spending, either per capita or as a percentage of the GDP.6 The US funded 50.9% of its NHE through private payers in 2016, compared with the OECD median of 25.0%. While public spending on health care is also higher than in most OECD countries that have a majority (>80%) public payer system in place, private insurers drive the largest segment of excess cost in the US health care system.3 Furthermore, the gap between publicly and privately funded health care prices in the United States has widened from 2000 to 2016, with the Medicare Payment Advisory Commission estimating that private insurers pay prices 50% higher than Medicare payments for identical services.17

EVIDENCE-BASED STRATEGY

The APHA has called for universal coverage of health care for all US residents for decades.18 This has included calls for a unified, nationally coordinated and nationally funded approach (ie, SP) to health care expenditure since the late 1970s. This goal for coverage, met by the majority of other developed countries in the world, is no longer in question, but the best approach is still being debated in policy and political spheres. In this debate, the evidence in support of SP has grown rapidly in the past decade. In addition, recent polls conducted of broad clinician samples have shown that a majority of doctors “strongly support” policy reform to implement SP.19 The American College of Physicians (ACP), the second largest provider organization in the United States, has also recommended that US policy initiate a transition to a system of universal coverage, through either an SP or a public payer choice capable of supporting universal coverage.20

Single-Payer Health System

In 1993, the APHA leadership and Executive Board developed 14 Points on Health Reform in order to organize and guide the essential criteria for reform for public health.21 These points continue to guide the principles of the public health field in developing proposals for national health reform.22 Overall, the evidence clearly demonstrates that SP is the most optimal structure for health reform in order to support these principles.

International Evidence of Quality and Cost

Overall, a SP system will significantly simplify the revenue collection and benefit payouts to a single agency.23 Countries with SP systems experience significant cost savings over their multipayer counterparts through the streamlining of billing and insurance procedures, the creation of a more equitable and predictable spread of risk throughout an entire populace, and the leveraging of bargaining power to contain costs.23

Taiwan

The National Health Insurance (NHI) system was introduced in 1994, modeled in part on the US Medicare program, although it was created to cover all citizens and foreign residents in Taiwan, boasting a 99.9% enrollment rate.24 Benefits are uniform and comprehensive, covering hospital care, physician care, pharmaceuticals, and other services. Patients in Taiwan can choose their doctors or hospitals freely instead of being limited to a certain network of providers like in the United States.25 Also, the government negotiates the reimbursement rates; thus, collaborating with other providers increases every provider’s market share and simultaneously mitigates the consequences of health services provision fragmentation.25

Canada

The Canadian health system, administered by the provinces, is a funding partnership between the provincial and federal governments.26 Provider, diagnostic, and hospital costs are covered based on a federally negotiated fee schedule and providers are not allowed to receive private payments at or above negotiated costs for any covered services.26 Private insurance covers complementary services not covered by the national system.26 Provinces administer billing and reimbursement services, but these must be comprehensive, universal, portable across provinces, and accessible.26 Comparative analyses of physician utilization in Canada and the US demonstrate higher utilization of appropriate services among populations that are sicker and lower income in Canada, suggesting that more equitable allocation of resources in the United States could lead to improved public health.27

Australia

Australia provides coverage through a hybrid, SP, universal health system available to all citizens and permanent residents.28,29 The costs of publicly funded primary and other health services, representing 67% of all health spending, are shared by national, state, and local governments, with the remainder paid through individual and employer contributions.28,29 Australia and other countries using a hybrid approach, mandate co-pays or deductibles for additional, private plans in order to manage utilization of specialist and other high-cost services and use an Electronic Medical Records systems to track patient utilization patterns.28–30

Financial Feasibility

The economic benefits of a SP system are rapidly realized by reducing the high administrative costs, primarily billing and insurance management-related costs, in the current US health delivery systems, even after accounting for expanded coverage to all those currently uninsured and residing in the United States.8,31 These wasted health care expenditures emanate from the use of multiple differing insurance companies, allowable charges, reasons to deny care, coding, provider network negotiations and care restrictions, deductibles and co-pays.30,31 Further, system-wide cost savings are realized by eliminating the processes for collecting co-pays and out-of-pocket expenses from patients and managing multiple payers.30,32 One review estimated a mean of US$ 556 billion in potential annual savings.32 Within the estimated increased federal expenditures required to support universal coverage through a SP system is the offsetting cost from less expenditure going to more costly private sector care under the status quo.30 In a review published by RAND Corporation, SP system offering universal and comprehensive coverage models were projected to generate a total net savings of US$ 121 billion annually to NHE.32 Certain models with supplemental insurance options demonstrated reductions in annual NHE by US$ 211 billion and federal expenditure by US$ 40 billion, even without accounting for the theorized savings from administrative efficiency.32 A more recent economic review showed that 20 of 22 SP proposals from the past 30 years would provide net savings within the first several years of implementation.31 Relative to the projected growth in health care costs under current conditions and trends, all of these proposals would offer longer-term net savings.31 Indeed, a SP health system is not only financially feasible, but also the most fiscally viable and sustainable approach for all.

Reducing National Pharmaceutical Expenditures

A national drug formulary is cost-effective feature of universal SP health care systems (eg, the 2013 Medicare for All Act, intended to rein in ever-increasing US drug expenditures).33,34 A national formulary can achieve reduced drug expenditures in 2 ways. First, it restricts duplicative and unnecessary medications within a class of drugs while allowing waivers to provide access for the occasional exception.33,35 Second, by supporting price negotiation at the national level, manufacturers will have substantial incentives to be included as formulary drugs.34 The Veterans Administration Health system exemplifies a national formulary system that been shown to change physicians’ prescribing behaviors favorably while providing substantial cost savings through drug price reductions from manufacturers and reductions in unnecessary drug use.33–35

Access and Equity

A SP system would address the socioeconomic disparities present in our health care system. People who are uninsured and underinsured are more likely to delay seeking medical care.36 Medical debt is also associated with housing instability and homelessness.37 A SP system that breaks down financial barriers to care would help resolve the rationing of medical care based on SES.38 One study of health care expenditures in Canada found that implementation of SP financing system reduced income inequality by 16% solely through more equitable health care utilization.39 Because a SP health system would create health care savings through a more efficient administrative system, some of these savings can and should be used to tackle health disparities in this country. A SP system also creates new opportunities to reduce health disparities, even beyond the impact of eliminating demographic differences in rates of insurance and timely access to health care services.

SP financing also includes coverage for workplace injuries and illnesses could eliminate cost shifting within the workers’ compensation system that currently burdens workers with 50% of the costs, adding inequality to injury.40 Clinical factors are also a source of inequities in health care services in insured populations. For example, coverage of mental health and behavioral health services have not been on an equal footing with medical and surgical services in the United States for-profit health insurance environment.41 While substantial gains in parity were made since passage of the ACA, the challenge of real mental health parity in regulating managed care for mental health remains.41 Publicly financed health care is far more likely to achieve real parity than a for-profit insurance industry.7,42

Improving the Value of Care

A SP health care system may emphasize provision of preventative services and coverage of chronic health care conditions. As discussed above in Taiwan, enrolling individuals with low income in comprehensive health benefits decreased the need for costly emergency and urgent care.18 Providing comprehensive health benefits can direct patients towards less expensive scheduled care, as in the example of dialysis coverage being associated with lower health care costs because of fewer emergency dialysis visits.43 A SP system should include funding to improve access to primary care services across the country, in order to shift care to lower-cost delivery with higher-value outcomes.13,20 A SP system aligns the interests of the national insurer to cover preventative care upfront in order to avoid costlier and less effective care later.

Evidence for the ability of capitation alone to make health care more efficient is mixed. Studies have found the providers in an FFS system do tend to induce more demand, for example increasing elective hospital admissions.44,45 Within the current US system, the evidence for capitation using Accountable Care Organizations (ACOs) is also mixed, with concern that ACOs may increase cost by promoting consolidation of insurers and hospital-systems.46 This conflict is alleviated by transition to a SP model which is available to all without any artificial limits to the risk pool. However, in the absence of strong evidence, alternative value-driven payment models can and should continue to be studied after the implementation of universal health care through a SP financing model, recognizing that any payment structure to physicians and hospitals might operate differently under a new insurance system.

ACTION STEPS

In October of 2021, APHA joined several national and international organizations in declaring that health care is a human right. Furthermore, APHA holds that a national SP system is the optimal design for simultaneously improving health and lowering the cost of care in the United States. In doing so, APHA joins Physicians for a National Health Program, Public Citizen, Congressional Black Caucus, ACPs, American Medical Association—Medical Student Section, American Medical Student Association, American Medical Women’s Association, American Nurses Association, and other national and international organizations in calling for legislation and administrative policy reforms to implement a national SP system.

To this end, the APHA urges:

Congress to enact policies directing: The Centers for Medicare and Medicaid Services (CMS) expand Medicare and Medicaid to provide universal coverage to a harmonized package of health care services (including vision, hearing aids, behavioral health, dental and long-term care) and pharmaceuticals without exception—regardless of race, sexual orientation and sex identity, citizenship, residency, carceral system or institutional status—to include all those living in the United States. The CMS expand Medicare and Medicaid to provide reimbursement financing using a whole health focus on parity between medical, surgical, dental care, and especially treatment for mental health and substance use disorders. The removal of any and all statutes, laws, rules, regulations, policies, or practices inconsistent or in conflict with universal coverage by CMS programs, including the elimination of all deductibles and co-payments—so that there are no financial barriers in accessing health care. Appropriate budgetary and revenue collection reforms of federal health care financing and CMS administration policies to create and sustain a single funding mechanism to support a whole health focus on comprehensive, universal coverage by US health care providers. The Department of Health and Human Services (HHS) and CMS to regulate, monitor, and report on health disparities as an accountability mechanism. State and local health care system reimbursement policies become tied to measurable patient-centered outcomes and health equity targets. Funding and technical assistance be provided to state and local jurisdictions and individual health care provider organizations to: reform their reimbursement practices to adjust for billing practices under a SP system, implement health disparity screening and reporting systems at all levels. The creation of standards, timelines, and milestones for progress toward full interoperability of health care provider data systems across the United States. Funding for HHS and CMS to provide technical assistance and direct support to underserved or under-resourced health care providers (FQHCs, CHCs, HCH, low-resource tertiary care centers, etc.) to implement interoperability standards. HHS to update and strengthen privacy practices and the data security infrastructure for CMS, while supporting interoperability goals for health care providers. Funding for HHS to modernize and update CMS data and data security infrastructure to facilitate the transition to SP health system and expansion of coverage to everyone in the United States. State legislatures, agencies, and other public servants, to: Work with the full Federal administration and State agencies to adopt reforms to transition their health care financing and reimbursement procedures to a SP system. Community partners to engage in: Legislative advocacy and educational campaigns to inform legislative and executive branch representatives and staff on the short-term and long-term benefits of a SP system in coalition and partnership with APHA. Public education campaigns. Community outreach and engagement, to facilitate collaboration on the design and implementation of a SP system. ACKNOWLEDGMENTS

This manuscript includes excerpts taken from APHA policy #20219, which is published in the APHA policy database available to all APHA staff and members. The authors thank the APHA Joint Policy Committee and Governing Council for their support in endorsing the policy described herein.

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