A Warning For The US About Single Payer Health Care

Using an actual, real life, example.

American healthcare has its problems. In fact, when I did a survey of which healthcare system we might desire to have the one I described as “God's Own Clusterfuck” was that American system. I also ended up plumping for something like the Singaporean system - government covered catastrophic health care along with a medical savings account. Exactly the system that Obamacare actually makes illegal.

Hmm, well, OK. But there’s still that large constituency in the US for single payer health care. And what they really mean by this isn’t to move to just the one government insurance policy like Medicaid or Medicare. What is really meant is government provided, government supplied, health care. Something a bit more like the Veteran’s Administration system for military retirees.

That is, many a covetous glance is cast at our own Dear NHS as the way that American healthcare should move.

Hmm, OK. It’s an idea. But how good is it?

Now we cannot just point to NHS outcomes and insist that that’s what the US would get. Culture does matter after all. To get to anything at all like the NHS the US would have to entirely, wholly, change its medical training system for example. Over there doctors pay their own training fees which is one reason that once they’ve finished residency they get $500k a year - to pay back their $500k in student loans.

But, you know, OK - can we find any method of illustrating what true government provided health care would be like in the US? Given the culture, background, incentives and all that of the US overall economic structure?

One answer is that VA system, which only a few years back was being described as disastrous, actually a stain on the society. There was some reform, things did get better but from what I hear it’s all slipped backwards again. It’s not something talked about because those who might do so are also those terribly embarrassed by the manner in which reform of a government institution didn’t provide a long term solution.

Anything else? Well, yes. The Indian Health Service.

The Indian Health Service (IHS) is an operating division (OPDIV) within the U.S. Department of Health and Human Services (HHS). IHS is responsible for providing direct medical and public health services to members of federally recognized Native American Tribes and Alaska Native people. IHS is the principal federal health care provider and health advocate for Indian people.

The crucial word there is “direct”. This is the Feds employing the doctors, paying for the drugs, building the hospitals - this is the NHS in fact it’s just for Indians (Native Americans these days). Anyone with any knowledge of the American system would predict that this is shit. The Native Americans have been run by the Feds since whenever (Bureau of Indian Affairs) and they’ve been right royally fucked over by them too. Just everything in that system is the most appalling, disinterested, bureaucracy.

A fact I sometimes use to remind what a truly progressive America would be like - one where the Feds ran all aspects of all lives. But that’s just me being mean, using actual observation rather than theory to describe what would happen.

So, how bad is this Indian Health system?

Facing Unchecked Syphilis Outbreak, Great Plains Tribes Sought Federal Help. Months Later, No One Has Responded.

Well, OK, so folk are fucking around a lot. It happens, you know? STD rates are not - not necessarily - a function of a health care system.

The syphilis rate among Indigenous people in the Great Plains is higher than at any point in 80 years of records. More than 3% of Native American babies born in South Dakota last year had the preventable and curable — but potentially fatal — disease.

But congenital syphilis rates are an indicator of a health care system. That’s an appalling rate. For comparison, the NHS:

There were 65 babies born in England after 1 January 2015 with congenital syphilis reported to ISOSS by the end of June 2020 (figure 1).

That’s a rate of 0.008 per thousand births (not same source nor calculation, so might not agree with above). Or, a percentage of 0.0008%.

There is a significant difference between 3% and 0.0008%.

That performance of that Indian Health Service is, in fact, absolutely fucking awful. At the level where those responsible for it should be shot. That is not mere hyperbolic rhetoric.

Desperate for help, in late February of this year tribal leaders from four Great Plains states took the extreme step of asking U.S. Department of Health and Human Services Secretary Xavier Becerra to declare a public health emergency. The Great Plains Tribal Leaders’ Health Board asked the secretary to deploy commissioned officers from the U.S. Public Health Service to help diagnose and treat people for syphilis, and to provide emergency funding for the tribes to improve their response capabilities.

More than 10 weeks later, Becerra has not responded.

That’s what single payer, single provider, health care would be like in the US. Because that’s what single payer, single provider, health care is like in the US.

My favoured explanation - on the basis of nothing at all except personal prejudice - is that this isn’t just nor only because everyone hates the Indians. It’s a function of economies of scale. We’re all used to the idea that there can be increasing economies of scale - it becomes more efficient to pump out 100,000 cars a year rather than 100 cars. But press an economist and he’ll also point out that there are diseconomies of scale. One of which is that management systems simply become overwhelmed, nothing ever happens because the information flow within an autocracy (which is what any one organisation is) cannot cope with the complexity being considered.

Health care is simply something that cannot be organised at that Federal level - it needs to be at a lower and more responsive one.

But, agree, that’s just prejudice on my part. The observable fact is that Federal Government run and supplied health care is ghastly, ghastly, shite. So that’s not really a justification of a single payer, single provider, health care system, is it?