Comment writer asks retired doc about single payer

This post is a reply to a comment made on one of my earlier postings that inquired about the single payer option for U.S.health care or at least what were my thoughts.

I believe the major issue is whether the single payer system that we may eventually end up with allows a parallel system of private care as is the case in Great Britain or if government forbids people to spend their own (or insurance) money for services not provided by the single payer government plan, as is the case in Canada. In the later arrangement the patient's life and health is literally in the hands of the government and without the private option there is no practical appeal to the edicts of the bureaucracy that control the expenditures of the single payer system. Of course, in Canada not infrequently folks go south for health care that is denied or so delayed that it is for practical purposes denied. Also, recently there is an interesting and encouraging move to some elements of private care becoming available in Canada (see here). As the U.S. seemingly is moving to more government involvement in health care, there seem to be a directionally opposite move in Canada where they have had years to see how well or badly their hyper-egalitarian health care system works in the real world.

We have had Medicare since 1965 and it is not going away.The best we can hope for after the re-working of the medical care system comes to pass is for the people to be able to purchase health care denied by the government system without having to travel overseas. ( Maybe the private care movement in Canada will be mature enough by then so we can go there for care.)

An interesting twist on this general topic is the suggestion made in a WSJ October 2008 editorial to "allow"seniors to opt out of Medicare entirely, not just Part B.See here for a discussion of how that might be good for some and harming none, something economists seem to refer to as Pareto Optimal.Currently if someone wants to opt out of Part A he will loose Social security benefits.

I did not realize that until recently.Here is the rule in the words of the government:

"Individuals entitled to monthly benefits which confer eligibility for HI ( hospital insurance,Part A of Medicare) may not waive HI entitlement. The only way to avoid HI entitlement is through withdrawal of the monthly benefit application. Withdrawal requires repayments of all RSDI and HI benefit payments."
h/t to Junkfood Science)

This was not the way the Medicare law was written. You have to wonder what prompted the SS administration to add on this rule. Why would they object to someone opting out of Part A? It would only be a saving for Social Security.

The terms one tier and two tier are sometimes used to distinguish between the systems exemplified by the British and the Canadian systems. One Tier would be Canada and two tier would be Great Britain. In this article in the Archives of Internal Medicine there is a discussion about the ethics of the two systems. Interestingly, one of the authors who supported a two tier system from a practical and ethical point of view is Dr. Ezekiel Emanuel who is the brother of Rohm Emanuel.I hope Rohm will give some thought to his brother's views.