Last night I went to see one of my favorite musicians, Billy Bragg, in a splendidly rabble-rousing musical plea for social justice and political equality. Today is International Workers Day, celebrating the achievements of millions of working people who struggled and continue to struggle to equalize the balance of power in the workplace (balance requires equal weights on each side of the fulcrum, after all). What better time to think about healthcare in this country?
During the week I work for a nonprofit Medicaid HMO, supervising a case management team working directly with the poorest and sickest of Medicaid recipients to help them manage their healthcare. We provide education, transportation and social service referrals, and facilitate improved provider access and authorization processing. We collaborate with providers to promote free flow of information between patient and doctor, and between doctors. Our goal is to empower people to be mindful and effective in managing their healthcare, improving their quality of life and reducing costs by minimizing waste. And it works, driving costs down by a minimum of 10% for each target population in the last year (I speak for my program alone, since I am ignorant of others). It’s single-payer healthcare, driven by a monthly per-capita fee that must be stretched to cover all medical expenses for the aggregate. Expenses increase along with the acuity of patient needs, so the most sensible way to manage costs is to figure out interventions to reduce acuity (prevention, early detection, timely access, chronic disease management, effective discharge planning, etc.), and then to implement those interventions in the most efficient manner possible. Everybody wins. And the beauty of doing it in a single-payer system is that interventions can be implemented across the board, touching all members of the targeted populations, and protected by provider agreements and state contracts.
Is it always pretty? No. But it’s a hell of a lot prettier than what’s available to the uninsured working poor. Aside from federally-funded clinics (FQHCs) or charitable agencies, there is nowhere that an uninsured person working a minimum-wage job can afford to pay for a primary doctor’s visit, let alone any lab work or medications. Expansion of Medicaid, one of the possibilities made available to states by Obamacare, would allow these hardworking, responsible adults to maintain their lives when assaulted by illness. Under the current system, a competent, able-bodied worker may be lost to the workforce by something as simple as inability to pay for antibiotics for a case of strep throat which can, if left untreated, have deadly complications. Business coalitions that advocate for employers of low-wage staff (janitorial, grocery, etc.) are clamoring for Medicaid expansion so that their employees can remain productive, saving the enormous costs of onboarding new employees. Another step toward a single-payer system? Sure, but how does that hurt the people with private insurance? Until the single-payer model comes into direct competition with the existing private insurance structure, there is no real conflict, right? Everyone wins if the poor are receiving basic primary healthcare in a cost-controlled managed-care environment instead of receiving preventable, high-cost treatment at the cost of the population as a whole.
Some of us whose lives are deeply entwined with this issue think the benefit to our society if everyone embraced single-payer healthcare would far outweigh the inconveniences. But that’s a discussion for another day.