While the concept of a universal health care system for the United States has been around for many years, the debate intensified during the 2016 presidential race. The Medicare for All Act was introduced in 2017 by Sen. Bernie Sanders (I-Vt.) in an effort to expand health care for everyone. California legislators also recently debated the merits of universal health care.

In California, the Health for All Act was introduced by Ricardo Lara, (D-Calif.), whose name may be familiar to those who followed the dialysis staff-patient ratio legislation this past year. Lara ended up tabling that bill, but his Senate colleagues passed a universal health care bill during the last session.

The state assembly had other ideas, however, stopping the bill in its tracks because there was no mechanism for financing — with an estimated cost of more than $400 billion a year — and an unsure path of how care would be delivered. However, the assembly has pursued universal health care in other ways, lending support to the Fair Pricing for Dialysis Act (AB-251), a bill that would require dialysis providers that operate in the state to refund commercial insurers any revenue that is greater than 15% more than the cost of care. Union officials in California supported the legislation and are helping to gather enough signatures to place the issue as a ballot measure for November.

Not the best solution

More recently, JAMA published two papers on universal health care. Victor R. Fuchs, PhD, of Stanford’s Institute for Economic Policy Research, said our current system in the United States costs too much for the marginal care it delivers.

“The fragmented financing system [in the U.S.] is one of the principal explanations for the high cost of medical care in the United States. A careful consolidation of financing into some form of single-payer system is probably the only feasible solution,” he wrote in the Dec. 2, 2017 issue of JAMA.

However, operating a single-payer system in the United States for its 325 million people could be daunting. Even Canada, he notes, with one-tenth the U.S. population, created insurance plans for each providence.

“In the United States, that would mean 50 separate state health insurance plans,” he wrote. “Some states might rise to this challenge … some states would encounter major difficulties.”
In a corresponding article, C. David Naylor, MD, DPhil, from the department of medicine at Dalla Lana School of Public Health and the Institute for Health Policy, Management, and Evaluation at the University of Toronto, said the Canadian system has its flaws as well.

“Health care reform discourse in Canada and the United States would be vastly improved if more commentators, advocates, and lawmakers could overcome the cross-border obsessions and misperceptions that distort contemporary debates,” he wrote. “Canada does offer important lessons for reform in the United States, not least in its relentless commitment to equitable access for some key services, its administrative efficiency, and its success in cost-containment. However, Canada’s health care arrangements are rooted in different values, facilitated by a different model of democratic governance, and reflect a different era, both in the conditions that fostered their creation and in an outmoded architecture that makes them a dubious exemplar for the United States.”

In a recent discussion I had among nephrologists who had experience with universal health care — caring for patients in Germany, England and Canada — most felt the system had merit.

“It is my personal opinion that the survival of the (National Health Service) is largely attributable to the comprehensive primary care system (340 million GP consultations in 2012) which, up to this point, has served to rescue people with minor ailments from over-investigation/treatment by specialists,” British nephrologist Roger Greenwood, MD, said. “Primary care which has been interlinked historically with social/community services, also underpins the excellent performance of the NHS with end-of-life management and support for the elderly and infirm.

“Another contributor to the success of NHS has probably been the largely salaried medical work force with very few doctors working privately outside,” Greenwood said. “This helps keep the lid on over-investigation and over diagnosis.

Like the United States, Greenwood said the NHS is struggling with caring for an aging population that has a multitude of medical treatment options. Cost will continue to increase in the future. It is just a matter of how much you pay – and who writes the check.

Fuchs, VR. JAMA. 2018;doi:10.1001/jama.2017.18739.
Naylor CD. JAMA. 2018;doi:10.1001/jama.2017.19668.

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Mark E. Neumann is Editor-in-Chief of Nephrology News & Issues.