Universal publicly funded health care: Establishing accountability without competition

By Stephen Kemble, M.D.

Consider H.R.676, the House single-payer bill kept "off the table" during health reform negotiations. It proposes public financing of universal health care, but leaves care delivery (doctors and hospitals) private and independent.

This is not the same as "socialized medicine," in which government owns the hospitals and employs the physicians. It uses a "social insurance" model in which everyone is included in a single risk-pool, with no exclusions from coverage based on health status, and it eliminates competing private health insurance plans.

Effective government-sponsored programs may use private plans provided they are made to function as a single risk-pool, as in many European countries.   In these systems government requires universal and open enrollment, standardized benefits and fees, and risk-adjusted funding of plans. However, in general, countries using multiple plans have higher health care costs.[1] Single-payer financing is most cost-efficient.


* Benefits are comprehensive, with minimal or no co-pays.

* Patients have free choice of providers.

* Health care is independent of employment status.

* Universal health care is less expensive because it has much lower administrative costs and allows effective cost controls. Countries with universal health care spend about half of U.S. per-capita total health care spending, and they cover everyone.[1,2]

* Lower total health care costs means less pressure to restrict and control physicians' professional decisions.

* Streamlined administration is much easier and less expensive for providers.

* Quality improvement programs work much better in a unified market.

* Public programs (Medicaid and Medicare) would no longer be dumping grounds for the sickest, most expensive populations. A universal risk pool would relieve their fiscal problems.

* Universal health care can remove health care expenses from medical malpractice, worker's compensation, and automobile insurance, drastically reducing their costs.

* Accountability in government is theoretically to the people, although this can often be sabotaged by special interests.


* Government can be inefficient, irrational, and inflexible ("administration by acts of Congress," as with U.S. Medicare).

* Special interest pressures often lead to bad policies in government programs.

* A publicly funded plan means pressure to reduce taxes may lead to under-funding over time. This may lead to pressures to ration care, reduce fees, and control doctors, as is already happening with private insurance in the U.S. However, this would happen at a much lower total spending level than with competing private plans, because a single-payer system carries much lower administrative overhead.

* No competition means we need another means to ensure accountability. (Of course, competition in U.S.-style health insurance does not provide accountability to quality health care anyhow.)

Establishing accountability in publicly funded health care

The legislative branch must define the broad structure of publicly funded health care and how it is to be financed.

To prevent corruption by special interests, a public plan needs a carefully designed administrative structure, accountable to quality health care, but insulated from special interest pressures. This could be accomplished with a system of national, state, and regional boards, with representation from the essential stakeholders in health care: physicians and other professional providers, hospitals, and the public who are or will be recipients of care. These boards would be charged with assuring quality, cost-effectiveness, and fair reimbursement for hospitals and physician services.

This administrative structure must have the autonomy to implement continuous quality improvement. It must be able to modify policies based on feedback from providers and patients at the front lines, without having to go back to the legislature for every administrative adjustment. Quality improvement programs are most cost-effective when led by physicians, not by insurance plans or government.[3,4]

Other functions of these boards should include allocation of government funding for health care education and training, incentives to meet manpower needs in provider shortage areas, medical research, public health programs, and scope-of-practice issues.

They should also have substantial influence over the public financing of the health care system, including health care tax rates (premiums), to ensure that the funding of the system continues to reflect the realistic costs of providing quality health care, to ensure public health care funds are spent cost-effectively, and to ensure sustainability.


The high administrative cost of competition among health plans means escalating pressures to limit coverage, deny care, reduce physician and hospital reimbursement, and add administrative burdens to providers.

Adding a competing "public option" would not help. It would perpetuate the high administrative costs of private insurance, and the overriding incentive for private plans would not be to offer a better product; it would be to avoid covering the sick, dumping them onto the public plan.

Only a universal health care financing system with a single risk pool could simultaneously align incentives to encourage quality health care while reducing cost.

Instead of the centrally administered managed care strategies now employed by insurance plans, a universal system should implement a system-wide continuous quality improvement program focused on the processes of care.

A few communities in the U.S. (Intermountain Healthcare in Utah, Rocky Mountain Health Plans in Colorado, Community Care of North Carolina) have successful, cost-effective, physician-led, quality improvement programs without insurance company intermediaries, showing us that it is possible.[3,4,5]

If we want cost-effective health care building on proven examples of "what works," we need a universal health care system with a single risk pool at the state or national level, with public funding and private care delivery, accountable to the public good, and with a physician led continuous quality improvement program.

Dr. Stephen Kemble is assistant professor of medicine at the University of Hawaii John A. Burns School of Medicin, and also in private practice as a general adult psychiatrist. He is a member of Physicians for a National Health Program. In September he was appointed by Hawaii’s Gov. Neil Abercrombie to the Hawaii Health Authority, charged with designing and then running a universal health care system for Hawaii.

1. American College of Physicians. Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries. Ann Intern Med 2008;148:55-75.
2. Chernichovsky D. Not "Socialized Medicine" -- An Israeli View of Health Care Reform. NEJM 2009;361:e46.
3. James BC and Savitzdoi LA. How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts. Health Affairs 30, no. 6 (2011); DOI:10.1377/hlthaff.2011.0358
4. Bodenheimer T and West D. Low-Cost Lessons from Grand Junction, Colorado. N Eng J Med 2010; DOI: 10.1056/NEJMp1008450.
5. Community Care of North Carolina: Putting Health Reform Ideas into Practice in Medicaid. The Kaiser Family Foundation Publication #7899, May 2009. (

This article originally appeared at OpEd News: