from
PLOS
The United States is
the only high-income nation without universal, government-funded or
-mandated health insurance employing a unified payment system. The US
multi-payer system leaves residents uninsured or underinsured, despite
overall healthcare costs far above other nations. Single-payer (often
referred to as Medicare for All), a proposed policy solution since 1990,
is receiving renewed press attention and popular support. Our review
seeks to assess the projected cost impact of a single-payer approach.
Methods and findings
We
conducted our literature search between June 1 and December 31, 2018,
without start date restriction for included studies. We surveyed an
expert panel and searched PubMed, Google, Google Scholar, and
preexisting lists for formal economic studies of the projected costs of
single-payer plans for the US or for individual states. Reviewer pairs
extracted data on methods and findings using a template. We quantified
changes in total costs standardized to percentage of contemporaneous
healthcare spending. Additionally, we quantified cost changes by
subtype, such as costs due to increased healthcare utilization and
savings due to simplified payment administration, lower drug costs, and
other factors. We further examined how modeling assumptions affected
results. Our search yielded economic analyses of the cost of 22
single-payer plans over the past 30 years. Exclusions were due to
inadequate technical data or assuming a substantial ongoing role for
private insurers. We found that 19 (86%) of the analyses predicted net
savings (median net result was a savings of 3.46% of total costs) in the
first year of program operation and 20 (91%) predicted savings over
several years; anticipated growth rates would result in long-term net
savings for all plans. The largest source of savings was simplified
payment administration (median 8.8%), and the best predictors of net
savings were the magnitude of utilization increase, and savings on
administration and drug costs (
R2 of 0.035, 0.43,
and 0.62, respectively). Only drug cost savings remained significant in
multivariate analysis. Included studies were heterogeneous in methods,
which precluded us from conducting a formal meta-analysis.
Conclusions
In
this systematic review, we found a high degree of analytic consensus
for the fiscal feasibility of a single-payer approach in the US. Actual
costs will depend on plan features and implementation. Future research
should refine estimates of the effects of coverage expansion on
utilization, evaluate provider administrative costs in varied existing
single-payer systems, analyze implementation options, and evaluate
US-based single-payer programs, as available...
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