What -if Scenario: Single-payer Healthcare

Building on the last conversation about AI helping us make decisions, I used chatGPT to see how much it would cost to implement single-payer healthcare in the United States. Presidential candidate Kamala Harris was in favor of a universal healthcare system in which healthcare is paid by a single public authority, not a private authority.

The first question I had was to find out what savings could be realized by eliminating HMO’s with the help of chatGPT.

Eliminating Health Maintenance Organizations (HMOs) and transitioning to a Medicare for All system could lead to additional savings beyond just the reduction in administrative costs. Here are several other areas where savings could potentially be realized:

**1. *Lowering Healthcare Provider Administrative Costs***

• Billing and Administrative Simplification: Providers (hospitals, doctors, clinics) spend a significant amount of time and money on billing and dealing with multiple insurers, each with different rules and requirements. A single-payer system would streamline this process, reducing the need for large administrative staffs in healthcare providers’ offices.
• Estimated Savings: This could save the healthcare system an additional $200 billion to $300 billion annually, potentially totaling $2 trillion to $3 trillion over ten years.

**2. *Reduction in Marketing and Profit Margins***

• Elimination of Marketing Costs: Private insurers spend large sums on marketing to attract customers, which would be unnecessary under a single-payer system.
• Profit Elimination: HMOs and other private insurers include a profit margin in their operations, which would no longer be necessary.
• Estimated Savings: Combined, this could result in savings of $50 billion to $100 billion per year, or $500 billion to $1 trillion over ten years.

**3. *Bulk Purchasing and Price Negotiation***

• Pharmaceuticals: The federal government could use its bargaining power to negotiate lower prices for drugs, as the Veterans Health Administration currently does. This could significantly reduce the cost of prescription drugs.
• Estimated Savings: Potential savings could be 15-30% on drug spending, which is around $450 billion per year. Over ten years, this could mean savings of $500 billion to $1 trillion.
• Medical Devices and Services: Similar negotiations could apply to medical devices and services, further reducing costs.

**4. *Reduction in Unnecessary Services (Cost Containment)***

• Preventing Overutilization: HMOs sometimes incentivize providers to perform more procedures or tests, some of which may be unnecessary. A single-payer system could reduce this overutilization by focusing more on evidence-based care.
• Estimated Savings: While difficult to quantify exactly, some estimates suggest this could save 5-10% of total healthcare spending, or approximately $150 billion to $300 billion per year, leading to $1.5 trillion to $3 trillion over a decade.

**5. *Eliminating Underinsurance and Cost Shifting***

• Reduced Cost Shifting: Currently, costs are often shifted between different payer systems (e.g., private insurance, Medicaid, uninsured patients). A single-payer system could reduce or eliminate this, leading to more predictable and possibly lower costs.
• Improved Health Outcomes: By ensuring that everyone has comprehensive coverage, preventive care and early treatment can be emphasized, reducing the need for expensive emergency care and chronic disease management down the line.
• Estimated Savings: The economic benefits of better health outcomes could add up to $200 billion to $400 billion over ten years.

**6. *Fraud Detection and Reduction***

• Unified System: A single, integrated system could make it easier to detect and reduce fraud in the healthcare system.
• Estimated Savings: Reducing fraud could save $50 billion to $100 billion per year, or $500 billion to $1 trillion over ten years.

**7. *Improved Public Health and Workforce Productivity***

• Long-Term Economic Gains: Healthier populations tend to be more productive, which can boost the economy. Better health outcomes from a universally covered population could lead to indirect economic benefits.
• Estimated Impact: This is harder to quantify but could contribute to GDP growth and reduce other social costs related to poor health.

Summary of Additional Savings

Combining these additional savings with those from reduced administrative costs could result in significant financial benefits:

• Administrative Simplification: $2 trillion to $3 trillion over ten years.
• Eliminating Marketing and Profits: $500 billion to $1 trillion over ten years.
• Bulk Purchasing/Price Negotiation: $500 billion to $1 trillion over ten years.
• Reducing Unnecessary Services: $1.5 trillion to $3 trillion over ten years.
• Eliminating Cost Shifting: $200 billion to $400 billion over ten years.
• Fraud Reduction: $500 billion to $1 trillion over ten years.

Total Potential Savings

The total potential savings from these measures could range from $5.2 trillion to $9.4 trillion over ten years. This would substantially offset the estimated gross cost of implementing Medicare for All, potentially bringing the net cost closer to $20 trillion to $27 trillion over a decade, depending on how effectively these savings are realized.

The second question I had was what are some costs that would increase under a Medicare for All system? We know that government is a bureaucracy and anyone who’s been to a DMV can see inefficiencies.

Yes, when considering both the potential savings and cost increases, it’s possible that the overall costs of implementing Medicare for All could rise. Here’s a simplified way to think about it:

**1. *Potential Savings***

• Administrative Savings: $2.5 trillion to $3 trillion over ten years.
• Provider Administrative Simplification: $2 trillion to $3 trillion.
• Eliminating Marketing and Profits: $500 billion to $1 trillion.
• Bulk Purchasing and Price Negotiation: $500 billion to $1 trillion.
• Reducing Unnecessary Services: $1.5 trillion to $3 trillion.
• Fraud Reduction: $500 billion to $1 trillion.
• Total Savings: $7.5 trillion to $12 trillion over ten years.

**2. *Potential Cost Increases***

• Increased Utilization: $3 trillion to $5 trillion over ten years.
• Higher Administrative Costs: $1 trillion to $2 trillion.
• Higher Provider Reimbursements: $2 trillion to $4 trillion.
• Transition Costs: $500 billion to $1 trillion.
• Cost Overruns/Inefficiencies: $600 billion to $1 trillion.
• Labor Costs: $1 trillion to $2 trillion.
• Expansion of Benefits: $2 trillion to $4 trillion.
• Total Cost Increases: $10.1 trillion to $19 trillion over ten years.

**3. *Net Effect on Costs***

• Best-Case Scenario:
• Savings: $12 trillion
• Increases: $10.1 trillion
• Net: Potential $1.9 trillion in savings.
• Worst-Case Scenario:
• Savings: $7.5 trillion
• Increases: $19 trillion
• Net: Potential $11.5 trillion in additional costs.

Conclusion

The overall costs could go up if the potential increases in spending exceed the savings. In the worst-case scenario, Medicare for All could lead to a significant rise in overall healthcare spending, particularly if increased utilization, higher reimbursement demands, and inefficiencies are not effectively managed.

On the other hand, if savings from administrative simplifications, bulk purchasing, and other areas are fully realized and cost controls are effectively implemented, the system could either break even or possibly even save money. However, achieving this balance would require careful planning, efficient implementation, and strong political will.

The actual outcome would likely fall somewhere between these scenarios, depending on the specifics of the implementation, how effectively cost controls are applied, and how the healthcare system and providers respond to the changes.

I wanted to find out what a middle scenario would cost. Not the best-case, not the worst-case scenario.

To estimate the cost of Medicare for All in a “middle scenario,” we’ll assume moderate success in both realizing potential savings and managing cost increases. This scenario will neither achieve the best-case savings nor suffer the worst-case cost increases but will represent a more balanced outcome.

**1. *Moderate Potential Savings***

• Administrative Savings: $2.75 trillion over ten years.
• Provider Administrative Simplification: $2.5 trillion.
• Eliminating Marketing and Profits: $750 billion.
• Bulk Purchasing and Price Negotiation: $750 billion.
• Reducing Unnecessary Services: $2 trillion.
• Fraud Reduction: $750 billion.
• Total Savings: $9.5 trillion over ten years.

**2. *Moderate Potential Cost Increases***

• Increased Utilization: $4 trillion over ten years.
• Higher Administrative Costs: $1.5 trillion.
• Higher Provider Reimbursements: $3 trillion.
• Transition Costs: $750 billion.
• Cost Overruns/Inefficiencies: $800 billion.
• Labor Costs: $1.5 trillion.
• Expansion of Benefits: $3 trillion.
• Total Cost Increases: $14.55 trillion over ten years.

**3. *Net Effect in a Middle Scenario***

• Total Savings: $9.5 trillion
• Total Cost Increases: $14.55 trillion
• Net: $5.05 trillion in additional costs over ten years.

Conclusion in a Middle Scenario

In a middle scenario, where moderate levels of both savings and cost increases are realized, the overall cost of Medicare for All could rise by approximately $5 trillion over a ten-year period.

This estimate suggests that while significant savings can be achieved, the increased demand for healthcare services, potential higher reimbursement rates, and other cost factors could lead to a net increase in healthcare spending.

However, it’s important to note that this middle scenario represents a broad estimate, and actual outcomes could vary based on the specifics of policy implementation, economic conditions, and the healthcare system’s response to a single-payer model.

Lastly, I wanted to find out what kind of tax increases the average American would incur if a single-payer, Medicare for All system would be implemented in the United States.

Implementing Medicare for All would likely require significant tax increases to cover the costs, as it would shift the funding of healthcare from private insurance premiums and out-of-pocket expenses to the government. The impact on the average American would depend on several factors, including income levels, the structure of the tax increases, and the overall cost of the program. Here’s a breakdown of potential tax implications:

**1. *Overall Funding Needed***

• Estimated Additional Cost: In the middle scenario discussed earlier, Medicare for All could result in an additional $5 trillion in net costs over ten years, or $500 billion per year.
• Total Healthcare Cost: If the total cost of Medicare for All is around $30 trillion over ten years (or $3 trillion per year), the government would need to raise this amount through taxes, replacing current private healthcare spending.

**2. *Possible Tax Mechanisms*

Several tax mechanisms could be used to fund Medicare for All:

1. Payroll Tax Increase

• Current Spending: Employers and employees currently spend a significant portion of their income on private health insurance premiums.
• Proposed Increase: A payroll tax of around 10-15% could be implemented to fund Medicare for All.
• Impact on Wages: This tax would be shared between employers and employees, potentially replacing the premiums employers currently pay.

1. Income Tax Surcharge

• Progressive Tax Rates: An additional income tax surcharge, particularly on higher-income individuals, could help fund the program. Rates might increase by 5-10 percentage points on higher brackets.
• Impact on Middle-Income Households: Middle-income households might see an increase in their income tax rates by 2-4 percentage points.

1. Wealth and Investment Taxes

• Capital Gains: Increasing taxes on capital gains, dividends, and other investment income could contribute to funding.
• Estate Tax: A higher estate tax could also be implemented.

1. Value-Added Tax (VAT)

• Broad-Based Consumption Tax: A VAT of around 5-10% could be introduced, which would apply to most goods and services, raising significant revenue but also affecting all consumers.

1. Corporate Taxes

• Corporate Income Tax: Increasing corporate income tax rates could be another source of revenue, potentially offsetting some of the costs passed on to consumers.

**3. *Impact on the Average American*

• Lower-Income Households: Might see minimal or no increase in income taxes, but they would still contribute through payroll taxes or VAT. However, they might benefit from the elimination of out-of-pocket healthcare expenses and premiums.
• Middle-Income Households: Could see a combined increase in payroll and income taxes ranging from 4-10% of their income, but this could be offset by savings from no longer paying health insurance premiums and out-of-pocket costs.
• Higher-Income Households: Likely to face the most significant increases, potentially 10-20% more in combined taxes, especially if additional surcharges on income and investment gains are implemented.

**4. *Net Effect on Individuals*

• No Premiums or Out-of-Pocket Costs: While taxes would go up, individuals and families would no longer have to pay health insurance premiums, co-pays, deductibles, or other out-of-pocket healthcare expenses. For many, the increase in taxes might be less than what they currently spend on healthcare.
• Employer Impact: Employers might see reduced costs due to no longer needing to provide private health insurance, potentially leading to higher wages or reduced overall compensation costs.

Examples

• Single Worker Earning $50,000:
• Current Costs: May pay $4,000 to $7,000 in premiums and out-of-pocket costs.
• Under Medicare for All: Might see a tax increase of $2,000 to $5,000 but would eliminate the $4,000 to $7,000 in current healthcare costs.
• Family of Four Earning $100,000:
• Current Costs: May pay $10,000 to $20,000 in premiums and out-of-pocket costs.
• Under Medicare for All: Might see a tax increase of $5,000 to $12,000 but would eliminate $10,000 to $20,000 in current healthcare costs.

Conclusion

For the average American, the tax increases under Medicare for All could range from 4-10% of income, depending on their earnings and the structure of the taxes. However, these increases would be offset by the elimination of private healthcare costs, meaning many people could end up paying less overall when combining taxes with healthcare costs. The exact impact would vary widely depending on income levels, household size, and how the new tax structure is designed.

And there you have it, AI helping us answer questions that would take teams of researchers and policy experts. I’ll do more What-if Scenario analysis in future blog posts.