Versions of Healthcare Systems

People mean different things when they speak of single payer. Taiwan is the only true single payer system in the world. Our closest neighbor to the north is often describes as a single payer, but in Canada, there are 13 provincial and territorial health plans, with the federal government providing financial support. Moreover supplementary private insurance is growing in Canada and is important in most countries. Most doctors are private and hospitals are tightly-regulated government-funded institutions.

Single payer is different from universal healthcare. Universal healthcare implies that everyone has access to healthcare. Single payer suggests the government pays for the whole thing, so that the entire show is run centrally. So you can have a single payer that supports for-profit private facilities and doctors, or you could have a government-owned and administered health system. Moreover physician services, hospital care, long-term care, social services, community services, medications, mental health and dental care can all be funded by different mechanisms. Sometimes portions are not funded at all.

As in Canada, France has self-employed physicians billing a single payer. But there are gaps and balance billing is permitted, so 90% of the French carry supplementary private insurance. Except for people on public assistance, the patient pays the full bill for out-patient care and are very quickly reimbursed by the government. this allows some degree of market forces to influence prices, but generally prices are dictated by an official government fee schedule. Hospitals are entirely paid for at public (government-run) hospitals that account for 65% of French facilities. . The private hospitals are funded by a blend of public and private insurance payments.

Because supplementary insurance is a big part of the French healthcare system, it resembles a tiered medical system, with one set of rules for those on public assistance and another for those who can afford private supplementary insurance.

England of course has the NHS which covers about 90% of people. It is a classic two-tier system with 10% of the people carrying supplementary insurance. Most countries that offer universal healthcare have statutory tax-funded heath plans supplemented by private insurance. This includes Australia, New Zealand, Japan, Brazil, Denmark and many others. Many lower-income countries offer universal healthcare access to government-run facilities which offer limited services.

Germany has the oldest statutory health system that goes back to Bismarck in 1883, but there are hundreds of payers; insurance companies (sickness funds) that are highly regulated, much like utilities. Individuals have the choice to opt out of the public system and substitute private insurance, which 12% of Germans do. This is a two-tier multi-payer system.

Israel mandates that everyone sign up with one of four non-profit health plans funded by income taxes. Out of pocket expenditures account for 22% of healthcare spending, so copays are high.

In Sweden, local and regional authorities pay for all care, so technically, there are 21 different payers. In Norway, counties, municipalities and the central government share responsibilities for payments to different sectors, like GPs, specialists and hospitals. The Netherlands runs a hybrid public/insurance scheme where everyone is enrolled in the public system and about 80% supplement with private insurance.

India offers free healthcare to everyone at government operated facilities. These are not necessarily well-funded and most people use the parallel private system. Only 37% of Indians have insurance. Both access and quality of care vary tremendously from state to state.

Singapore has multiple funding streams, including one for large hospital bills, a health savings account and a safety net. People use their savings account to purchase insurance and to purchase services directly. Singapore relies on market mechanisms to keep costs down.

Japan has a mandated universal coverage from one of 1400 employment-based plans and 47 regional plans for the unemployed and elderly.

Taiwan is the only true mandated single-payer system in the world, where the central government funds private physicians and hospitals. There are still copays and out-of-pocket payments except for select populations, like government employees and low-income populations.

So there are a lot of ways to skin the healthcare cat. Designing a healthcare system that includes universal coverage is a slippery, squirmy sausage-making process.

The only way to secure universal healthcare is to mandate that everyone contributes tax revenue and has access, whether they want to or not. Opting out is problematic if people can opt back in when they become ill. That’s like calling the insurance company after the house is on fire. In the language of actuaries, this is called “adverse selection.”

There is good reason to make sure there is universal coverage, but single payer is problematic for reasons we will go into in the next post. The distinction is of extreme importance as we shall see.

Definitions for a Discussion of Univeral Healthcare

Universal healthcare is going to be a political issue again under the Biden administration and probably will be for the foreseeable future.

Before anyone talks about healthcare, they should define their terms. I define healthcare as the large system that is supposed to deliver actual care related to health. This care is usually delivered by health professional like physicians, nurses, therapists and others.

Healthcare is about insurance, Medicaid and Medicare, hospital systems, health economists, policy-makers and so on.

Providing health care is complicated, but the systems of healthcare are complex, in a technical sense.

Universal healthcare is a system where nobody goes without some form of coverage. One way of accomplishing this is single payer. Paradoxically in the US, people are talking about multiple single payers; one for the military and the VA, one or the poor, perhaps one for the elderly, although expansion of Medicare or Medicaid to the general public is one way to achieve a large single payer that coves the majority of Americans. That’s where “Medicare for All” comes in. What most people mean by single payer is the elimination of health plans and other middle men who finance health care. Some people refer to single payer as a true one payer for the entire country, much along the line of the French system.

I define insurance as an agreement with a private or public entity that protects against financial catastrophe by assuring compensation for losses in return for a premium. In the US, we cannot speak of health insurance since it has become a financing mechanism for every virtually type of care, no matter the cost. What we call health insurance is merely a mechanism, for funding care. Low price services are covered which makes them more expensive and raise premiums. The administrative cost is high; think of $20 to get the average claim out, compared to a $20 brace. Now it’s a $40 brace.

It is better to talk of these as health plans, which are prepaid based on an actuarial estimate of total annual expenditures for a given individual or group of individuals. The premium is set at about 1/3 above the average (technically 1 standard deviation above the mean.) This means the insurance company will win two years about of three, There are a lot of ways to maniputale this estimate and the set price of a premium.

Some people, myself included, refer to universal access to health care. To me this implies that everyone can get to a doctor. Some may have to pay, if they can afford it, but there would be financial support and resources for those who could not. The level of support would depend on income and the potential cost of a specific treatment. But here we are getting ahead of ourselves. Universal access implies some sort of blend of true insurance with out-of-pocket expenditures.

Now that we’ve defined our terms, we can then talk about the pros and cons of single payer. That will be the subject of the next post.

Time to Reboot the Old Blog

It may be time to reboot the old blog. My social media presence has increased and the discussions have become more intense. More importantly the tendency for people to twist my words and misrepresent my position has become intolerable.

A case in point has involved my departure from Vaccinate Washington. In a discussion with my co-founder, I expressed the need for caution in establishing COVID-19 vaccine mandates for children. Maybe it’s because she is a teacher, but she responded with great hostility and dismissiveness.

It seems that the political polarization I saw coming in my last blog has deteriorated to the point that everyone is consciously deciding to misinterpret anyone who introduces a bit of a grey area into their discourse.

For example, just prescribing caution about children’s vaccine mandates provoked a “medical freedom” activist to contacted me with an invitation to be on his podcast. I didn’t think that was wise.

I am a radical centrist, part of the alt-center. I won’t easily allow myself to be mischaracterized.

So the plan is to start writing a couple of blog posts a week and to look for media mentions from the past couple of years and back date them. I may well transfer all the posts from the past that are currently hidden. This blog was active from about 2007 to 2016 under the moniker “The Physician Executive.”

Keep your eyes on this space as I start posting more and varied media, both old and new.

Vaccine opposers lack any evidence

This is important: Dorit Reiss on vaccine misinformation in the Point Reyes Light.  The anti-vaccine crowd is vicious, rabid and unfortunately very poorly informed. Yet they have been able to get the attention of enough media to cast doubt on the effectiveness and safety of the most important medical intervention ever devised.

When the only argument against requiring vaccines for school relies on mistaken beliefs about vaccine safety, it cannot stand. Vaccines are safe, effective and save lives. Immunization mandates make our schools safe. By shoring up California’s mandate, S.B.277 is helping to safely protect our kids and our communities.

Renewed Posting

I found a bunch of unpublished posts some months ago. It seems I don’t know how to work wordpress, or maybe one of the updates threw me for a loop. Well, I kept on  writing, sometimes offline, and finally found the time to fix the problem.

This morning at Rotary, I made the observation that a year ago I had a lot of projects going but didn’t know if I would get traction with any of them. Now I have the opposite problem; everything is firing on all cylinders at the same time. Patient Direct Care came out of nowhere, PanZoe has transitioned to an effort on 360Care, a local integrated charitable clinic. EverMed is pitching for 20,000 lives in the next few months.

This morning Clark County Public Health disseminated the information on 360Care’s community meeting.

Paul Levy feels his direct reports should be practiced at writing at least 1000 words a day, in order to communicate with their stakeholders. It is time to jump back on that bandwagon.

So if you see posts dated some time ago that weren’t there before, please accept my apologies. I’m still catching up.

House Bill Aims to Curb Employers Ability to Force Doctors to Leave State

I prepared this potential op-ed prior to the death of HB 2931 in the Washington legislature. Non-compete clauses (also known as restrictive covenants) in physician contracts have had a devastating effect on the primary care workforce in Vancouver, Washington and other border regions of the state.

I understand the need to protect employers from the costs of recruiting a physician who then turns around and threatens to compete from across the street (really… who does that?) On the other hand, large groups in the state have thrown their weight around and hospital systems have thrown temper tantrums. I would prefer to eliminate restrictive covenants for family physicians, but there is good evidence from numerous sectors fo the economy that putting sharp limits on the enforceability of restrictive covenants is good for the economy. The best example is Silicon Valley,  where companies treat their employees very well, manage them extraordinarily well and continue to work with the intellectual capital they attract long after it leaves to spin off new entities and foster even more innovation.

Other physicians need the support, but so do baristas, hairdressers, nail spa workers and tattoo artists, who are unfairly unlimited by the legacy companies. I have to believe it makes these companies lazy and less considerate than they would be otherwise.

There were several bills, but I addressed the one widely regarded as the most likely to cross to the senate. In the Senate there was SB 6625 sponsored by Senators Conway, Hasegawa, Keiser, Chase, which restricted non-competes to 6 months for hourly wage workers. HB 2406 was sponsored by Representatives Manweller, Sells, Stanford, Magendanz, Tarleton, Moscoso, Ormsby and S. Hunt and stipulated that non-compete clauses were null and void in the case of a listed number of low hourly wage work such as fast food and dry wall applicators. HB 2931, sponsored by Representatives Stanford and Ormsby was the most sophisticated of the three and tried to outline certain parameters for which it is inappropriate to impose a non-compete. In short, if you are not an executive, non-competes would not be enforceable beyond one year.

None of the bills proposed geographic limits as “reasonable” in a non-compete.

All I can say is “we’ll be back,” even though I am poised to become an employer of physcians and stand to benefit from the applicability of these absurd covenants. There is still this thing called “doing the right thing.” Here is my unpublished opinion piece.


House Bill 2931 limits how employers can impose non-compete agreements on prospective employees and will be good for all industries in the state, although it will have an unexpected beneficial effect on health of Washingtonians. The bill received a vote on the House Floor Tuesday and will now go to the Senate for consideration.


Non-compete agreements in health care protect hospitals and larger medical groups, ostensibly from the high cost of physician recruitment. However, once a doctor agrees to be employed by a medical group, these agreements become a not-so-subtle means of controlling the doctors. An unhappy doctor could be required to leave the city, county or state because the agreement states that he or she is not allowed to practice their profession under any circumstances within the exclusion area. Since doctors have families and children, the non-compete agreement becomes a leash which can only be broken at substantial personal cost, which many families simply are not willing to accept. In one draconian example, one employer in Southwest Washington defines the geographic exclusion area as three counties. The doctor is often left with a Hobson’s choice of staying at an unhappy job with incompetent and potentially dangerous management or leaving town. No one is left to advocate for you, the patient.


Non-compete agreements are outrageous and unethical in healthcare. They disrupt the doctor patient relationship and hurt our workforce. When physicians leave the state, even for a short period of time, they rarely come back. Most medical groups spend a huge amount of money recruiting, but nobody tracks losses when doctors leave. In the end, it is the patients who suffer when they lose a trusted provider. I have never seen an administrator look an elderly woman in the eye and explain how his contract forced her doctor out of town.


It should come as no surprise that the Washington Hospital Association is profoundly opposes HB 2931. The Washington State Medical Association debated the issue heatedly, and emerged officially neutral. At least one large group made veiled threats to leave the association if even a watered down proposal were considered. The Washington Academy of Family Physicians is the only group that supports the bill, reflecting the public health orientation of primary care sector. Oddly enough, Republicans tend to like bills like HB 2931, because they foster free markets. Democrats like them because they protect employees. This is a bipartisan issue that aims to clip “Big Corporate,” not “Big Government.”


In many industries, non-compete agreements are merely an over-reaching effort to own their workforce. As one misdirected lobbyist asserted at the House Labor Committee, “our people ARE our intellectual property.” One wonders how Silicon Valley has thrived, since California is a place where these covenants are nearly completely unenforceable. Perhaps economic development is constrained when tech companies are allowed to impose draconian non-compete clauses?


There are numerous options which would make covenants more fair to communities, patients and doctors, but none of the corporations that run the state’s health care apparatus will even discuss the matter. It is time to reclaim the natural rights of individuals to work where they please without undue interference from anonymous corporations. Now it is up to the Senate to make HB 2931 law.


Why Overpay for Healthcare?

I firmly believe that family medicine is rooted in communities. It is the only way the physician can develop an understanding of the local culture, industry, and lifestyle to “get it” from the patient’s perspective.

Live, work and serve in the community was a principle articulated by Ian McWhinney in his Introduction to Family Medicine in 1981. Cost shifting, that is using your revenue from paying patients to care for those who could not afford care, was a time-tested method of paying for healthcare for decades. This was a tacit understanding between paying patient and physician which exists no longer. Although it is not a direct part of the physician-patient relationship, it has always been part of the landscape and responsibility that a physician embedded in a community would be expected to live up to. It is also part of the responsibility of a community in taking care of their own.

Coaching, Counseling – What is the difference?

There remains a remarkable stigma over mental health. Counseling is profoundly personal and incredibly effective when the chemistry is right between patient and counsellor.

One of the neat things about health coaches is that they can offer mental health counselling but also practical advice on motivation, behavior change, diet and exercise in relation to chronic disease.

It;s a great combination that expands the usefulness of a behaviorist working hand in glove with the family physician.