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With campaign season for California's governorship underway, several candidates have been declaring support for single-payer health care. From KFF Health News' article about the situation, it appears many Democratic candidates see it as a way of remaining competitive in the primary. KFF Health News previously published an article on the outgoing governor's campaigning on single-payer health care, only for that campaign promise to not materialize, with one director of a nurses' organization saying that the governor "pulled a bait and switch on Californians, purposely mixing up universal healthcare with single-payer."

Apparently, the state projected that single-payer health care would cost the state over $500 billion a year, which dwarfs the state's annual budget of around $350 billion. It is true that taxes could be raised, Medicare and Medicaid funds might be applied differently, and current premiums be redirected, but even aside from the funding question, the logistical challenges of proposal seem daunting. Notably, the only state to have passed single-payer health care (Vermont) ended up reversing course. Perhaps citizens would be better served by candidates who are willing to address underlying reasons for the expensive costs of health care, rather than following candidates who promise single-payer solutions.

People know that visits to emergency rooms can be expensive, but KFF Health News detailed the interactions within one particular visit and the associated cost. The patient understandably felt that "Paying $3,100.24 for literally sitting in the ER entertaining my kids for an hour and a half feels kind of incredible." (The patient's insurance covered more than that amount, with the total billed amount as over $6,700). On the other hand, it is unclear what the visit should have been priced at.

A big part of the problem is that emergency rooms are... for emergencies, meaning that they must be staffed for what might happen, not what will happen. With salaries of medical professionals being as high as they are, it is understandable that ER visits would need to cover the unused capacity and would therefore cost more than what a member of the general public might expect. There is also the element of the hospital being compensated for specific knowledge rather than actual work (a matter of "knowing where to hit the hammer").

At the same time, it appears that the patient received very little "active care" from the hospital (the patient spoke to the doctor "for no more than five minutes"). Additionally, it appears that the patient might not have been charged more even if she required some more medical attention than simply being monitored, although it seems likely that in that case, the hospital would have found new billing codes to apply. With visits so unpredictably expensive, it is not difficult to imagine patients trying to avoid the emergency room, which is probably not in the public interest.

Perhaps an alternative billing structure would be for the insurance plans of nearby patients to pay a fixed monthly fee per patient to sustain the emergency room. Emergency rooms would then have more steady revenue, and patients could then be charged less for each visit. Patients with non-participating insurance plans would be charged substantially more. Practically, such an arrangement could introduce some complexities in terms of how insurers would determine which emergency rooms to support for their patients. While this arrangement is probably better for patients, it is unclear how insurers would regard such a proposal.

KFF Health News published an article detailing how the levels of service at various long-term care facilities have suffered under real estate investors, including the death of some residents due to inadequate care. Interestingly, "While one research study found REIT [real estate investment trust] investments were associated with higher spending on nursing wages, another concluded that after being bought by REITs, nursing homes frequently replaced registered nurses with less skilled nurses and aides. A third analysis concluded that health inspection results were worse after REIT investment." Tangentially, the article also notes that "Researchers also found that investor-owned hospital chains that sold buildings to REITs were more likely to close or go bankrupt," although it is possible that hospital chains that are more likely to sell to investors were already not doing well financially.

On paper, the REITs are only the owners of the facilities, not the operators. However, if there is a pattern of inadequate care at REIT-owned facilities, it raises the question of whether REITs apply unreasonable financial pressure on operators and whether they might not give quality of care sufficient consideration when selecting operators. Theoretically, fines and lawsuits would deter negligence, but patient families have complained about how long it has taken to enforce these actions. If these operators are the only ones who are negatively affected, then the structure provides REITs with a liability shield, allowing them to continue their practices for longer.

Policy analysts have predicted dire consequences on rural health because of lower Medicaid reimbursement, and KFF Health News published an article on the challenges presented by the ending of dialysis service at one rural hospital. One patient profiled has to drive an additional hour (one-way) to get treatment. An extra hour might not sound that bad until realizing that the patient makes three round trips a week. Another patient decided to rent a place to be closer to treatment. Dialysis is a relatively common procedure, so one can imagine the effect of rural hospitals closing, where patients who are unable to get adequate treatment die earlier.

In this case, the leader of the rural hospital tried to keep the dialysis service going, even reaching out to private companies to gauge their interest in taking over the service's operation. Unfortunately, the hospital "lost $1 million a year on its dialysis service due to low reimbursement rates that didn't cover operational costs" and "they [private companies that might have taken over the service] all passed after realizing they would lose money."

While the legislation that reduced Medicaid reimbursement also introduced a Rural Health Transformation Program, "States can use only up to 15% of their funding to pay providers for patient care," limiting the applicability of that program to cases like the one outlined in this article. The intention of the program is to find better ways of delivering care (for example, new mobile dialysis units or home dialysis), but those ideas do not apply to this case because the program that reimburses the hospital for dialysis would not "cover outpatient dialysis." One of the patients profiled in the article also said that doctors told him that he is not suitable for home dialysis. Even in the optimistic case that new innovations in healthcare delivery are able to challenge many of issues posed by reduced Medicaid funding (it is unclear if anyone truly thinks that case will come to pass), there is still the question of how patients will be affected before those innovations take root.

The Affordable Care Act standardized many aspects of health insurance and granted more protections to patients -- including the guarantee that patients cannot be denied insurance coverage because of pre-existing health conditions. However, such patient protections came with a cost, and the cost of health insurance has risen substantially since then. KFF Health News published an article about how some people are trying to skirt at least some of those patient protections and offer insurance coverage for a lower cost through an option available in fourteen states known as farm bureau health plans. Notably, however, these health plans are not required to accept all patients. As a result, "farm bureau plans may be 30% to 50% cheaper than unsubsidized marketplace plans." Leadership at Tennessee's Farm Bureau Health Plans noted that "People don't like that we underwrite, but if we did everything like the ACA, we'd be just like an ACA plan."

While these plans might sound like a relief to patients looking for lower premiums, they will likely undermine the intent of the Affordable Care Act if they become popular. Essentially, these farm bureau plans will be able to cherry-pick the healthy patients while denying coverage to the expensive patients, leaving those patients for the plans on the Affordable Care Act exchanges. Over time, premiums for Affordable Care Act plans would grow faster than the premiums of these farm bureau plans because the plans would need to pay more for medical care. The article notes that "This creates an uneven playing field for insurers and drives up premiums for the people who can't get into farm bureau plans." Left in place long-enough, these plans could cause the insurance landscape to look similar to what was in place before the Affordable Care Act: healthy people being able to secure more reasonable premiums, and unhealthy people paying for very expensive coverage. It seems that these plans -- which appear to be a perfect substitute for mainstream insurance plans, other than regulatory quirks -- should probably be regulated with the same requirements as mainstream insurance plans.