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Dissecting Aetna’s surprising single-payer stance

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Aetna chief executive Mark Bertolini told employees in a private meeting Thursday that he thinks the United States "should have" a debate about single-payer.

"Single-payer, I think we should have that debate as a nation," Bertolini said in a video tape of his remarks provided to Vox by an attendee at the meeting.

You can read his whole answer in my story — but here in VoxCare, I want to catch you up on what has happened since the video leaked this morning.

Bertolini had a previously scheduled earnings call with health care analysts on Friday, where he gave more detail about the type of single-payer system he thinks is worth debating. He gave the example of Germany, where the government contracts with private companies to provide a standardized set of benefits to all residents.

"If you look at Germany, they have four big funds that start with the base benefit from the German government and sell base buy-ups beyond that as a public private partnership," Bertolini said.

Here is the rest of Bertolini's answer to investors:

The discussion, which actually in an employee meeting got leaked to Vox and Sarah Kliff, which was on my Twitter feed — that’s why I read my Twitter feed before I go for Q&A — was a comment by an employee that said people keep calling for single-payer.

Right now, the debate is a group on the left saying, “We must have single-payer and a group”; on the right saying, “The government should get the heck out of health care; there is nowhere in the Constitution that says we need to supply people health care.”

I think instead of shouting back and forth across the stage, let’s discuss what single-payer means. Is it a single source of financing, which does not yet get at the cost structure? Is it a health care system where the government owns the doctors and hospitals and operates them as well, like the NHS in the UK? What is that? So that when we start yelling single-payer back and forth, let’s discuss that.

Right now, in this country, the government doesn’t run anything in health care other than the ACA, and they’re doing a poor job of that. Aetna was the first financial intermediary for Medicare. We have the first check somewhere in my office to Hartford Hospital. We ran Medicare. The government didn’t. So what is single-payer, what does that mean? Let’s be clear when we say that, so that as the American public hears this comment about single-payer, they know what we’re talking about.

This is a good point: Single-payer systems can come in all shapes and sizes. There are some, like England's, where the government both finances all health care and owns the facilities. There are others, like Canada's, where all citizens enroll in a government-financed plan but the doctor offices and hospitals remain privately owned.

And there are still others, like Germany, where citizens are required to enroll in nonprofit "sickness funds," which offer a government-mandated set of health benefits. There are actually way more than four funds, as Bertolini suggests. One recent brief estimated there are 200.

Germany actually isn't traditionally thought of as a single-payer system; most health experts would consider it a multi-payer system, because you have multiple, competing health insurance plans. But the German system has many of the efficiencies of a single-payer system because all of its sickness funds band together to negotiate and set prices. You can read more about the German health care system (exciting Friday night, I know!) in this great brief from the Commonwealth Fund.

You don't have to look to Germany for this type of single-payer. Just look at Vermont.

When Vermont was working on its now-failed bid to build a single-payer system in the early 2010s, it settled on a model that sounds a whole lot like what Bertolini is describing.

The architects of the Vermont single-payer effort planned to run the state's universal coverage program. They figured the bidding process would bring in experienced and efficient health insurers who were steeped in the business of providing medical benefits.

And there was some politics involved too: Insurers were less likely to oppose a system that wouldn't put them out of business. William Hsiao, a Harvard professor who helped design the program, wrote:

Preserving a role for private insurance would also reduce opposition to the plan from this sector, especially because the dominant insurance company in the state, Blue Cross Blue Shield of Vermont, would be a natural contractor for the single-payer system.

Vermont's single-payer system never got off the ground; the state backed off when it recognized the significant tax hikes it would need to finance such a system. Still, it's notable that both Bertolini and the Vermont architects saw a similar path toward how a single-payer system could become a reality in the United States.

We have a winner! Introducing VoxCare's name for the Senate health care working group...

We received many, many submissions from VoxCare readers when we asked for a less-clunky name to use for the Senate working group on health care. We got 247 submissions, in fact.

And while many were great, there was one that Dylan and I loved the most: Brocean's 13. An homage to the movies and gender make-up of the Senate working group, it just felt right. This title was submitted anonymously — but congratulations, Vox reader, wherever you are!

Chart of the Day: Insulin prices are skyrocketing

Journal of the American Medical Association

While the US represents only 15 percent of the global insulin market, it generates almost half of the pharmaceutical industry’s insulin revenue. According to a recent study in JAMA Internal Medicine, in the 1990s Medicaid paid between $2.36 and $4.43 per unit of insulin; by 2014, those prices more than tripled, depending on the formulation. Read more in a new story from Vox's Julia Belluz.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

News of the day

  • "Republicans misstate, again and again on TV and at town halls, what’s in their health-care bill" “These lawmakers face two potential backlashes: one if opponents of Obamacare perceive the bill does not go far enough, and another from Americans worried that the bill would eliminate their coverage. The result has been a confused sales effort — and a series of flat misstatements and contradictions about what’s actually in the bill.” —David Weigel, The Washington Post
  • "Trump health chief: Senate will vote on ObamaCare repeal by August" “Health and Human Services Secretary Tom Price is predicting the Senate will vote on an ObamaCare repeal and replacement bill before the August recess, even as GOP senators refuse to give a timeline.” —Jordain Carney, The Hill
  • "Industry Hopeful Senate Health Care Debate Focuses on Policy, Not Politics" “'If there’s a thoughtful, deliberative process in the Senate that’s about policy and not politics, there’s going to be a lot more engagement with industry to try and get to a meaningful compromise here,' John Gorman, founder and executive chairman of the Gorman Health Group, a consulting firm focusing on the health insurance industry, said in an interview.” —Mary Ellen McIntire, Morning Consult
  • "Senate GOP making tax credits look more like … Obamacare" “There’s growing support for the idea of pegging the tax credits in the House repeal bill to income and making aid more generous for poorer people. But those moves — while they may win consensus among Senate moderates — are unlikely to sit well with House conservatives.” —Jennifer Haberkorn, Politico
  • "British hospitals having major computer problems as the result of an apparent cyberattack" “Hospitals across England canceled appointments and turned away patients Friday after suffering an apparent cyberattack. Hospitals in London, northwest England and other parts of the country reported problems with their computer systems. They asked patients not to come to the hospitals unless it was an emergency.” —Associated Press

Analysis and longer reads

  • The Last Person You’d Expect to Die in Childbirth" “The ability to protect the health of mothers and babies in childbirth is a basic measure of a society’s development. Yet every year in the U.S., 700 to 900 women die from pregnancy or childbirth-related causes, and some 65,000 nearly die — by many measures, the worst record in the developed world.” —Nina Martin, ProPublica
  • "Rural Shoppers Face Slim Choices, Steep Premiums On Exchanges" “People living in sparsely populated areas who shopped for coverage on the state health insurance marketplaces in 2017 frequently had just one or two insurers from which to pick and often faced significantly higher premiums than did people in more urban areas, according to a new study.” —Michelle Andrews, Kaiser Health News
  • "Is Rape A Pre-Existing Condition? Not Exactly" “Before the Affordable Care Act was passed in 2010, insurance companies didn't specifically include rape as a pre-existing condition that would allow them to deny victims coverage or charge them more. But a handful of conditions and interventions that can follow a sexual assault could have led people who were raped to be excluded from buying policies.” —Alison Kodjak, NPR

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