Making Single-Payer Reform Work for Behavioral Health Care: Lessons From Canada and the United States

Abstract

The claim is often made that the adoption of single-payer health care in the United States would result in dramatic improvement of services for people with mental health and substance use disorders. Evidence from this sector in countries with such frameworks is mixed, however, presenting both positive and negative lessons for an American audience. Focusing on Canada as an example, this article sheds light on this topic by drawing on sources in the professional and academic literature, government reports, news stories and features, and research on-site by the author. A concluding section highlights key policy issues that American single-payer advocates will need to address for meaningful reform of the behavioral health care sector.

Cost analysis in implementation studies of evidence-based practices for mental health and substance use disorders: a systematic review

“…We address this gap by conducting a systematic review of the literature to understand the types of costs and costing methods which have been used to date in implementation research of evidence-based behavioral health interventions in the USA and Canada. We focus on these two countries due to their similarities in the epidemiology of behavioral health disorders, overlapping related health policies [8], and flow of both patients and programs across the border [9]. We exclude other countries due to the unique nature of the US healthcare financing [10].…”

The Economic and Social Impacts of Providing Universal Healthcare in the United States: A Rapid Scoping Review

“…There is overwhelming evidence that individuals in the US are foregoing care because of nancial limitations, both for those uninsured and for those underinsured or with prohibitively high deductibles or copays (3,4,9,12,19,(25)(26)(27)(28)(29)(30)(31)(32). Universal healthcare would eliminate the majority of this issue, though individuals still suffer nancial risk under universal healthcare systems (33). However, universal healthcare will undoubtably require individual contributions in the form of taxes.…”

“…In fact, in one proposal from Oregon, a proposed plan that would double or triple taxes while providing universal care with no premiums or copays still forecasted the average household would pay less (37). Estimates for the US and examples from other countries show that a system with little or no out of pocket costs (e.g., copays, premiums, deductibles) would lower costs for most, but not necessarily all, individuals (1,4,17,22,23,33,38,39). One estimate for a nationalized healthcare system estimated an average annual savings of $2400 (40).…”

“…Individuals without insurance have a higher odds of death (3), increased mortality (31,54,63), delays in starting treatment, reduced treatment adherence and worse outcomes (12,21,54), and increased maternal morbidity compared to those with insurance (64,65). While the exact impact on expansion or contraction of services covered will vary by proposal and its relation to an individual's current coverage, many universal healthcare proposals would expand coverage to provide comprehensive bene ts (3,23,33,(38)(39)(40)48). It was noted however that long wait times are associated with poorer health outcomes (53) so while increased wait times are not inevitable they may counteract some of the positive outcomes likely to be seen.…”

“…In addition to economic costs or bene ts, universal healthcare systems can have positive or negative provider and patient experience that will impact satisfaction. Concerns about wait times and rationing of care have been put forward as potential negative consequences of increased demand and cost control measures (3,4,13,21,33,35,40). Reviewed literature put forward that international comparisons and economic modeling showed these fears may be unfounded (3,26,27).…”