The 2019/2020 Harkness Fellowship — A research proposal.

Some of you may know that I had applied to the Commonwealth Fund’s Harkness Fellowship for 2019/2020. For me, applying was an opportunity to take a comprehensive view of the Canadian and US health systems and to compare opportunities and learnings to enhance both. The “competition”, I knew, was fierce, but I threw my hat in the ring anyway to see what would happen. Unfortunately I wasn’t successful, but I figured that putting my research proposal out in the public sphere would help add to the body of related work that is out there on enhancing health care delivery service and governance. So here it is, my research proposal, and offered for public comments and thoughts. My sincere thanks to those who supported me through this journey, and I also thank the Commonwealth Fund for the opportunity to apply and to have had my research proposal reviewed. And good luck to those who were successful this year!

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Originally submitted in November 2018.

“Development of a publicly-managed, regionalized and highly-integrated health care delivery system concept model within a single-payer insurance framework for a US state”

Most recently championed publicly by American politician Bernie Sanders and becoming a major policy objective within a certain contingent of the Democratic Party [1], universal access and specifically the “single-payer insurance system” is slowly gaining traction among American voters in recent polls [2][3][4]. And while the single-payer system requires significant tax increases to sustain [5][6] and state initiatives on instituting this system in Democratic party-majority held states like California and Colorado were rejected by voters [7][8], enthusiasm for this system has certainly not faded, as seen recently in the 2018 midterm election results in Colorado, where the governorship was won with the single-payer system included as an election platform policy point [9][10].

It is already well documented that the single-payer system has proven its value as being efficient and effective, considering the UK’s experience [11][12]. The country enjoys being globally ranked as having one of the lowest per capita cost in health care delivery while maintaining a high standard of care provided[13]. Despite the vitriol that some Americans display towards the single-payer system and universal access, branding it as inherently abhorrent because it can be politically construed as left-leaning and “socialist”, and historically being opposed by powerful business and provider lobbies [14][15], the American health care delivery model continues to lag in both cost and performance [16][17]. Recent attempts by majority lawmakers to suppress the Affordable Care Act has resulted in a loss of insured coverage since the act was first introduced [18]. Majority lawmakers have offered little clarity in terms of alternatives to increase access to health services, considering (albeit contradictory) promises by the executive branch to do so [19][20].

As access and affordability of care has proven to be a major point of concern for Americans during the 2018 midterm elections [21], it can be suggested that momentum in the context of health care reform is swinging towards universal access and some form of single-payer system (understanding, however, that there may be some level of misinterpretation of what this system implies among Americans [22]). There are variations in the implementation of the single-payer system to consider, however.

Single-payer. Fine. But which one?

The UK and Canada both institute single-payer supported health care systems with the “payer” being the government in both countries. What differs is which level of government and who provides those services. In the UK, the single-payer is the national government who also operates and delivers publicly insured health care services. Providers delivering publicly insured health care services are also employees of the government. This system has been described as “National Health Service” or the Beveridge model [23]. In Canada, the “single-payer” are each individual provincial government, where care is “privately” delivered. This system can be described as “National Health Insurance”. “Private delivery” in this context is somewhat of a misnomer—while a private agency or multiple agencies are accountable for the delivery of publicly insured health care services, these agencies are publicly-overseen and funded. Physicians, while given jurisdictional independence to operate professionally and privately, are on contract to their respective province for the publicly-insured services that they render. But if compared to the American care delivery context at a high-level, care delivered this way resembles how U.S. Medicare is provisioned by state, where a certain breadth and depth of publicly insured health care services are provided by private providers to a population [25]. Returning to the Canadian system, each province is given some flexibility to publicly insure health care services and have the complete jurisdictional authority to define how care is delivered. This offers another point of comparison, mimicking the jurisdictional authority that US states have within the larger federal context in the control of their internal affairs. In order to receive federal transfer payments to support provincial health care delivery, the provinces must abide by federally defined principles that taken together, provide universal access to medically necessary health care services. These principles are briefly stated as follows: public administration; comprehensiveness; universality; portability; and accessibility. As long as the provinces meet these principles, the federal government will not prescribe how health care services ought to be delivered by the provinces and will offer regular (and needed) financial support to fund their health care delivery models. I suggest that when considering the cultural and political differences between American states and their relationship with the federal government, the Canadian single-payer arrangement may perhaps be considered the most “palatable” system to adopt among state legislators.

Thus in the context of this proposal, if Americans adopt a single-payer system, they should consider a variation of the Canadian implementation. The model respects the jurisdictional authority and integrity of each state while defining certain delivery objectives that will provide universal access to medically necessary health care services. As Canadians are already duly aware, however, this model is by no measure perfect and requires reform within its current design.

Keep the baby. Throw the bath water. Single-payer challenges

The single-payer interpretations in the UK and Canada both provide universal access to all. And while current iterations of single-payer in both countries are certainly not perfect in terms of how efficient, effective and timely care is delivered, the perception of the challenges afflicting the Canadian health insurance and delivery system appear to be even greater [26]. All provinces have to tackle with to a certain degree a lack of coordinated, integrated and seamless care [27]. This lack of coordination, as described by journalist André Picard, includes complicated and duplicated fee schedules, poor continuity of care when there is an obvious lack of a “medical home” (this to do mostly because of a poorly integrated and governed primary care sector), a lack of a unified electronic health record and the cost this imposes on continuity of care and transitions in care, and perhaps most pressing, poorly designed administrative structures overseeing health care delivery [28]. Picard further notes that poorly developed administrative structures manifest as “huge variations in practice and outcomes across the country and even from one institution to the next,” where there are “many managers but very little management.” He adds that “no corporation, no coherent system, would tolerate these kinds of inefficiencies [29].”

This provides an opportunity: What about a regionalized model of care delivery that aims to address these shortcomings? Enter the Alberta experiment.

Regionalized, integrated publicly-managed health care delivery

The province of Alberta was the first province in Canada to move to a regionalized delivery model of care, in a way replicating the UK’s federated model but on a provincial scale (with exceptions, of course [30].) What has emerged is a single health care authority that provides publicly insured health services within almost every health sector (the exception being, to an extent, the delivery of primary care services) after 12 separate health entities were combined into one [31]. Clinical and administrative support services, like information technology, human resources, procurement and logistics, among others, were also regionalized and no longer duplicated per entity, realizing a degree of administrative efficiency. With a management structure that resembles that of a large private corporation, its design would be familiar to US private sector executives. The organization is currently implementing a provincial Electronic Health Record in order to improve coordinated health care delivery and transitions in care, among other goals. Some of the challenges that Picard had identified would, I suggest, in effect be addressed through such a model. This leads to a question: What would a regionalized, publicly-funded model of care delivery look like in the U.S. context, where publicly insured services were delivered by the state with a mirrored model of integration, like that seen in Alberta?

The proposal: marrying a US state with publicly-managed, integrated and regionalized health care delivery

To address the fragmentation of care delivery in the US, I suggest the development of a concept model of how a publicly-managed, integrated and regionalized delivery provider can operate within a state, where universal access is offered and defined by a clear set of publicly insured medically necessary health services, modeled after Alberta’s experience. This research will provide the underpinnings for a model that, as suggested by the current trajectory of American discourse, may be a plausible model to adopt.

In doing so, the concept will attempt to answer the following questions:

What “medically necessary health services” will be insured [32]? What is the administrative and governance structure for this organization? How will each health sector be addressed? (This model will assume the delivery of public health and primary care services.) And how will urban and rural geographies be considered? What mix of public management will be present? What goals/outcomes will drive the model? How will it be funded? What legislation is required to operate this model? What state “attitudes” will need to change for this model to be acceptable? What externalities can be anticipated through the introduction of this system? (This includes the effect on other states and on for-profit and non-profit providers in the state).

Among other questions this concept will attempt to answer, primary to its investigation is whether the model is both feasible as a replacement or compliment to current delivery systems in the US, and whether it would be more effective and efficient in national and global rankings. The Albertan experience is mixed, suggesting that since its introduction the new model is highly integrated [33], but the province continues to spend a great deal per capita on health services ($7,329) [34] despite having a younger population [35]. Although this amount is still less than the per-capita cost found on average in the US ($11,916), it is far from the Commonwealth Fund’s highest ranked health care system, the UK ($5,170) [36]. I suggest that these costs can be lowered though improvements to the Alberta model’s administrative structure by eliminating duplications, increasing transparency, and clarifying accountability and responsibility while better integrating primary care delivery and containing provider costs [37]. These improvements can be modeled within this concept, and its cost estimated.

Proposed research design

The concept model will be designed through the support of provincial and state health care administrative and policy leadership in both countries through a series of surveys, interviews, and analyses.

  • A US state will be chosen for the concept model, and legislative reconciliation between Alberta and the state will provide the parameters for how this system will be designed and operated.

  • A clarified, high-level “bucket” of medically-necessary health services will be derived though a comparison of Canadian and UK legal and administrative frameworks.

  • Each iteration of the concept model will have a “gate review” where attached health policy experts will have an opportunity to discuss and suggest improvements. The model will be incrementally developed until a final design is arrived to.

  • Surveys will be prepared to understand relevant attitudes and externalities related to this model. Stakeholders for the surveys will include but are not limited to: non-profit/for-profit delivery organizations; insurers; state health authorities; local public health jurisdictions; provider groups; educational institutions; and public members.

  • Costing analysis will be derived for the concept model using available costing estimations from the Canadian Institute for Health Information, the Commonwealth Fund and support from the placement state’s own cost estimations, among other sources.

Expected contributions

Should Americans vote to institute a single-payer system, this concept model will provide the groundwork and example for a state-sponsored, publicly managed, regionalized, highly-integrated care delivery system. Other single-payer systems and related health delivery model implementations exist, though this research will provide US policy makers a specific example of the development and reconciliation of an already established health care model in Canada that is replicated (with improvements) within a US state. For Alberta, the concept model will provide the sole health care delivery authority an opportunity to incrementally improve its organizational structure based on the concept model’s suggested design improvements.

Proposed placement in the United States

Ideally Colorado State will be chosen as an example state for the concept model. It reflects certain population and geographical characteristics that are similar to the Albertan context. The state had also previously put a single-payer system to vote (ColoradoCare) and would be well positioned to build upon the failed initiative and identify what segments of the proposal did and did not resonate among voters, lawmakers and administrators. Alberta’s model will be used as comparison, and much of the background work used in that state’s attempt can form the basis of this new concept model. This proposed research will also provide an attempt to clarify the publicly insured benefits that would be covered. Placement within the state’s health administration will be best. Receptive academic support will be equally desired, considering the conceptual difficulty in framing this work. Attachment with the newly elected governor’s office can provide political leadership for this effort.

Research references/footnotes

[1] Relman, E. (2018, October 15). Democrats are embracing a radical change to US healthcare, and it could be the defining political fight for years to come. Retrieved from

[2] Alonso-Zaldivar, R., & Kellman, L. (2017, July 20). 62 percent of U.S. want federal government to ensure health care for all, poll says. Retrieved from

[3] Blumberg, Y. (2018, August 28). 70% of Americans now support Medicare-for-all-here's how single-payer could affect you. Retrieved from

[4] Guskin, E. (2018, April 12). About half of Americans support single-payer health care. Retrieved from

[5] Medicare for all is a meaningless slogan. (2018, October 13). Retrieved from

[6] Editorial Board. (2017, June 18). Single-payer health care would have an astonishingly high price tag. Retrieved from

[7] Chang, C. (2017, June 30). What Killed Single-Payer In California? Retrieved from

[8] Matthews, D. (2017, September 14). Single-payer health care failed miserably in Colorado last year. Here's why. Retrieved from

[9] Haberkorn, J., Scher, B., Emery, T., Bazelon, L., & McCoy, M. (2018, August 03). Single-payer, once shunned, makes a comeback in Colorado governor's race. Retrieved from

[10] Lopez. (2018, November 07). Jared Polis becomes first openly gay person elected governor in America. Retrieved from

[11] Gawande, A. (2017, June 19). Getting There from Here. Retrieved from

[12] Triggle, N. (2017, July 14). NHS ranked 'number one' health system. Retrieved from

[13] How does health spending in the U.S. compare to other countries? (2018, February 13). Retrieved from

[14] Zurcher, A. (2018, October 10). Why Trump's slamming Medicare for all as 'socialist' healthcare. Retrieved from

[15] Merelli, A. (2017, July 18). A history of why the US is the only rich country without universal health care. Retrieved from

[16] Bort, R. (2017, July 14). The U.S. health care system has been rated the worst (by far) among high-income nations. Retrieved from

[17] Partanen, A. (2017, March 18). The Fake Freedom of American Health Care. Retrieved from

[18] Weixel, N. (2018, May 01). Poll finds 4M lost health insurance in last two years. Retrieved from

[19] Costa, R., & Goldstein, A. (2017, January 15). Trump vows 'insurance for everybody' in Obamacare replacement plan. Retrieved from

[20] Klein, B. (2018, October 19). Trump: 'All Republicans' support pre-existing conditions, but White House policy says otherwise. Retrieved from

[21] Sarlin, B. (2018, November 6). Midterm exit polls: Health care is top issue for voters. Retrieved from

[22] Kilgore, E. (2018, May 15). Voters Who Like 'Medicare for All' May Not Support Single-Payer. Retrieved from

[23] Liu, J. L. (n.d.). Exploring Single-Payer Alternatives for Health Care Reform. Retrieved from Pg. 4

[24] Ibid.

[25] Ibid. Pg. 5

[26] Carroll, A. E., & Frakt, A. (2017, September 18). The Best Health Care System in the World: Which One Would You Pick? Retrieved from

[27] Picard, A. (2013, October 31). The Path to Health Care Reform: Policy and Politics (The 2012 CIBC Scholar-in-Residence Lecture). Retrieved from Pg. 159

[28] Ibid. Pg. 160

[29] Ibid.

[30] For example, physicians are on contract with the province to provide publicly insured health services and are not employees. Primary care services continue to lack any sensible integration within the larger health care system, though efforts like the “Primary Care Networks” try, with mixed results.

[31] Alberta Health Services. About AHS. Retrieved from

[32] This considers the “Three dimensions to consider when moving towards universal coverage” as defined by the World Health Organization’s 2010 report, Health systems financing: the path to universal coverage. World Health Organization: World Health Report 2010 – Health Systems Financing: The Path to Universal Coverage. 2010, Geneva: World Health Organization. Pg. 13.

[33] Alberta Health Services. (2018, June 8). AHS ranked among best in world for integration of care. Retrieved from

[34] How does health spending differ across provinces and territories? (2018, January 10). Retrieved from

[35] Alberta ranks 2nd highest on health-care spending despite youthful population | CBC News. (2017, November 07). Retrieved from

[36] How does Canada's health spending compare internationally? (2018, January 10). Retrieved from

[37] Physician compensation, for example, is the highest in the country, with an average pay of $380,000 annually.

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