An Australian perspective on a Californian single-payer healthcare system

As an Australian living in San Francisco, I’ve taken an interest in the ongoing debate among Californians about the benefits of moving to a single-payer healthcare system.

In Australia, citizens are covered by the government’s Medicare policy. There’s a set fee for physician consultations and most medicines and procedures are subsidized. While it was perhaps a blessing to grow up with such a system, it also made me hopelessly naïve to the situation in the U.S.

That changed in 2018 when I landed a postdoc at UC San Francisco. In my first few months, I was covered by a U.S. health insurance policy but was told the administrative burden of processing a claim without an assigned primary care provider would likely be more trouble than it’s worth. With that in mind and knowing my asthma rarely became problematic, I held off refilling my regular medications until the paperwork was sorted.

That was fine for a week or so. And then my lungs realised they were no longer surrounded by an Australian summer.

With my wheeze and my wallet, I went to the local pharmacy thinking that healthcare in the U.S. would be like back home. What a miscalculation. While a cannister of albuterol is available over-the-counter in Australia for about $8, I was told I needed a prescription and that without insurance I’d be out of pocket about $80. What’s more, the consultation fee to get a prescription was going to cost $270! Needless to say, I came to appreciate the full musical repertoire of my lungs over the ensuing weeks.

Eventually, the paperwork was organized, my breathing improved, and I learned the basics of how things operate here. To my surprise, I also realised that with appropriate coverage the healthcare available in California is fantastic.

Compared to my situation in Australia, I pay less to see a physician, I find it easier to get in touch and make appointments with healthcare services, and I pay substantially less for my medications. My primary care provider has also been able to improve my asthma treatment.

How can that be true? Let me explain.

Although there is a maximum amount a physician can be reimbursed by the government for a patient consultation, there is nothing stopping physicians charging patients more. In my experience, general practitioners often charge up to double the standard reimbursement, while specialists routinely charge hundreds of dollars more. Oddly, the competition among specialists has become like a high-end retail market where the more one charges the more people believe the product to be of superior quality. This results in a lot of patients being referred to the same overcharging clinics.

With medicines, Australian’s are at the mercy of what the government includes on the Pharmaceutical Benefits Scheme (PBS). This is a list of essential medicines that are available on prescription at a subsidized price. The typical co-payment for an employed adult is about $35 per month’s supply of medication. However, if a medication is not on the PBS, or a doctor wants to prescribe it for something other than its recommended use, patients must pay the unsubsidized price.

My general practitioner in Australia wanted to prescribe montelukast for asthma until he realised it would cost me $75 per month because asthma is not an approved indication (according to the PBS). We tried alternatives but ultimately settled on a sub-standard regimen. Since being in the US, I’ve been paying about $3.30 per month to use montelukast and my asthma symptoms have improved.

My early experiences in California demonstrated how uncomfortable and deflating it is to live here without adequate insurance. I wouldn’t wish it upon anyone. A single-payer system would make high-quality healthcare accessible to all and experts say it would reduce costs substantially.

However, it’s critical to consider the potential problems a single-payer system may introduce. Australia certainly doesn’t set the perfect example. In my opinion, Californians shouldn’t get on board without a guarantee that those currently insured appropriately will continue to receive their existing level of healthcare.

David Boettiger is a health policy research fellow at the UC San Francisco, and a citizen of Australia.

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