Still Think A Single-Payer System Is Best? Read This First

Neil Chesanow

Disclosures

December 22, 2015

Single-Payer System: Why It Would Ruin US Healthcare

Many doctors believe that the real problem with the Affordable Care Act (ACA) is that it didn't go far enough—that what it should have been, if it had been politically possible, was a single-payer system that extended health insurance to all Americans and would have benefited doctors and patients alike.

However, a recent Medscape article looked at the problems inherent in a single-payer system, dubbed "Medicare-for-all," and identified many that could be significant.

One critic noted that single-payer systems in Canada, the United Kingdom, and other developed countries have to impose strict central planning. Rather than leave healthcare choices up to individual physicians, their patients, and free-market forces that could balance supply with demand, the government sets the rule. This would inevitably result in shortages of some services and gluts of others.

And with no competitors, central planners could arbitrarily decide what physician payments should be. Studies of countries with universal coverage show that their doctors earn up to 70% less than doctors here.

Another disturbing aspect of a single-payer system is the lack of competition among payers, which would reduce physicians' control over standards of care and reimbursement. In a multipayer system, doctors can choose which insurers to work with—even opting out of Medicare and Medicaid, as doctors are increasingly choosing to do. They couldn't in a pure single-payer system.

Critics also point to waiting lists so long in the much-vaunted Canadian single-payer system that some Canadians choose to come to the United States or other countries to receive timely care. Britain's National Health Service, often held up as model of how single-payer can work, is plagued by chronic problems in the quality of care that put some patients at life-threatening risk. The closest analogue we have to a single-payer system here, the Veterans Health Administration, has been rocked by scandals about untimely access and is staffed by too few doctors, who, one critic charges, "work shorter hours just punching a clock."

In addition, public opinion has been shifting away from support for "healthcare for all" ever since the buildup of the ACA. Even in Europe, the heart of the single-payer movement, the concept has encountered embarrassing defeats. Concluded one doctor who was critical of single-payer: "We have the finest healthcare system in the world, and it continues to get better."

The article sparked dozens of impassioned comments from physicians. But, interestingly, whereas a companion article arguing the benefits of a single-payer system drew mostly critical comments, the majority of doctors who responded to the article detailing the downsides of Medicare-for-all begged to differ with its gloomy prognosis. Several doctors proposed reconceptualizations of the current system rather than an either/or solution.

"In the present system, I can decide which insurers make unreasonable demands and place unreasonable restrictions on patient care and tell patients to either change insurance or find another doctor," noted a psychiatrist who agreed with the article's premise. "In a single-payer system, he who pays the piper calls the tune—the doctor and patient are no longer in control of the treatment a patient gets. Do we really want Washington bureaucrats controlling healthcare?"

"Single-payer is like oxycodone for pain management: It seems to work, but it creates a bevy of new problems, the nature of which can not be easily undone," a preventive medicine specialist contended. "The damage that will be unleashed, we can only speculate about. The best solution is neither single-payer nor keeping the current system. It's to reform the entire system, but with the American Medical Association, the health insurance industry, the pharmaceutical industry, and the medical device industry all pointing guns at the heads of our congressional representatives, it won't happen any time in the foreseeable future."

"I am a solo, private PCP," an internist wrote. "I support a single-payer/simplified healthcare system. My income is decent but dropping because I am forced to use an electronic health record (EHR) and other costly technology. Having an EHR compels me to hire more staff. I guess the experts quoted in the article work with big groups or medical centers that can absorb these expenses. The dream of young physicians to be self-employed is vanishing."

"We do not have the best healthcare in the world; we're not even in the top 10 by any measure except our per capita spending," a surgeon observed. "We already have wait lists and rationing, when insurers demand preauthorizations and delay care with ridiculous denials requiring more physician time in the appeal process. Physicians are not powerless in a single-payer system. We are vital to its success and, as in Canada, would negotiate fee increases, access, goals, and quality measures with the government. Hundreds of billions of dollars now going to high-salaried management, extraordinary pharmaceutical costs, and the shareholders of companies involved in healthcare that could be redirected to building a much better system of universal care."

"I am tired of the back-and-forth, as well as the power the insurance companies have over care," an orthopedic surgeon resignedly wrote. "Let's just go full socialized medicine, and I will work accordingly. I will make a high—if not top—government salary. The government can pay off my remaining loans. I will show up at the clinic at 9 AM; take a 20-minute coffee break; see a few patients; play around on the Internet; and take a leisurely, hour-plus lunch; schedule as few surgeries as possible; give most patients NSAIDs, physical therapy, and braces instead; leave around 4 PM; take little, if any, call; and put in minimal effort. Sounds good to me! If the American public really thinks 'affordable healthcare that every other developed nation has' is the answer, then so be it. Everyone wants cheap, Walmart, convenient medicine. Well, let's give it to them! I am over working 15-hour days, just to see 40% of my earnings confiscated for 'the greater good.'"

To which a general practitioner responded, "I want an orthopedist who is busy and skilled, with high-volume experience with the same procedure using an efficient multidisciplinary team approach, and a clean hospital or surgicenter available in which to operate. I couldn't care less about your personality, bedside manner, community service, or patient satisfaction surveys. A government-run, central-authority–dictated system with a casual work schedule as you wish for—tongue in cheek, I hope—will erode your skills, probably increase your complication and malpractice rates, and diminish your professional growth."

"Let me tell you about medicine in England," an emergency physician volunteered. "My elderly sister-in-law died of spinal shock after a fall at home. It took the doctors 2 days to get an MRI, which, had it been done promptly, might have saved her life. In England, nothing gets done without layers and layers of reviews and approvals. People wait months for a CABG. Specialists are booked out for months. This is not the kind of medicine I want to be a part of."

"And yet outcomes in England are far better than in the USA!" an internist replied. "And they are even better in other countries with a single-payer system—for example, Sweden or France. England spends much less on healthcare than the other western countries, but all spend much less than the United States, and yet they all have better outcomes. Imagine a system where you (as a patient) don't have to worry about being able to afford healthcare, and not have to forgo treatment because you can't pay the copayment or afford the medication, yet enjoy medical care whose outcome is far superior to ours by all available studies!"

"Don't try to disparage single-payer by defending medical care in the United States as it is: inefficient, wasteful, overpriced, and poorly distributed," an oncologist commented. "If single-payer won't fix those problems, then it shouldn't be adopted. But to pretend that our current system is working well for everyone at a price we can all afford—well, that's not true."

"A hybrid system is the answer," an emergency physician maintained. "Basic medical, dental, and eye coverage for all US citizens makes sense. A single-payer system would provide this, and if you enact some EMTALA (Emergency Medical Treatment and Active Labor Act) protections and tax incentives for those providing this basic, safety-net care, providers to continue to stay in the game. It would also, however, pave the way for more private, concierge-type medical practices. Insurance companies would remain to provide 'buy-up' plans for consumers wanting more health coverage, and plenty of providers would tailor their practices for this group. Many practices, however, would offer both."

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