Letter to American College of Surgeons on single payer: enact Medicare for all
Sherif Emil, MD, CM, FACS
Irvine, CA
Bulletin of the American College of Surgeons
Volume 93, Number 12
In August 2003, an article endorsed by 7,784 physicians and medical students, “Proposal of the Physicians Working Group for Single-Payer National Health Insurance,” was published in the Journal of the American Medical Association.1 In his commentary on the article, Thomas Russell, MD, FACS, Executive Director of the American College of Surgeons, reminded us that “tremendous administrative costs and competition between plans that have a for-profit mentality have resulted in an arcane and costly system, which diverts money from patient care and breeds the corporate mindset that has become pervasive in the medical profession,”2 a position espoused by me and thousands of my colleagues in Physicians for a National Health Program. However, Dr. Russell did not believe that “the crisis in health care has reached a threshold that would command such a startling transformation.”2 To this, I responded, “The crisis in our health care system may be below the threshold only because we keep elevating the threshold.”3 Five years later, it appears that we may have finally reached the threshold, as evidenced by the resurfacing of health care as a major issue on the national agenda and in the presidential election.
Our present system of health care delivery is not sustainable. It may putter along for a decade or two, but it will finally collapse. And as it self-destructs, tens of thousands more will be hurt. Presently, the Institute of Medicine estimates that 1,500 Americans die every month due to lack of health care coverage. I would argue that it is not universal health care that is un-American—it is our present system.
Few in the surgical and medical profession would disagree that change is needed. Respected surgical leaders are speaking out. Donald Trunkey, MD, FACS, called the U.S. health care system the “best mediocre health care in the world.”4 In a lecture at Rice University, the late Michael DeBakey, MD, FACS, stated, “Our health care system is in disarray and cannot be rectified by the incrementalism approach.”5
The disagreement has to do with the type of change. You cannot build a second floor on a house with a rotten foundation. Although we have all the components to indeed have the best health care in the world, our health care delivery system is terminal. The problem of the uninsured is the most visible and perhaps the most profound. I travel frequently on surgical missions to east Africa. I am ashamed to say that I am starting to see here in California the type of late presentations and catastrophes I typically see in Kenya, Tanzania, and Zambia. But multiple other problems abound. Private insurers thrive by denying care and injecting tremendous inefficiency into the system. The burden of insuring the riskiest patients-the elderly, the poor, end-stage renal failure patients, Native Americans-is shifted to the government. Physicians practice with their hands tied behind their backs. I cannot get a simple X ray or blood test on most of my patients until the test is authorized. Often, the patient has to be sent to another facility.
Patients are trapped in health care plans that treat them as widgets that can be manipulated for financial gain. Choice of physician has become a luxury most patients cannot afford. This, in turn, has created stagnation among some physicians who, consciously or unconsciously, know that they have a trapped audience. Continuity of care is easily disrupted if insurance shifts to a different plan or is lost altogether, the treating physician changes practice, or job changes occur. Resources are poorly utilized due to competition driven by market forces, not quality. While 46 million are uninsured and millions more are not getting the care they need, hospitals are closing under financial stress. Why would we want to take this system, which is already at the breaking point, and expand it to cover everyone?
Medicare for all! Despite all the criticisms directed at Medicare, it has survived for more than 40 years, given our elderly the peace of mind we all deserve, improved the health of its beneficiaries, avoided micromanagement of clinical interventions, preserved patient freedom to choose their physician, and sustained efficiency in claim reimbursement. It has done all that with virtually no shared risk, providing services for almost all its beneficiaries. Despite its difficulties, the program’s popularity was recently evidenced by the congressional overturn of a presidential veto, an effort the College valiantly led. When we advocate for a single-payor model, our opponents immediately bring up waiting lists in Canada and other industrialized countries. Joint replacement is typically the sentinel operation used to demonstrate inadequate wait times in Canada. Ironically, most joint replacements in the U.S. are also paid for by a single-payor system: Medicare! Under Medicare, waiting lists are not an issue because spending and system capacity are significantly higher than those in Canada. We should also remember that Canadians spend approximately half of what we spend per capita on health care, cover everyone, and have public health and some tertiary care outcomes superior to ours. Shrinking the waiting list is a national priority in Canada, as evidenced by last year’s attendance of Prime Minister Stephen Harper at the annual “Taming of the Queue” conference. The Canadians have problems with their system, but they have a system.
The conventional wisdom is that a single-payor system is not popular with the public or physicians and cannot be realized in the U.S. But in a recent survey by the American Academy of Pediatrics, one-third of pediatricians favored a single-payor system, a substantial finding given that it is very difficult to get this many physicians to agree on another specific alternative. In a survey of 904 Massachusetts physicians randomly chosen from the American Medical Association master file, almost two-thirds of respondents identified single payor as “the structure that would provide the best care for the most people for a fixed amount of money.”6 In poll after poll, a majority of Americans favor a universal health care system, even if financed through increased taxation.
Americans, the public, and their physicians have a major decision ahead. Will health care continue to be treated as a commodity bought and sold according to means or as a service sought and delivered according to need? American surgeons should continue to lead the world in innovation and creativity, but they should also apply the results of their resourcefulness to any patient in need, in an atmosphere of evidence-based care, patient freedom to choose their doctor, and resource optimization, free from micromanagement and bureaucratic hassles. I don’t believe this can be achieved through expanding or amending our current nonsystem.
As called for by an idealistic, young surgeon in the August Bulletin, “When physicians place the health of our patients as our first consideration, we reclaim our autonomy, our morale, and ultimately our dignity as a profession.”7 A radical shift in our approach and our priorities—a shift that would produce a startling transformation—is necessary! References
1. Proposal of the physicians’ working group for single-payer national health insurance. JAMA. 2003;290:798-805.
2. Russell TR. From my perspective. Bull Am Coll Surg. 2003;88(10):3-4.
3. Emil S. Crisis in health care [Letters]. Bull Am Coll Surg. 2004;89(1):53.
4. Trunkey DD. A growing crisis in patient access to emergency care: A different interpretation and alternative solutions. Bull Am Coll Surg. 2006;91(11):1322.
5. DeBakey ME. The role of the government in health care: A societal issue. Am J Surg. 2006;191:145-157.
6. McCormick D, Himmelstein DU, Woolhandler S. Single-payer national health insurance. Physicians’ views. Arch Intern Med. 2004;164:300-304.
7. Kuy’S. Stand..d up for patients. Bull Am Coll Surg. 2008;93:(8):23-24.