Weighing the Evidence for Single-Payer

By Ann Settgast, M.D., and Elizabeth Frost, M.D.
Minnesota Medicine, Nov. 2009

As physicians, we are troubled by the direction of federal health care reform. Whether via a public health insurance option or an insurance mandate, the proposals on the table build on the structure of our broken system—the most costly, fragmented, and bureaucratic in the world.

President Barack Obama acknowledged in his national address this summer that a single-payer system is the only way to cover all Americans. We agree, and we encourage him to re-embrace this solution to the health care crisis.

Conventional wisdom leads us to believe there are only two culprits responsible for skyrocketing health care costs—doctors and patients. Doctors order too many unnecessary tests, and patients demand too much care. We acknowledge that overtreatment of patients guided by improper incentives must be addressed. The issue of patients overusing care also must be confronted. However, the problem of overuse is minuscule compared with the consequences of underuse. In its most extreme form, underuse of health care contributes to more than 45,000 deaths in the United States annually, as revealed in a study by Wilper et al. in the American Journal of Public Health. But blaming doctors and blaming patients ignores the elephant in the room: private insurance.

Our unique multipayer financing structure based on private health insurance produces enormous waste. Of every health care dollar spent in the United States, 31 cents is spent on administration (more than double that of other industrialized nations). So we are wary of proposals that seek to simply expand private insurance and in so doing provide a bailout for this industry. Such expansion may decrease our embarrassing numbers of uninsured, but it will not solve our problems. Private insurance has been likened to an umbrella that melts in the rain. Consider the disturbing fact that 62 percent of all personal bankruptcies are related to medical bills. More astonishing is the fact that 77 percent of Americans who go bankrupt because of medical bills had insurance when they became ill. Because it is a business, private insurance has, at its core, the bottom line. The only way to succeed is to selectively recruit healthy patients or to deny coverage to patients when they become sick. As professionals who strive to make sick people well, we find this model for our system illogical and fatally flawed.

Elimination of U.S.-style private insurance has been a prerequisite to achieving universal health care coverage in every other industrialized nation. We ask, “What if the rest of the world is right?” Only under single-payer can we eliminate the administrative costs associated with billing hundreds of payers and the sizeable overhead of the private insurance industry. These overhead dollars are spent marketing, underwriting, lobbying, and fighting claims—none of which makes our patients healthier. Elimination of this administrative waste would save more than $400 billion annually.

As physicians, we are obligated to use evidence-based medicine. The reform debate must be held to the same standard. Ample evidence, including studies by the Congressional Budget Office and the Government Accountability Office, shows single-payer can assure universal coverage while saving money. For those who say competition among insurers is needed to keep costs down, we say the experiment must end. It has been tried. It has failed. For those who ask whether something is better than nothing (ie, implementation of a public option), we again look at the evidence. A number of states have tried to patch their systems with piecemeal reforms over the past two decades. None has produced universal coverage while controlling costs.

For those who suggest we would lose choice under a single-payer system, we ask, choice of what? Choice of insurance plan—yes. Choice of doctor and hospital—no. A high-quality system is not one in which our patients choose their insurance plan but one in which they choose their doctor. Single-payer is the only reform option that actually expands choice. Bringing private insurance or a public option to more Americans retains limited provider networks and restricted choice.

For those who say single-payer is socialized medicine and worry that government bureaucrats will suddenly begin making health care decisions, they need to remember that single-payer is publicly financed but privately delivered. Medical decisions should be made by patients and doctors.

Given the magnitude of these difficult economic times, including a projected $1.8 trillion federal deficit for 2009 and rising unemployment, it is high time to reconsider the most fiscally conservative and financially sustainable option for reform—a single-payer system.

Ann Settgast and Elizabeth Frost are primary care physicians practicing in the Twin Cities. They co-chair the Minnesota chapter of Physicians for a National Health Program.