A Single-Payer System: Best for Doctors and Patients Alike?

By Neil Chesanow
Medscape, Dec. 21, 2015

Recently, Medscape published two provocative articles on the viability of a single-payer healthcare system in which experts took opposing views on the issue. In one article, one group argued why it would save US healthcare; in the other, another group made the case that adopting a single-payer system would be the ruin of US healthcare.

In the article on why a single-payer system would be our salvation, Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and an architect of the Affordable Care Act (ACA), contended that although the ACA has been "a step forward for the country," it "does not deal with the problem of waste and complexity in the system," as he feels a single-payer system would.

And James Burdick, MD, a transplant surgeon at Johns Hopkins University School of Medicine and author of the forthcoming book "Talking About SINGLE PAYER," argued that a single-payer system is "a more economical way to use healthcare resources. You could reduce expenses and still improve quality. That's a tremendous opportunity that you don't have in many other fields."

Of course, as the article pointed out, this would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a workforce of 470,000. But Dr Burdick believes it would likely restore doctors' authority. And those who favor single-payer say that for all practices, administrative costs would plummet because there would be only one set of payment rules. Prior authorizations, narrow networks, and out-of-pocket payments would be eliminated, proponents of a single-payer system maintain.

The article also pointed to evidence of growing physician support for a single-payer system. For example, a 2014 survey of Maine physicians conducted found that nearly 65% of respondents preferred the single-payer option over trying to fix the current system—up from 52% in a 2008 survey. Physicians in general seem more open to a single-payer system.

Americans are warming up to the idea too. A tiny majority (51%) support Medicare for all, according to a national poll released in January. Many experts believe that the movement for a single-payer system may start at the state level, although the public's abiding mistrust of government must still be overcome.

The article ignited impassioned arguments about the pros and cons of a single-payer system among the well over 100 physicians who responded with comments. Several doctors proposed thoughtful alternatives to "Medicare-for-all."

"Commercial insurance is a failure and a joke," one doctor opined. "Families pay more than $15,000 per year for health insurance and still have $2500 in deductibles, plus high copays. Patients are reluctant to get healthcare in outpatient settings, since private insurance does not cover anything unless a catastrophic event occurs. Many doctors no longer accept private insurance owing to their numerous administrative burdens. We easily forget that the primary goal of private insurance in capitalism to make a profit for the CEOs of insurance companies and the shareholders who own stock in them. Personally, I would prefer a 100% Medicare practice."

"Medical insurance is supposed to be only for catastrophic events, like car insurance," another physician shot back. "Can you imagine if Americans wanted insurance to pay for routine maintenance and fuel for their cars? The healthcare system is broken. You solution is to break it some more. My solution for my family is to live within our means, never go into debt for more than 30 days at a stretch, and never purchase health insurance—except very high-deductible, catastrophic-event insurance. Emergency rooms are for broken bones, gushing wounds, anaphylaxis, and other genuine emergencies, not sniffles and sprains. A full medicine chest and a bit of common sense is our family's strategy."

"A government-run single-payer system is without a doubt the only way to provide effective medical health therapeutic and management, a doctor contended. "For those who desire a higher level of care—and can afford it—there will be a concierge and private-pay system. As medicine advances technologically, this will become a necessity. The loss of jobs in the insurance industry will be partially offset by an increase in the added positions in the government medical system."

"Obamacare barely passed through Congress with Democrat-only votes, and only with the assistance of bribes, threats, and lies," an anesthesiologist fumed. "It has never garnered more than 30% public approval; and it has been changed over 40 times by the Obama regime illegally, without benefit of legislation by the legislative branch. The clowns who thought it was such a terrific idea back then are the same clowns braying for single-payer now. Why we are supposed to trust them this time? Why is it that the only answer to failed socialist government programs is more socialist government programs?"

"Single-payer reform would be an audacious step," a radiologist observed. "It would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a workforce of 470,000—and replace it with one unified payer. EXCEPT that when the government takes over, it will cost $1.4 trillion and require a 900,000-person workforce."

"A one-payer system will not be like 'Medicare-for-all'; it will be end up becoming more like 'Medicaid-for-all,'" a pulmonologist warned. "How many of you in private practice could make a living if 100% of your patients were on Medicaid?"

"Yes, turn it over to the government," a doctor acerbically wrote. "They will make our lives easier and reduce our paperwork and the onerous documentation requirements during patient encounters. Oh wait! They are the ones doing now that with Medicare. Never mind."

"I don't see one valid point against single-payer in these comments, just the usual 'anticommunist' stuff," another doctor reasoned. "A number of comments trashed the Veterans Administration (VA). The VA system has a lot going for it, considering the level of acuity of the population it serves—starting with a functional electronic health record. Do the detractors think that a random assortment of for-profit HMOs would do a better job serving the high-utilization health needs of veterans? Basic healthcare is like a utility—something everyone needs, and in the best interest of our society to make sure everybody gets."

"Why does it have to be a single-payer?" one doctor wanted to know. "Why not a government payer for essential care and let private payers compete for the rest?"

"Why not allow anyone to buy Medicare as their insurance, rather than just those over 65?" another doctor counter-proposed. "Young, healthy people could get Medicare, and the premium would be much less than commercial insurance. Their utilization of medical services is generally lower, so the money generated would be a net to Medicare. If commercial insurance wants to compete, it would have to lower its rates. This would generate competition among Medicare and commercial insurers and drive premiums down. If you want Medicare, then get it. If you want commercial insurance, then get it. Let the individual decide, but give the option of Medicare."