What is single payer and why should obstetrician-gynecologists care?

By Carrie Ann Terrell, M.D., FACOG
MetroDoctors: The Journal of the Twin Cities Medical Society, November/December 2015

Having a baby in Minnesota is a pretty good deal. Many pregnant women have health insurance. Most pregnant women who are not already insured are eligible for medical assistance (MA). The majority of visits and tests during pregnancy are covered by insurers in a package which precludes prenatal care, delivery, and post-partum care for up to six weeks.

Yet, insured women are becoming more concerned about potential charges, more commonly asking “will this be covered?” and finding themselves with large unpaid medical bills.

Given Minnesota is enrolled in the Affordable Care Act (ACA) and continues to support Medical Assistance why are women focusing more on coverage, medical bills, and policies than on their health and pregnancies. Additionally, why is the United States ranked 28th[1] for maternal mortality and falling if we are insuring more women?

Despite ACA and excellent medical assistance, women are still underinsured in Minnesota. Women seeking pregnancy and gynecological care with good insurance have high deductibles commonly in the thousands of dollars. For many women the understanding is employment equals benefits equals health insurance. The summation of the deductible along with co-pays for visits (clinic, Labor and Delivery, ER, OR, lab, and ultrasound) results in out-of-pocket costs which are insurmountable and lead to feelings of betrayal and mistrust of the insurance system or her employer.

Many women assume if they pay their monthly premium everything else should be covered. Even our more savvy patients do not understand which visits, texts, procedures will be covered or at least what percentage. Insurance companies compete by avoiding unprofitable patients and shifting costs to patients or providers. This system avoids caring for the sickest patients and creates huge administrative costs. Meanwhile, health insurance CEOs are financially rewarded for generating profits which do not increase the wellness of our communities.

How often have we heard a middle-aged patient, a friend, a coworker exclaim she is simply retaining a job until she qualifies for Medicare? How many of these patients put off visits, cancer screenings, wellness exams until Medicare “kicks in”?

A single payer program is essentially Medicare for all. The program would provide comprehensive coverage with free choice of providers and no direct charges to patients. A public agency would manage the plan and budget.

Insurance company profits and multimillion-dollar company executive bonuses would be eradicated. Mandatory referrals and pre-authorization for medications would vanish. Improved access, the ability to obtain and monitor outcomes in a systematic way, and the ability to collect evidence-based care uniformly would improve the health of our populations.

There would be no confusion as to when or if a visit, lab, medicine, or surgery would be paid for. The funding would be accomplished by taxes. Note these taxes are in lieu of premiums, co-pays, and deductibles.

The Lewin Group recently studied the economic feasibility of a Minnesota single payer system. It found that such a system could provide comprehensive health and dental coverage to every Minnesotan while saving the state an extraordinary $189.5 billion in health spending over 10 years. The median-income Minnesota family would save an average of $3,512 per year on health care.[2]

Daily, I am saddened and frustrated with our current processes and systems. I envision a world wherein women can get the care they need when they need it without concern for cost. I desire a system in which the money invested in health care or insurance actually benefits patients.

The U.S. spends 25-31 percent of our health care dollars on administrative costs.[3,6] Administration of health care includes: running our practices/clinics/hospitals, paying executives to help us run our businesses, and dealing with various insurance companies.

According to a study published in 2010 by Dante Morra and Sean Nicholson, “We estimated physician practices in Ontario spent $22,205 per year interacting with Canada’s single payer agency – just 27 percent of the $82,975 per physician per year spent in the United States.”[4] The money spent on the administration of insurance includes: health insurers’ advertisements, lobbyists, eight-figure executive salaries and six-figure bonuses and profits for the investors in those companies.

As physicians we feel a lot of pressure to do our part to decrease the costs of medicine. We receive grades from our community (MN Community Measurement), the government (Meaningful Use), and insurance companies on how well we prescribe generic medications, integrate technology into patient care, the ordering of expensive tests, and our patients’ lab values.

While I do my best to limit excessive testing or prescribing I cannot have my practice do away with coders, billers, administrators who translate my clinical work into claims. I have no input on how many insurance companies exist or the rules for submitting claims.

I am asked to focus on certain measures to elevate my practice’s tier within insurance companies. As an academician I fully appreciate and am eager to participate in programs which will improve the health of my patients or reduce unnecessary costs. Society and government do not and legally cannot put the same obligations onto insurance companies.

We do not expect Medica, Blue Cross, HealthPartners to decrease their costs to patients or improve the health of their customers. And how can they? Citing Morra and Nicholson again, “U.S. senior administrators also spent more time per physician than those in Ontario, mostly on overseeing claims and billing tasks. Very little time was spent in Ontario or in the United States on submitting quality data to payers or reviewing data on quality.”[4] So, we spend time and money dealing with insurance companies while trying to take care of patients and they spend time and money accepting, rejecting and negotiating our claims.

It’s not difficult to imagine how much more effective my care could be and how much safer, healthier, happier my patients would be if we spent a fraction of the money earned by insurance companies on actual health care.

I realize my view and expectations of a single payer universal health care system are probably oversimplified and even naive. I understand any proposed plan may increase taxes for some, even me, while lowering out-of-pocket costs for most Minnesota families. Currently, Governor Dayton has created the Minnesota Health Care Financing Task Force to evaluate and make recommendations for how Minnesota can increase access to care and the health of its citizens.

Our country started Medicare 50 years ago with the same objectives. It has been wildly successful for our population over age 65 and has increased coverage to younger individuals over time: In the 1970s we added long-term disability and end-stage renal disease. In the 1980s we added hospice care. In the 1990s and 2000s prescription drug coverage and those affected with ALS.[5] These Medicare expansions demonstrate that we see value in universal health coverage for many U.S. citizens. I am confident Minnesota could create a system which is fiscally responsible and able to fulfill all Minnesotans’ health needs.

As a physician, I believe in good health and good health care for all our community members. As an OB/Gyn physician, I believe in good health and health care for our women. I believe providing women with attainable, equitable health results in healthier families and societies.

We’ve been told over and over our current system is not sustainable. We know our outcomes are not improving. We know our patients are dissatisfied with their current costs and coverage. We know insurance executives earn a salary much greater than ours. We know our hospitals barely stay afloat and cannot invest in basic infrastructure.

We know something has to change. Let’s do it in the right way. Let’s change it for the better.

Carrie Ann Terrell, M.D., FACOG, Assistant Professor and Division Director General OB-GYN at the University of Minnesota.


1. Nicholas J Kasselbaum, M.D. et al. Global, regional and national levels of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet, Volume 384, Issue 9947, 13-19 September 2014, pages 980-1004.
2. Cost and Economic Impact Analysis of a Single-Payer Plan in Minnesota. Prepared for Growth & Justice. Submitted by: John Sheils and Megan Cole – The Lewin Group.
3. Steffie Woolhandler, M.D., M.P.H., Terrie Campbell, M.H.A., and David U. Himmelstein, M.D. Costs of Health Care Administration in the United States and Canada. N Engl J Med 2003;349:768-75.
4. Dante Morra, Sean Nicholson, Wendy Levinson, David N. Gans, Terry Hammons and Lawrence P. Casalino. U.S. Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting with Payers. Health Aff August 2011 10.1377/hlthaff.2010.0898.
5. Thomas R Oliver, Philip R Lee and Helene L Lipton. A Political History of Medicare and Prescription Drug Coverage. Milbank Q. 2004 June; 82(2): 283- 354. doi:10.1111/j.0887-378X.2004.00311.x PMCID: PMC2690175.
6. D.U. Himmelstein, M. Jun, R. Busse et al., A Comparison of Hospital Administrative Costs in Eight Nations: U.S. Costs Exceed All Others by Far. Health Affairs, Sept. 2014 33(9):1586-94.