Health Beat: The Single-Payer System – Maybe it’s Time for Another Look

Could the billions of dollars America spends on health care be allotted more efficiently, with better service for patients?

By Kathleen Kozak, M.D.
Honolulu Civil Beat, May 20, 2015

All across the nation, health insurance exchanges are facing some difficult financial realities. Right here at home, the Hawaii Health Connector has already announced a contingency plan for ceasing operations and deferring the management of the insurance exchange to the federal government as of Sept. 30.

The main reason is money. It’s very expensive to run the IT platform and also deal with all of the intricacies of the different insurance plans and their rules. The Health Connector is not sustainable the way it is run now.

The billions of dollars that are spent on health insurance make the industry very profitable. But for whom?

The insurance industry has operating costs, and after paying their CEO millions of dollars, their chief executives, their presidents, vice presidents, secretaries, and even low-paid clerks, everyone gets a piece of the premiums. After all is said and done, there are millions of dollars spent on things other than actual care for the sick. That’s not even looking at what’s paid to hospitals, pharmacies and doctors like me.

What might streamline the health care costs now and into the near future? Well, when I first started in practice, I abhorred the idea, but perhaps a single-payer system might be the best solution after all.

Under a single-payer system, all residents nationwide would be covered for all medically necessary services, including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs.

I’m all about free choice, and want people to have options, but from what I see right now, insurance companies make most of the decisions regarding care anyway.

Take medications. Each insurance plan contracts with different pharmaceutical companies to provide preferred drugs at a cheaper cost. Technically, the insurance plan didn’t say someone can’t have his or her brand name drug to treat, say, high blood pressure, but that the cost would be so large each month that people are financially forced to choose the drug that is preferred on the insurance formulary.

Every January when the formularies change, I have dozens of patients calling to change their medicine because their insurance picked a different preferred drug for their medical condition, and they want to change their pills and save money. Medically this doesn’t make sense. Generic medicine is cheap, but even that has a high co-pay if it’s not preferred. Why have such a system? Because it saves money for the insurance companies to have most of their market share taking certain medications to guarantee a lower cost for the pills.

As for diagnostic testing, well, these days insurance plans require pre-authorization for most testing to be completed, and that doesn’t happen immediately. All the notes from the visit have to be done immediately, making other patients wait for paperwork. The staff  has to call a 1-800 number for the company, and plead its case. The insurance company has to process the request and then get approval from its own selection of decision-makers, who may or may not be doctors, nurses, or even medically trained. So the patient waits.

If it takes too long, and the patient is getting worse, then there is only one option. Go to the emergency room where prior authorization isn’t needed anymore. Testing can be done without any pre-approval and the patient can be taken care of immediately. But if the ER visit is considered medically unnecessary, it might not be covered by insurance. Who has to pay the bill? The patients, who already paid their insurance premium to give them coverage for scans and tests that their doctor recommends, but now can’t do.

So what might be the benefit of a single-payer system? Am I the only one who thinks this is a good idea? Not according to a recent poll. Fifty percent of those surveyed supported such a system.

First of all, it would eliminate the confusion of the different rules that each insurance carrier operates under. It would streamline paperwork because there would only be one system to deal with. Costly executives with high salarie? Well, they would have no role.

Perhaps the issue of drug formularies could be fixed. Instead of picking one medicine for a certain patient who has HMSA, another for someone with Humana, and a different one for Medicaid or Quest, patients could be treated with the most effective medicine available for their condition.

Instead of having to check a spreadsheet of each test that requires prior authorization from each different insurance company, if patients need a CT scan, they could just have it done. Right now we delay those who need approval and fast-track those who can just have their scan done anytime.

Health Maintenance Organizations could go away. Why should people be forced to see only doctors at one facility just because their insurance says so? I know specialists at other medical centers that have more expertise than some of the ones I work with, but HMO patients can’t see them if we have the same specialty here, unless that doctor recommends it, too. Again, another barrier to getting the care that patients need by the doctors they need it from.

A single-payer system doesn’t have to be the government, but it should be truly non-profit, so that any extra money is put back into the system, not paid to shareholders or as bonuses to executives. It could also be one of the ways to put the power back into the patients’ hands and even provide a platform for their medical records to be available to any doctor who sees them through some type of insurance portal. No more duplication of tests because it’s all available to all providers, not just those at a certain medical facility, like what happens now.

Years ago, when one of my colleagues said he supported a single-payer system, I thought he was nuts, a maverick, going against the norm, bucking the status quo. Now I see that he just had a lot more expertise with the inefficiencies and inequities of the health care system than I did at the time. But I’ve caught up, and really see a value of eliminating the very system I work in, because in the end, all of us just want good quality care and less hassle when we are sick, so we can focus our energies on getting better, not going broke paying for it. 

Kathleen Kozak, M.D., is an internal medicine physician at Straub Clinic and Hospital. She is also the host of The Body Show on Hawaii Public Radio.