If we really want fair and less expensive health care, it’s single payer

By Samuel Dickman, M.D., and Steffie Woolhandler, M.D., M.P.H.
The Salt Lake Tribune, July 23, 2016

Americans spend twice as much for health care as Europeans or Canadians. Although our cost growth slowed recently, it's too soon to celebrate: The slowdown has made health care much less equal.

In a study in this month's Health Affairs, we found that health spending for poor and middle class Americans has stayed virtually flat since 2004, while care for the wealthiest one-fifth of families skyrocketed. By 2012, the wealthy were seeing doctors 40 percent more often than others, and the dollar value of their care exceeded that of the poor by 43 percent. For the first time since the advent of Medicare and Medicaid, the rich — who are far healthier than others — are getting the most care.

What's behind the troubling increase in health care inequality? For most Americans, copayments and deductibles are going up but incomes aren't. In job-based plans, deductibles (what patients have to pay before insurance kicks in) now average $1,318. And after that, most people still face big copayments.

As a result, many working families skip care, and those who can't often find themselves submerged in medical debt.

Overdue medical bills now account for most debts sent to collection agencies, and crowdfunding sites like GoFundMe feature thousands of pleas from families struggling to pay medical bills.

The poor face even greater obstacles. Nineteen states — Utah included — have refused Obamacare's Medicaid expansion, even though the federal government would pick up almost all of the costs. And even when states expand Medicaid, complex eligibility rules and enrollment procedures keep many needy families out, and many doctors won't accept Medicaid. Having an insurance card doesn't mean much if you can't get into a doctor's office. Of course, matters are even worse for the 29 million uninsured Americans.

The millions of Americans hit with catastrophic medical bills aren't just falling through the cracks. They're being punished by design: The system we've built cuts costs by making it more expensive to go to the doctor. Policy leaders have pushed big copayments and deductibles as the right cost-control strategy. But that strategy favors the rich; a $1,318 deductible hits low-wage workers hard, but is barely noticeable for a CEO.

Other countries use more equitable and effective cost control methods. Canada's single payer, Medicare-for-all system provides universal, first dollar coverage, and has kept costs low and quality high. It saves vast amounts by cutting out private insurance middlemen and the paperwork they inflict on doctors and hospitals and by bargaining to drive down drug prices. These measures could save Americans more than $500 billion annually, enough to cover the 29 million who remain uninsured and eliminate copayments and deductibles for everyone.

In 21st century America, wealth trumps health in determining who gets care. Single payer reform would reverse that inhumane calculus.

Samuel Dickman, M.D., is a native of Salt Lake City and is now a medical intern at San Francisco General Hospital. Steffie Woolhandler, M.D., MPH, is a professor of health policy at the City University of New York.