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For
Against
Single-Payer System: Why It Would Save US Healthcare
Leigh Page
|September 29, 2015
Why America Should Have a Single-Payer System
Donald Berwick, MD, helped launch the Affordable Care Act (ACA)—considered at the time to be the only health reform this country would need—when he was administrator of the Centers for Medicare & Medicaid Services (CMS) in 2010 to 2011.
But 5 years later, Dr Berwick and millions of other Americans are calling for a new round of reform that would involve much deeper changes: a single-payer system. Dr Berwick says he still supports the ACA—"It's been a step forward for the country," he says—but adds, "The ACA does not deal with problem of waste and complexity in the system."
Other single-payer advocates are less forgiving. They think that the ACA has pampered the commercial insurance industry, providing it with millions more customers and allowing it to jack up charges to levels that fewer Americans can afford.
The single payer would be the US government.
Single-payer reform would take an audacious step. It would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a work force of 470,000—and replace it with one unified payer. A small vestige of the industry would remain to cover nonessential services, such as LASIK surgery.
Advocates often envision a single-payer system as an expansion of Medicare, or "Medicare for all." Single-payer systems in Canada, Australia, Denmark, Norway, and Sweden—as well as other types of centrally run systems—have much lower per capita health spending and generally better health outcomes than the United States.[1] However, this is also true for non–single-payer systems outside of the United States. The United States simply has the highest healthcare costs, regardless of the system.
The single-payer approach has a moral argument—that everyone should have a right to healthcare—but it also has a practical argument, says James Burdick, MD, a transplant surgeon at Johns Hopkins University School of Medicine and author of Talking About SINGLE PAYER!, which will be published later this year. "It's a more economical way to use healthcare resources," Dr Burdick says. "You could reduce expenses and still improve quality. That's a tremendous opportunity that you don't have in many other fields."
According to a 2014 study,[2] the new, streamlined system would save US healthcare $375 billion per year, owing mainly to removal of the inefficient administrative costs of multiple payers. The authors calculated that the savings would cover millions of people who are still uninsured and terminate high deductibles and other out-of-pocket costs levied by commercial insurers.
Restoring Doctors' Authority
Terrence McAllister, a pediatrician with a solo practice in Plymouth, Massachusetts, thinks that a single-payer system would restore the medical profession's independence and authority. Dealing with multiple commercial insurers makes it very difficult to be independent. "The profession is becoming more and more dependent on employment, and that usually means serving the needs of hospitals," he says.
Dr McAllister's wife, Leann, who administers the practice, sees a renaissance for small practices under a single-payer system. In the United States, small practices often have to make do with lower reimbursements because they lack negotiating leverage with insurers. There are no such negotiations in a single-payer system. "I could build a business plan with far more certainty," she says.
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 say.
Under the Canadian single-payer system, physicians turn in a slip of paper for each encounter. Dr Burdick says that a Canadian orthopedic surgeon who moved from the United States told him he was greatly relieved to no longer have an extra room in the back for coding clerks and claims files. "I fill out the chits for each encounter, and my secretary bundles them up and sends them in," he told Dr Burdick. Indeed, a 2011 study[3] found that US doctors spend almost four times more money dealing with payers than do doctors in Ontario, Canada.
Dr Berwick did not support a single-payer system until late 2013—several months into his campaign to be the Democratic nominee for governor of Massachusetts, his first foray into electoral politics. While campaigning, "I became more and more familiar with all the obstacles people faced in education, housing, and employment," he says. "I concluded that our healthcare system takes money away from these things."
He thinks a single-payer approach could clean up a highly inefficient system. "There is too much complexity and administrative hassle in our healthcare system," he says. "We need to simplify the payment structure."
Evidence of Growing Physician Support
Dr Berwick lost the primary in September 2014, but during the campaign, he saw his single-payer message resonate with doctors. It definitely did so with the McAllisters. "He helped solidify our support for a single-payer system," Leann McAllister recalls. In March, Dr McAllister joined Physicians for a National Health Program (PNHP), a single-payer advocacy group that has more than 19,000 members nationwide.
Are more doctors flocking to support a single-payer approach? The only known recent poll of doctors is a 2014 survey of Maine physicians[4] conducted for the Maine Medical Association (MMA). The poll found that nearly 65% of MMA members preferred the single-payer option over trying to fix the current system—up from 52% in a 2008 survey.
The MMA 2014 survey showed that a single-payer system is especially popular among primary care and employed physicians. For example, more than three quarters of family physicians endorsed a single-payer system, compared with one third of radiologists. And whereas only 40.7% of physicians at fully physician-owned practices endorsed single-payer, 72.6% of those in fully hospital-operated practices did so.
Physicians seem more open to a single-payer system as the profession moves toward the Democrat Party, a stronghold of support for this idea. According to a study[5] published in July, 55% of doctors making political contributions in the 2013-2014 election cycle gave to Democrats. That's a substantial change from 18 years earlier, when 72% of contributing doctors gave to Republicans.
Proponents say there are plenty of reasons for doctors to like the single-payer approach. In addition to restoring physicians' authority and simplifying claims, Dr McAllister says that a single-payer system would simplify the clinical process, thereby boosting the quality of care. "From a clinical perspective, the main advantage is that I don't have to consider which insurance the patient has and make my plans for patients on the basis of that," he says.
It is also being claimed that a single-payer system may reduce malpractice litigation. There might not be a need to file a lawsuit to get future medical care, because a single payer would cover it. Still, it would not cover pain and suffering or economic damage.
Americans Are Warming Up to Single-Payer
There are signs that the public is also warming up to a single-payer system. A slight majority of Americans (51%) support Medicare for all, according to a national poll[7] released in January for the Progressive Change Institute. The survey also found, however, that more than one third oppose Medicare for all. Also, there is a wide partisan divide. Whereas 79% of Democrats supported a single-payer system, only 23% of Republicans did so.
Interest in single-payer may continue to grow, owing to the rise of high deductibles and other out-of-pocket costs for patients, according to Steffie Woolhandler, MD, a Harvard internist and cofounder of the PNHP. Although the ACA expanded coverage to millions more Americans, she says it also accelerated the trend toward high deductibles. "Now people with insurance are finding that they can't afford to use it," she says. (The assumption is that a single-payer system will not include high deductibles.)
A study[8] released by the Commonwealth Fund in May found that the proportion of US adults with high deductibles tripled from 2003 to 2014. It estimated that almost one quarter of insured US adults had such high out-of-pocket costs relative to their incomes that they were deemed to be underinsured. One half of this population reported problems with medical bills or debt, and more than 2 of 5 said that they didn't seek needed care because of the cost.
"The trend in this nation is to shift the costs of healthcare more and more onto individual families," Dr Berwick says. "High deductibles take money out of people's pockets under the guise of personal responsibility. There is a great shift of wealth away from the middle class and working people."
Dr Woolhandler says it may take years for many Americans with high deductibles to understand just how toxic they are. "People might need to have a major medical event to see how badly the system is failing them," she says.
Leann McAllister makes an analogy to parents who deny pediatric vaccines until they understand that their own child could die without them. "Americans are often motivated by fear," she says. "They may react only when they see that our healthcare system could fall apart."
The Massachusetts practice administrator also says that high deductibles produce an imbalance in physician supply. In less wealthy areas, such as Plymouth, she says, patients faced with large out-of-pocket expenses simply forgo care, permanently reducing demand for doctors. She says no new physicians have come into the area for many years, despite a growing population.
Movement May Start on the State Level
The movement encountered a setback last December 2014, when Vermont pulled the plug on its single-payer initiative, the only one in the nation. The Vermont governor cited high projected costs for businesses and taxpayers, which cooled Vermonters' enthusiasm and almost lost him his reelection bid the month before.
Dr Berwick says it's only a temporary setback. "What happened in Vermont gives us lessons for the next wave of efforts," he says. Advocates within the state are already working on new approaches. Deborah Richter, MD, a family physician in Berlin, Vermont, and a leader of the state's single-payer movement, says she is working with legislators on a plan to publicly fund primary care activities only, and fold in specialists later. "We realize that you can't just flip the switch and suddenly have a single-payer system," she says.
The Vermont setback shows that people need to gain a better understanding of how a single-payer system would work, Dr Berwick adds. Although taxes and fees would rise substantially to pay for the system, these costs are less than what people had to pay for their own insurance. Businesses that already cover their employees would also see lower costs owing to efficiencies.
Dr Berwick thinks it's possible that single-payer systems will initially emerge at the state level. "The current polarization in Washington makes it difficult to enact it on the federal level right now," he says. Dr Richter likes the idea of state-operated systems within a national system, similar to the way in which Canada's single-payer system is run by each province. The federal government would determine what services are covered, and each state would determine reimbursement levels.
Dr McAllister, however, doubts that a one-state single-payer system would work well. He recalls that when Massachusetts instituted its own pre-ACA version of health reform, out-of-state patients flocked to emergency departments there, driving up the program's costs.
Public Distrust Must Still Be Overcome
One potential barrier for the movement is the public's abiding mistrust of government. "A very big obstacle to progressing this policy is the widespread perception that government is unable to solve problems," Dr Berwick told a national meeting of the PHNP last November.[9] "We need to make the case that government can solve problems and manage its business well."
Dr Berwick and others in the movement see government as a mechanism for doing good. "Trying to make government look less functional, that's the agenda on the right," he says. But if anti-government attitudes prove insurmountable, he thinks that a single-payer operation could be handed over to an independent board.
Leann McAllister said that another unfair criticism of single-payer is that it would be bureaucratic. "We have an even bigger bureaucracy with commercial insurers," she says. "They have plenty of unnecessary rules." For instance, when patients in her practice move to a different plan, they sometimes are assigned a new doctor, even though her husband is in-network. "It takes a lot of paperwork to correct that," she says.
Another potential downside that is cited for a single-payer system is waiting lists for elective procedures, such as those for hip and knee operations in Canada. The problem exists, but it's "way overstated," Dr Berwick says. "The fact is that Canadians wouldn't trade their system for ours."
Dr Burdick asserts that comparisons between US and Canadian waiting lists are unfair, because Canada scrupulously measures its waits and we don't. "We know the numbers of Canadians on waiting lists because they are counted, but no one keeps track of how long you have to wait for care in the United States," he says.
Dr Richter also discounts critics' tales of a vast movement of Canadians to the United States to receive care denied back home. Most Canadians who get care in the States, she asserts, fell ill or had accidents while visiting.
What Would It Be Like for Doctors?
It's hard to predict exactly how a single-payer system would affect US doctors, because it could be implemented in a variety of different ways. For example, Canadian doctors get fee-for-service payments, but Dr Berwick says US doctors could instead receive value-based payments, which Medicare is moving toward.
"There is really a wide range of choices," says the former CMS administrator, who helped develop value-based payments for Medicare. "A global payment or capitated payment system could be quite flexible. This would allow funds to be easily shifted to where they're most needed."
Many specialists are concerned that their reimbursements would be slashed under a single-payer system, but Dr Burdick says that this doesn't have to happen. "The spending problem in US healthcare does not really have to do with physician reimbursements," he says. "It has to do with the payments that physicians are generating."
Dr Burdick added that services covered by a single-payer system could be determined by a board of experts, like the United Kingdom's National Institute for Health and Care Excellence (NICE). He wants the US board to be dominated by physicians—as NICE is—but it should also be completely independent of political influence, which he says NICE is not.
Dr Berwick agrees that physicians should have a central role on policy-making committees. "Doctors would have a voice in the terms of their work, and rules for paying them would have to be maintained in a fair way," he says. "Right now, nobody knows how fees are set, and most doctors don't at all feel that they're in the driver's seat."
Dr Berwick is also a strong proponent of use of outcomes and quality data, as well as use of electronic medical records (EMRs). "Data would be an integral part of a single-payer system," he says. "This is already going on with commercial payers, and they are using data in ways that are not accountable or transparent. You need rules so that the data aren't misused and there are privacy protections."
Under a single-payer system, EMRs would be simpler to use and there would be fewer data-reporting requirements, Dr Berwick says. "Right now, doctors are driven crazy by multiple reporting and payment structures," he says. "It's very complicated and highly demoralizing. A single-payer system would be a lot simpler."
Conclusion
Dr Woolhandler says more work is needed before the United States embraces a single-payer system. "We have to get the word out about problems in the current system, and the ability of a single-payer system to resolve them," she says. "And we need good political leadership that can explain the advantages. Political challenges in Washington make it very challenging to adopt a single-payer system right now, but the situation could change rapidly. Look at the late 1950s. Who could have predicted all the reforms that happened the 1960s?"
References
1. Commonwealth Fund. Mirror, mirror on the wall, 2014 update: how the U.S. health care system compares internationally. June 16, 2014. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally Accessed September 1, 2015.
2. Jiwani A, Himmelstein D, Woolhandler S, Kahn JG. Billing and insurance-related administrative costs in United States' health care: synthesis of micro-costing evidence. BMC Health Serv Res. 2014;14:556. http://www.biomedcentral.com/content/pdf/s12913-014-0556-7.pdf Accessed September 1, 2015.
3. Morra D, Nicholson S, Levinson W, Gans DN, Hammons T, Casalino LP. US physician practices versus Canadians: spending nearly four times as much money interacting with payers. Health Aff (Millwood). 2011;30:1443-1450. US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers Accessed September 1, 2015.
4. Maine Medical Association. Payment reform survey. January 2014. https://www.mainemed.com/sites/default/files/content/Payment Reform Survey - (Crescendo).pdf Accessed September 1, 2015.
5. Bonica A, Rosenthal H, Rothman DJ. The political alignment of US physicians: an update including campaign contributions to the congressional midterm elections in 2014. JAMA Intern Med. 2015;175:1236-1237. http://archinte.jamanetwork.com/article.aspx?articleid=2278948 Accessed September 1, 2015.
6. Anderson GF, Hussey PS, Frogner BK, Waters HR. Health spending in the United States and the rest of the industrialized world. Health Aff (Millwood). 2005;24:903-914. Health Spending In The United States And The Rest Of The Industrialized World Accessed September 1, 2015.
7. Progressive Change Institute. Poll of likely 2016 voters. January 2015. https://s3.amazonaws.com/s3.boldprogressives.org/images/Big_Ideas-Polling_PDF-1.pdf Accessed September 1, 2015.
8. Collins R, Rasmussen P, Beutel S, et al. The problem of underinsurance and how rising deductibles will make it worse. Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2014. Commonwealth Fund. May 20, 2015. The Problem of Underinsurance and How Rising Deductibles Will Make It Worse Accessed September 1, 2015.
9. Berwick DM. Single payer: a powerful tool for better care, better health and reduced costs. Physicians for a National Health Program. November 25, 2014. Single payer: a powerful tool for better care, better health and reduced costs | Physicians for a National Health Program Accessed September 1, 2015.
Medscape Business of Medicine © 2015 WebMD, LLC
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this article: Leigh Page. Single-Payer System: Why It Would Save US Healthcare. Medscape. Sep 29, 2015.
Against
Single-Payer System: Why It Would Ruin US Healthcare
Leigh Page
|September 29, 2015
Single-Payer Would Be Bad for Doctors
A single-payer system—government-run healthcare for all—sounds like a noble ideal, but things quickly fall apart in the execution, according to its critics.
Michel Accad, MD, a cardiologist in San Francisco, says that because a single-payer system makes healthcare virtually free, "demand is almost unlimited," and the government has to set limits on what will be provided. Dr Accad writes a blog called "Alert & Oriented," which provides alternative views on healthcare systems.
Because the offer is so open-ended, Dr Accad says that single-payer systems in Canada, the United Kingdom, and other developed countries have to impose strict central planning. Rather than leave healthcare choices up to individual physicians, their patients, and free-market forces that could balance supply with demand, the government sets the rules.
These rules, Dr Accad says, are usually based on large quantities of data—comparing costs against probable outcomes—or on political considerations, such as the need to balance budgets without raising taxes. This approach, he says, will inevitably misallocate services. When central planning allocates care, there will be shortages of some services and gluts of other services. In particular, central planners will have a difficult time keeping up with cutting-edge technology and improvements in practice patterns.
Centralized systems also underpay physicians. "In a single-payer system," Dr Accad says, "planners decide arbitrarily what the payments should be, and payments fall because there are no competitors and no choice for providers to bid up payments."
Indeed, a 2011 study[1] found that reimbursements to US primary care physicians from public payers, such as Medicare and Medicaid, were 27% higher than in countries with universal coverage, and their reimbursements from private payers were 70% higher. Meanwhile, reimbursements to US specialists were 70% higher from public payers and 120% higher from private payers.
Lack of Competition Harms Doctors
Another disturbing aspect of a single-payer system is the lack of competition among payers, which would reduce physicians' control over standards of care and reimbursement.
In a pure single-payer system, doctors can only contract with the one payer available. Currently, in the United States, physicians have some choice of insurers to work with, and even in Medicare or Medicaid, doctors can opt out. But they couldn't do so in a pure single-payer system.
"Providers remain ostensibly independent, but the single payer exercises significant controls," such as determining what services are "necessary," wrote John McClaughry, founder of the Ethan Allen Institute, a free market think-tank in Montpelier, Vermont. The single payer is a "monopoly HMO," he added.
Critics say the single-payer program might start with acceptable reimbursement rates as a way to get physician buy-in, and then ratchet them down because there is no alternative. As Dr Accad has already pointed out, the single payer can reduce reimbursements with impunity, because it has a monopoly.
Rather than restrict choices further, opponents of a single-payer system want to open up choices in the current system. "We should strike down state barriers to insurers and allow their products to be sold nationally," says Jim Geddes, MD, a trauma surgeon near Denver.
Noah N. Chelliah, MD, a cardiologist in Grand Forks, North Dakota, agrees. "Auto insurance premiums are low because insurers had to compete with each other nationwide," he says. "The same could be done for health insurance."
"When physicians become essentially employees of the government, which is what happens in a single-payer system, then everything pretty much breaks down," Dr Geddes says. "Only physicians are the best position to determine the quality of care. We're the number-one patient advocates."
However, Dr Geddes does not believe that the United States would allow complete termination of commercial insurance. He thinks there would probably be private plans that people could purchase on their own, as is the case in the United Kingdom. However, "this would lead to a two-tiered system," he says. "I've seen it in the United Kingdom, and it's not what we should have here."
Waiting Lists in Canada
Canadian Medicare, administered by each province and funded through taxes, provides healthcare to all residents, with minimal out-of-pocket payments. Private healthcare is not allowed in Canada, so Canadians on long waiting lists have to go to the United States and other counties to get expeditious care.
Waiting lists are a familiar feature of single-payer systems, especially for higher-cost or cutting-edge healthcare. According to a report[2] by the Fraser Institute, an independent think-tank in British Columbia, Canada, the median waiting time to get treatment from a specialist has doubled in the past 20 years, to 18.2 weeks. Canadian patients wait the longest for orthopedic surgery (42.2 weeks), neurosurgery (31.2 weeks), and plastic surgery (27.1 weeks).
Dr Chelliah—whose North Dakota practice is 80 miles from the Canadian border—says that many Canadian patients on waiting lists come to him and other providers in the area for care. He thinks the waiting lists are intentional. "The way I see it, the Canadian system saves money by delaying care by rationing," he says. "The net result is that people die before they finally can get their care. I know that sounds provocative, but I think it's true."
A few years ago, he noticed that a Canadian friend of his was huffing and puffing and told him he needed to get a stress test. His Canadian family physician was initially reluctant to order one but finally agreed, and then it took 3 months to get the stress test done. Even though the results were strongly positive, the man wasn't scheduled for an angiogram until the following year. The angiogram found a 99% blockage, called a "widow-maker," and he finally got a stent. "This patient could easily have died," Dr Chelliah says.
Dr Accad pointed to a recent news report[3] from Canada, in which a leukemia patient had a bone marrow donor, but she couldn't get the transplant because there wasn't a hospital bed available for her. Though the problem sounds crazy, "patients in these systems tend to accept waiting lists," he said.
Quality Problems in the British System
In Great Britain, the National Health Service (NHS), operating separately in England, Scotland, and Wales, not only finances healthcare but also owns hospitals, physician practices, and the practices of other providers of care. However, about 10% of Britons have access to private facilities paid through private insurance.
Those who want to have expedited care buy private insurance. Dr Geddes recalls that his nephew had an anterior myocardial infarction while working in London. He was first transported to a nearby NHS hospital, but they didn't have a catheter lab to treat him, so he was sent to a catheter lab at a private hospital covered by his private insurance. "He probably would have died at an NHS hospital," Dr Geddes says.
Dr Geddes believes strict government controls and impossibly long waiting lists have created a fatalistic attitude among many British doctors, and this makes the waiting lists even longer. Many years ago, he traveled to the United Kingdom to watch a British surgeon operate. The surgery team showed up at 8:00 AM and had two cases for the day. "The first case took a little too long, and afterward we had a leisurely lunch," he says. "The second patient was an open-heart case and had already been prepped, but they decided they wouldn't have enough time." The operation was postponed. "In the United States, we would have gone ahead with the second case and just stayed late," Dr Geddes said.
Scandal at the VA: the US Version of British Healthcare
The unhurried attitude of his British colleagues reminded Dr Geddes of the time he spent as a resident at two hospitals in the Veterans Health Administration, which is part of the Department of Veterans Affairs (VA). "The VA medical staff has some good doctors, especially in VAs affiliated with universities," he says. "But as a general rule, the staff has shorter work hours. They are just punching a clock."
The VA system is as close as US healthcare comes to the British system. It operates 150 hospitals and almost 1400 outpatient clinics and provides care to 8.3 million veterans a year. Like the NHS, it also has waiting lists, which involved a scandal that rocked the VA in the spring of 2014 and caused the departures of the VA secretary and the system's top health official.
For years, the VA has set limits on how long its waiting lists can be, but the number of patients has been growing well beyond the system's capacity to deal with them. It turned out that many VA staffers were fudging waiting-list numbers so that they wouldn't exceed the limit. Dr Geddes wasn't surprised. "This is a subpar healthcare system," he says. "If we introduced a single-payer system in the United States, pretty soon it would look like the VA."
"A single-payer system is about control," Dr Geddes says. "It isn't about improving healthcare. There are many ways of doing that without involving the government. It's about the need to exercise control."
Vermont Abandons Its Single-Payer Dream
In the past few years, Vermont had been the darling of single-payer advocates. The state had been planning a system called Green Mountain Care since 2011. But suddenly, in December 2014, Governor Peter Shumlin announced that the effort would be abandoned owing to the cost.
Before the governor's announcement, Green Mountain Care was expected to make money. A 2011 report by an outside consultant predicted $590 million in savings in the first year. But to get those savings, state government would have had to take over all the operations of commercial insurers, without having any experience.
In the end, Green Mountain Care was slated to cost the state $4.3 billion in 2017—almost doubling Vermont's total budget of $4.9 billion for fiscal year 2015. This would have required a payroll tax of 11.5% and a 9% tax on income.
Vermont has not entirely given up on its single-payer dream. The state is now reportedly[4] planning all-payer rate setting, in which it would set payments for Medicare, Medicaid, and private payers. This would be done through a unique federal waiver from the Centers for Medicare & Medicaid Services (CMS), but the state has not yet formally applied for it. If CMS granted the waiver, Vermont would be able to exercise the price-setting controls of a single-payer system without the costs of actually running the whole system.
But for now, the dream is over. A single-payer system was never a realistic goal, says David J. Weissgold, MD, a retinal surgeon in South Burlington, Vermont. "The plan was naive and foolhardy," he says. "It's the kind of sweeping change that plays well politically. It has inspired a lot of people, but it's a fantasy, a kind of a dream state. I never thought it would work."
The advocates of a single-payer system refused to face the grim reality of actually running such a system, even though it was there for all to see just across the border in Canada, says John McClaughry.
Faced with rationing in Canada, Vermont single-payer advocates said it was simply caused by "stingy taxpayers," he says. When a Vermont single-payer physician debated a Canadian physician who listed the system's failures, her reply was, "We're Vermonters; we can make it work," McClaughry recalls.
McClaughry, a former advisor to President Reagan and Vermont legislator, says that single-payer is a fundamentally flawed concept, focusing on the need for healthcare rather than on true demand. "Demand, initiated by patients who may not understand what they really need, will be replaced by government-controlled allocation of services on the basis of what patients are determined to reasonably need," he wrote in a policy brief.
Waning Enthusiasm for Single-Payer
The VA scandal and the demise of the Vermont plan were not the only defeats for a single-payer system in 2014. Activists in Colorado failed to get enough signatures to get a single-payer measure on the November ballot. And in Massachusetts, Donald Berwick, MD, the former CMS administrator who ran for governor on a single-payer platform, won only 21% of the vote in the Democratic primary.
Even in Europe, the heart of the single-payer movement, the concept has encountered embarrassing defeats. In Sweden, owing to access problems in the country's single-payer system, about 10% of residents have opted for private health insurance, according to the trade group for Swedish private insurers. And in Switzerland, almost two thirds of voters rejected a single-payer proposal.
In the United States, public opinion has been shifting away from support of "healthcare for all" ever since the build-up to President Obama's Affordable Care Act (ACA). Gallup reports[5] that in 2000, 59% of Americans said the nation has a duty to provide healthcare for the poor. The number peaked in 2006 at 69%, but in polls since 2009, a slight majority of Americans oppose that responsibility.
Single-payer advocates are actually a subset of those calling for universal care, which includes advocates of multipayer approaches, such as the ACA. An April 2014 Rasmussen poll[6] found that 37% of eligible voters support a single-payer system.
Why Single Payer Is Still a Threat
Even though the single-payer movement has taken a beating recently, Dr Geddes doesn't think it's going to go away. He already sees many aspects of it in Medicare and Medicaid, which depend on central planning.
Dr Geddes says that just like a single-payer system, Medicare imposes arbitrary rules created through central planning. For example, Medicare dictates that certain patients have to be in the hospital for a certain number of days before they can be referred to a rehab hospital. Often, he says, patients can be transferred earlier, but they are forced to stay in a high-cost hospital bed. "The rules actually force doctors to waste resources," he says. "That's how a single-payer system operates."
Furthermore, Dr Geddes thinks the ACA will be just a temporary stop on the way to a single-payer system. Despite cost controls in the ACA, insurance premiums are rising significantly. He believes that health insurance will eventually become unaffordable, and the US public will rise up and call for abolishing private insurance and establishing a single-payer system.
That would be the wrong way to go, Dr Geddes says. "Our private healthcare system is working," he says "We have the finest healthcare system in the world, and it continues to get better."
Even as much of the rest of the world has embraced single-payer and other forms of government-controlled healthcare, such as price controls, they are completely dependent on medical advances created by the US system, he says. Advances in pharmaceuticals, medical equipment, and many surgical techniques come from the United States, where a free market encourages entrepreneurs, Dr Geddes says.
"The incentive is potential windfall profits," he says. "But if you take it away, the whole process of innovation will cease. No other country could take up the slack." Dr Geddes is a regent of the University of Colorado, whose state-of-the-art Anschutz Medical Campus hosts biotech firms financed by venture capital firms and others.
Even within the United States, he says, Medicare and Medicaid depend on the cost shift from private payers. "The only way physicians can afford to participate in Medicare is that they get higher payment from commercial insurers," Dr Geddes says. "Single-payer advocates talk about 'Medicare for all,' but if Medicare were standing alone, it would fall flat."
References
1. Laugesen MJ, Glied SA. Higher fees paid to US physicians drive higher spending for physician services compared to other countries. Health Aff (Millwood). 2011;30:1647-1656. Higher Fees Paid To US Physicians Drive Higher Spending For Physician Services Compared To Other Countries Accessed August 20, 2015.
2. Barua B, Fathers F. Waiting your turn: wait times for health care in Canada, 2014 report. Fraser Institute. November 26, 2014. https://www.fraserinstitute.org/sites/default/files/waiting-your-turn-2014.pdf Accessed August 20, 2015.
3. CTV News. Ont. teen facing unnecessary chemo due to bed shortage may soon get transplant. August 7, 2015. http://www.ctvnews.ca/health/ont-te...ed-shortage-may-soon-get-transplant-1.2507061 Accessed August 20, 2015.
4. Goswami NP. State gets set to embark on health system overhaul. Rutland Herald. May 22, 2015. State gets set to embark on health system overhaul : Rutland Herald Online Accessed August 20, 2015.
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Cite this article: Leigh Page. Single-Payer System: Why It Would Ruin US Healthcare. Medscape. Sep 29, 2015.
