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With election season in full swing, the debate over the future of the United States health care system is a hot topic. Is it time for the United States to adopt a single-payer system, as James C. Mitchiner, MD, MPH, FACEP, argues here? Or, would single-payer health care be an economic disaster, as Todd B. Taylor, MD, FACEP, suggests? What do you think? Send your comments to email@example.com.
Fundamentally, single-payer insurance is about changing the way we pay for the health care we already have. By consolidating the administrative costs of some 1,200 private health plans—each of which duplicates what the others do—we’d capture economies of scale and use the savings to expand access to more people and more services. Sometimes known as Medicare-for-all, single-payer advocates for expanding and improving our existing Medicare program to provide universal, cost-effective, and comprehensive care to all Americans.
To understand how single-payer works, emergency physicians only need to contemplate their own practices since the emergency department is a de facto single-payer environment. What we do, and how we do it, is enshrined in the basic principles of single-payer financing. Our emergency departments are open to all (universality); we treat out-of-town visitors who get sick or injured while staying with family or friends (portability); we have no cost barriers to care (open access); patients, as a general rule, can pick their emergency department (freedom of choice); and we treat all patients alike, regardless of age, income, employment, or pre-existing conditions (equality and equity).
Beyond what’s already cited, single-payer would have the following salutary effects:
- Comprehensive coverage, including preventive care, dental, vision, mental health, rehabilitation, substance abuse, and long-term care
- Severance of the link between employment and health insurance
- Elimination of narrow networks and “surprise billing”
- Ability to negotiate for lower prescription drug prices
- Progressive tax financing
- Enhanced ability of domestic firms to compete globally
- Payment for mandated EMTALA services
- Reduction in medical malpractice premiums
- Support for primary care
- Mitigation of physician burnout
Single-payer proposals in the U.S. Congress (H.R. 1384, introduced by Rep. Pramila Jayapal [D-WA] and Rep. Debbie Dingell [D-MI], and S. 1804, sponsored by Sen. Bernie Sanders [I-VT]), have so far enjoyed popular support, but also have engendered potent opposition, particularly by the insurance and pharmaceutical industries. Opponents of this legislation, and of single-payer in general, focus on its supposed defects, some of which I’ll summarize below as “The Seven Myths of Single-Payer.”
Myth #1: “Single-payer is socialized medicine.” This, the most overused takedown of single-payer, has no basis in fact. “Socialized medicine” refers to a system where the government owns the hospitals and clinics, and the physicians are paid as civil servants. Our version of single-payer, on the other hand, implies public financing of care that remains privately delivered by existing hospitals and private-practice physicians, who would be paid by negotiated fee-for-service, capitation, or salary, as they are now.
Myth #2: “Single-payer is one-size-fits-all, government-controlled health care.” Given that Medicare is government-financed healthcare, I ask my emergency medicine colleagues these questions: How many times in your career have you been forced to contact the feds to get permission to admit a Medicare beneficiary? How many times have you called a consultant, only to have them tell you, “Sorry, I don’t treat Medicare patients.”? And how many calls did you get from pharmacists last year, informing you that Medicare didn’t cover the prescription you just wrote for the senior you treated in your emergency department? Now compare your answers to those you would give for your managed care patients. Yes, Medicare does have payment penalties if you don’t order aspirin for heart attacks or antibiotics for pneumonia, but these are legitimate, evidence-based therapies that have been thoroughly vetted by medical specialty organizations.
Myth #3: “Single-payer would eliminate choices.” Really? Choice of what? Most working Americans are covered by employer-based insurance, which limits your choice to a doctor or hospital that’s in-network. If you want care from a non-network provider, you have to cover the expenses out-of-pocket. Under single-payer, there’d be no such thing as “network,” and the choice of provider would be up to you.
Myth #4: “Things are so bad in Canada.” Cross-border comparisons in health care generally are driven by population-based statistics. In that sense, despite spending 55 percent of what we do on a per-capita basis, Canada has a higher life expectancy, lower infant mortality rate, and overall comparable quality metrics to the United States. Yes, Canadians do have to wait for hip or knee replacements and MRIs. But Canadians are not wait-listed for emergency procedures, and no one stands in line for an emergency aneurysm repair. Polls show that Canadians, in general, are happier with their health system than we are with ours. Canadian physicians are not emigrating to the United States in large numbers. And if we adopted a Canadian-style system and funded it to the tune of $10,000 per person, it’s likely there wouldn’t be long waits for MRIs, even if many of them were medically unnecessary.
Myth #5: “Single-payer would stifle innovation.” There is no basis for this false belief. Many of the discoveries that drive modern American medicine originated in countries with single-payer variants: CT and MRI came from the United Kingdom; laparoscopic cholecystectomy came from Germany; coronary angioplasty originated in Switzerland; and the link between H. pylori infection and peptic ulcer disease was elucidated by an Australian physician. The country with the most medical journal articles per capita is Sweden. And in the United States, the largest single funding source for medical research is the government—ie, the National Institutes of Health.
Myth #6: “Under single-payer, physicians would get paid peanuts.” My friend and chief single-payer adversary, Dr. Todd Taylor, likes to remind everyone that single-payer is a monopsony—a single buyer—which means the government would control our remuneration (as if private insurers don’t already?). But the implication that we would be paid at Medicaid rates is unfounded. First, organized medicine, at the state level, would play a major role in negotiating fee-for-service rates with the government (as is done in Canada) and reject Medicaid-level fees. Second, no serious single-payer proposal has us getting paid at Medicaid rates. And third, being paid at uniform Medicare rates would balance the decrease in fees we would have received for treating patients previously covered by commercial insurance with an increase in fees for treating patients previously covered by Medicaid and those previously uninsured.
Myth #7: “We can’t afford it.” Some studies suggest single-payer would cost much more than what we spend currently, while others conclude it would cost less. It all depends on how you measure administrative savings, reduced pharmaceutical costs, and increased utilization under single-payer. But given the enormous and growing cost of the status quo ($3.5 trillion annually), and the failure of previous reforms to control costs and fund universal coverage, perhaps the more salient question is, how can we afford not to have a single-payer system?
In summary, single-payer is government-financed care rather than government-controlled care. Thus, it is not socialized medicine any more than the federal interstate highway system is socialized transportation. The additional taxes required to finance single-payer would be levied progressively, and their financial impact would be zeroed out by the elimination of health insurance premiums, copays, coinsurance, and deductibles, providing financial advantage to an estimated 95 percent of Americans. It is well beyond time the United States joined the world’s other democracies in providing high-quality, affordable, and accessible health care to all its citizens, a goal I believe can be achieved only through a single-payer Medicare-for-all program. Single-payer appears inevitable, and I believe ACEP should play a major role in creating it.
Dr. Mitchiner is an attending physician in the emergency department at St. Joseph Mercy Hospital in Ann Arbor and Chelsea.