By Dr. Sudip Bose, MD, FACEP, FAAEM
You’ve likely heard the term “single-payer” used during the course of discussions of how to solve the problems America is having in ironing out a healthcare system that works for all the people.
I’ve had some experience in a single-payer system of healthcare – the US military. I trained and worked in single-payer for over a decade when I was an Army doctor. I was both patient and provider. And I’ve got one thing to say about it: Don’t be disillusioned. Single-payer is not something that will solve all our healthcare concerns. It’s one option being discussed, but it’s not the golden ticket, if you will. Nothing is, actually. It certainly has its advantages, but there also are disadvantages that the American public may not like. There are good things and bad things about almost any healthcare proposal. It seems to me that in America, we’re at a crossroads of looking for the lesser of evils when it comes to healthcare.
So let’s look at the good, the bad and the ugly as it relates to a single-payer system.
Let’s start out by defining what single-payer healthcare is. This explanation that you can find on Wikipedia seems as good as any:
“Single-payer healthcare is a healthcare system financed by taxes that covers the costs of essential healthcare for all residents, with costs covered by a single public system (hence ‘single-payer’). Alternatively, a multi-payer system is one in which private individuals or their employers buy health insurance or healthcare services from multiple private or public providers.’
Also, there’s this one from the group, Physicians for a National Health Program (PNHP):
“Single-payer national health insurance, also known as “Medicare for all,” is a system in which a single public or quasi-public agency organizes healthcare financing, but the delivery of care remains largely in private hands. Under a single-payer system, all residents of the U.S. would be covered for all medically necessary services, including doctor, hospital, preventive, long-term care, mental health, reproductive healthcare, dental, vision, prescription drug and medical supply costs.’
Healthcare for all! No real options to worry about – just get treatment for what’s wrong until it’s made right, no confusion, everything and everyone is considered equal in the eyes of the single-payer system. You can think of it also as universal healthcare. So theoretically, everyone in the US would be able to see a doctor, go to a hospital, have preventative as well as long-term care taken care of, be treated for dental, vision, mental health and reproductive problems – also all Americans would have access to prescription medications as well as medical supplies (crutches, wheel chairs, oxygen machines and other such medical devices). Think of single-payer, or universal healthcare, as being a right that everyone has – not a privilege.
With that in mind, what many who support a single-payer system say is that coverage would be able to be provided at a fraction of the cost while maintaining similar medical outcomes. Saving money is a good thing. Also, proponents of the single-payer system say that people would not lose coverage when a change in their work or economic situation happens – say through a job loss or if their income diminishes in some other way.
The single-payer system theoretically would preserve the current way services are delivered – through independent doctors, hospitals and other medical providers. Proponents say that unlike socialized medicine — a system in which the government owns the medical facilities and employs the healthcare providers — the single-payer system maintains healthcare delivery as we know it today – but without the added stress and financial burden of a patient figuring out how to pay for it. Again, they point to Medicare as an example of the single-payer healthcare delivery system. (Although, remember that Medicare covers only 80 percent of the total cost of a hospital visit and doctor fees – if you opt in for both Parts A and B — and does not cover dental or vision care nor does it cover prescription medications.)
Looking at it from a proverbial “10,000-foot view” though, it looks pretty good.
Ah, but the devil is in the details. Let’s look more closely at those definitions of single-payer. Single-payer is “financed by taxes” also known as “Medicare for all.” Uh-oh. Forced payment by the federal government – taxes. We’re already having money set aside from our paychecks for income tax; we’re also having money set aside for Social Security, and for Medicare. And that forced purchase of Obamacare was one of the plan’s chief push-backs – that you can’t force American citizens to buy something they don’t want or say they don’t need. Now we’ve got to factor in this single-payer system. How much will that cost be to each American citizen? And what about people not in the work force, or younger citizens who aren’t working yet, or those who don’t have a job or can’t find one, or who don’t want one. What about those who can’t work due to some disability? How is that evened out? Lots of questions that will require answers, which will be controversial for sure.
Also, you’ll note in the definition that a key word used there is “essential.” Who is the judge of what that actually means? A broken bone? Yep, easy – gotta fix that. That one’s pretty obvious. But, for example, if someone hopes to have surgery on their neck or back to repair or fuse vertebrae that are pinching nerves and causing extremity numbness, loss of use, and/or pain – is that an “essential” surgery? Many would say yes, but there are many others who would point to statistics and outcomes for that kind of surgery and say no. The data on successful spinal surgery for something like that is overwhelmingly ambiguous. It works sometimes, it doesn’t work other times. But for a person who is convinced that this type of surgery would work for them, based on information they’ve gleaned from a variety of sources, especially their own doctors, it would be hard to persuade them that it’s not an essential surgery.
It’s also well known that single-payer systems in other countries ration care – sometimes, even often times, arbitrarily. If you think about it, a person who has to pay for healthcare each and every time they visit a doctor or a hospital ends up self-rationing their care. They know there will be a cost associated with their care and may opt to “tough it out” or play doctor themselves and self-diagnose because they don’t want to incur cost. Most people have a sense of when something related to their health escalates to the point where they know they should see a doctor, and when they can forgo a doctor visit. But when there’s no cost associated with seeking medical care – at least no immediate cost for a visit even though you’re paying taxes into the system to support universal care – people will seek a doctor’s care without thinking twice, which could overwhelm the system. And since a single-payer patient doesn’t ration healthcare by price, one of the ways it gets rationed is by the resulting long wait times.
In Canada, for example, that’s exactly what’s happening. The system there relies on long wait times to stem demand.
Think about this. Under single-payer, the government effectively becomes your insurer. Do you really want them to decide what medical care you qualify for or whether you’re even eligible to receive life-saving medical care at all? There’s a term that I’ve heard used by other doctors – one that I’m sure is disconcerting for a patient or a patient’s loved one to hear while referring to that patient – and that term is, “salvageable.” That word applies to a key concept in medical decision-making regarding a patient’s overall status (health, age, mental state, etc.) and whether or not something should be done to intervene medically to save that person’s life. Think in terms of a transplant — perhaps a kidney or liver transplant, or lungs or a heart. Do you really want the federal government determining whether or not you can make it over the bar they set as someone who is “salvageable”? What about my 65-year-old friend who recently received lungs from a donor after he was hospitalized for more than a month in intensive care because his lungs were fibrosing at a rapid rate? Under single-payer care overseen by the government, would he have been deemed as “salvageable”? If so, would he have gotten the life-saving transplant he received under his current insurance in time, before he died?
Let’s look at Medicaid as an example. Medicaid is a healthcare program extended to qualifying citizens who are unable to afford any other type of healthcare. Obamacare – the Affordable Healthcare Act – provided for an expansion of Medicaid at the federal level, and some states opted into it, some did not. Illinois is one of those states that did. In former President Obama’s own state of Illinois, 742 people seeking treatment under Medicaid died while waiting for medical care.
We can look to other countries that have implemented universal health care, such as Canada, England, France and others, and find story after story of people being not cared for because the system simply becomes overloaded at times. That’s been one of the key complaints – that patients can’t get the care they need in time for it to make a difference. Patients have been stuck in ambulances for hours on end – not even being seen by emergency department personnel – because there were no beds available to put them in. An 82-year-old Welshman who fell waited 8 hours on the floor after calling for medical help before an ambulance was able to get to him. Patients have died waiting for treatment. In an article written for the Huffington Post several years ago, writer Bacchus Barua made this point regarding lengthening waiting times in Canada:
“Since 1993, the average wait for treatment has almost doubled (to 18.2 weeks in 2013), per capita public healthcare expenditures have increased by about 40 per cent (after adjusting for inflation), and it is becoming increasingly apparent that patients are suffering the consequences.’
And yet, there is no real indication that politicians intend to introduce meaningful reforms to solve this problem.
The late prime minister of England, Margaret Thatcher, said something once that is a bit sobering as it relates to universal, government-controlled medical care and the taxpayers who fund it. She said, “The trouble with Socialism is that eventually you run out of other people’s money.”
Something to think about.
Let’s talk about doctors for a sec. Let’s talk about nurses, clinicians, technicians, admin, transport – anyone and everyone who works in a healthcare capacity, whether that’s in a private practice, a hospital, a specialty care center, wherever. They have taken on years of schooling and have gotten a massive amount of experience in caring for people and understanding how to help people get better and save lives. What becomes of them? Are they then governed by a federally implemented pay system regarding how much a particular medical procedure (a visit, an exam, treatment, surgery, etc.) will cost and how much they will earn? Are they capped at a specific number of patients that can be seen over a specific amount of time? For example, will the federal government impose a strict quota system on doctors, not allowing them to see more than X number of patients in a day? How will that work, exactly? And would that have a chilling effect on people wanting to enter into medical professions? Will we as a nation be able to keep up with patient demand and need?
To a large degree, doctors are entrepreneurs. They get their medical degrees, do their internships, residencies and get hospital privileges to attend to and see patients. They may join or form a group of physicians or strike out on their own. They earn a living based on the kind of medicine they practice, their experience level, and the number of patients they see in a day, week or a month. The more patients they see, the more money they make. There’s a debate that needs to happen related to a single-payer system related to essentially “capping,” the number of patients a physician can see.
Perhaps the answer lies somewhere else. Perhaps in a sort of mash-up of systems that combines the non-profit, for-profit and private healthcare delivery models would work. You could choose a main item off the menu as your entrée, and then select some a la carte items to supplement, as you would at a restaurant, depending upon your personal health and financial situations.
There are a lot of moving parts even in what is often seen as a relatively simple single-payer system. Is it really right for America? Let’s see how the discussion goes and this healthcare subject evolves.