Making the Case for a Single-Payer System

EDITOR’S NOTE: As congressional Republicans and the Trump administration grapple with challenges associated with their efforts to repeal and replace the Patient Protection and Affordable Care Act, talk continues to swirl about the possibility of a single-payer healthcare system. In this exclusive story, Howard Stein offers his personal opinion in making the case for doing just that.

There is daily discussion on the replacement plan for the Patient Protection and Affordable Care Act (PPACA), popularly known as Obamacare. Most would agree that the only positives to emanate from the PPACA were the elimination of denial of coverage for preexisting conditions and insuring millions who otherwise could not afford or acquire insurance (albeit with bargain-basement policies). Original Republican replacement bills proposed less-than-palatable alternatives.

Those who work daily in our current healthcare system know many of its deficiencies. American healthcare costs too much and provides average quality of care. Currently, the World Health Organization (WHO) lists America as having the 37th best healthcare system in the world. We spend roughly double the cost to care for each individual, compared to top-rated health systems. There are several factors that contribute to the high cost:

1. Lack of tort reform: Physicians and hospitals continue to be peppered by frivolous lawsuits. We now have a generation of physicians that practice defensive medicine, ordering unnecessary medical testing to cover their backsides. Some of these excessive tests actually can cause harm to patients, driving costs up further. Physicians are taught to do a thorough history and physical exam on each patient and evaluate for the likely causes of conditions. Many physicians quickly change their practice habits to order testing to decrease the chances of a lawsuit being filed, even if it does not result in finding the cause of the patient’s original complaint. Tort reform would permit physicians to practice evidence-based medicine, as they were trained. This would reduce cost and improve quality.
2. Elimination of health insurance companies: Most health insurance companies are businesses that seek to turn a profit for their shareholders and amass immense bonuses for their executives. This profit comes off the back of doctors, hospitals, and patients’ premiums. Health insurance companies have amassed armies of workers performing “utilization review,” providing roadblocks for providers to be paid and attempting to reduce testing/ care for patients. Health insurance companies run at approximately a 20-percent overhead. There is a huge pot of money that could be better spent in healthcare. Health insurance companies also do not cover millions of Americans, leaving that to taxpayers and government programs.
3. Cost of medical education: Physicians graduate with large educational debts. Many owe at least $350,000. In an attempt to recoup these monies, graduates flock to procedure-related specialties rather than fill the true needs in primary care. American healthcare is just beginning its transition from volume to value, but this will not occur fast enough for current graduates.
4. Unlimited end-of-life care: A large percentage of healthcare costs occur in the last six months of life. Without tort reform, many physicians will continue to feel compelled to continue expensive and sometimes futile care rather than comfort or palliative care. Hospice is still underutilized. Many families elect to continue expensive end-of-life care, as they have little or no financial skin in the game. Many physicians lack the skills required for effective end-of-life discussions with loved ones.

The countries with the top-rated healthcare systems utilize a single-payer system. Currently, France is the top-rated system, followed by Italy. They spend less than half of what we do in America per patient and hit significantly higher quality metrics. The common features of these single-payer systems that lead to success are as follows:

1. Tort reform: Short of a filing associated with an egregious act, there are essentially no medical malpractice lawsuits. Physicians can practice evidence-based medicine, as they were taught. Excessive medical testing is the exception. As there is less care, there is less harm to patients.
2. Government-run care: The government insures all citizens and immigrants. There is essentially no charity care or uncompensated care, as we wrestle with in America. All citizens have the same benefits. Cost-sharing is common, which puts financial skin in the game for patients. Many countries have insurance companies as “secondary carriers” to provide private care, if desired by the patient. America could copy this model or privatize the single-payer system.
3. Medical education: Most countries pay the tuition of medical students. Graduates can select specialties based on the country’s deficiencies, as all specialists are paid similarly.
4. End-of-life care: With tort reform, there is no incentive for physicians to promote futile end-of-life care. Physicians are educated on end-of-life family discussions, and the patients and their families seem to understand that if a disease/ condition is causing the end of life, there should not be a decision by a long-lost cousin who appears at the ICU bedside. Hospice care and comfort care, provided at home, are common.

The Medicare Trust Fund will be exhausted in as little as 10 years. Attempts at reducing cost via Accountable Care Organizations (ACOs), value-based population health, and physician health organizations are all steps in the right direction, but I fear it is too little, too late. A single-payer system will not be a welcome plan among Americans who are used to unlimited care. These healthcare systems in countries around the world are not flawless, yet no other better ideas have been brought forward.

I fear if we do not have the courage to act soon, we will endure far worse healthcare before a single-payer system is proposed and initiated.