Opinion

It’s time for a single-payer health care system in the US. Here’s why.

There are many arguments for a single-payer system, but for us it comes down to this: the incentive structure of the current system isn’t working.

Editor’s note: This is an opinion piece; the views expressed are the authors’ own and do not necessarily represent the views of The DO or the AOA.

The Student Osteopathic Medical Association is asking the House of Delegates to take up an important question: should AOA support a “Medicare for All” single-payer health care system? Support is steadily growing in the U.S., with a majority of Americans and many physicians indicating that they support a single payer health care system.

This is a controversial topic and some may consider support for a single-payer system naive and idealistic. However, we invite you to suspend any skepticism and engage in this conversation with us.

As DOs and medical students, there is probably much more that unites us than divides us. As students, we want to work in an efficient health care system, but not one where arbitrary cost-cutting trumps clinical judgment and evidence-based approaches to care. We want to see equitable distribution of resources in health care, but when many DO students’ debt burdens are over $240,000, we also want to protect wages so that we can pay back loans and achieve financial stability.

Kate de Klerk, OMS IV

Issues in the health care space are multi-faceted and Medicare for All is not a panacea. However, we think this shift would greatly benefit both patients and providers.

A fundamentally flawed system

Health care is exceedingly complicated and prohibitively expensive for patients. Despite many positive changes introduced by the Affordable Care Act, patient satisfaction with health insurance reached a 10-year low in 2015, according to the American Consumer Satisfaction Index, with many patients reporting that they don’t understand their health plans.

Our current system is also unaffordable for many Americans. As high-deductible, high co-pay plans become the norm in health care, 29% of patients with high-deductible plans report not seeking care because of cost. A system that discourages patients from getting care when they need it is fundamentally flawed.

The current system also presents challenges for physicians. Physicians report that they are spending more time on paperwork and less time interacting with patients. In 2017, 70% of physicians reported spending more than 10 hours on administration per week, with 32% of doctors spending more than 20 hours.

Mayra Salazar, OMS III

A 2014 study estimated that billing and insurance-related costs in health care were roughly $471 billion annually, a number that has grown exponentially since the 1970s. Physicians also experience frustrating limitations placed upon them by insurance companies, with formularies dictating treatment plans, rather than medical best practices or clinical judgment.

How Medicare for All would work

The current Medicare for All plan is outlined in House (H.R. 676) and Senate (S. 1804) bills that would expand and improve Medicare. In brief, this would be a publicly funded, privately operated health care system. The system would introduce universal coverage, spreading cost and risk out among all taxpayers. It’s predicted that a majority of Americans would spend significantly less on health care each year than they currently do. The proposed system would do away with co-pays and deductibles, and patients would have autonomy when choosing their health care providers. Physicians would benefit from simplified administrative processes and have greater autonomy in treating patients.

There are many strong arguments in favor of a single-payer system, but for us it comes down to this: the incentive structure of the current system isn’t working.

Health insurance companies are by-and-large for-profit, with inherent tensions between the provision of health care and the goal of maximizing profits. A quick look at the Fortune 500 reveals that the business of health insurance is one of the most profitable industries. UnitedHealth ranks fifth on the Fortune 500, ahead of Amazon.com at #8 and Alphabet (Google) at #22.

Insurance companies are not lean operations. They are large bureaucracies that have increased inefficiency in the health care system and deprioritized health outcomes. It is thought that switching to a single payer system would save roughly $200 billion annually by eliminating overhead costs alone and also reduce billing and paperwork expenses. Rising out-of-pocket costs and decreased usage of the health care system help a company’s bottom line, but have dangerous consequences on the health of Americans.

People over profits

When compared to other developed nations, the United States consistently ranks near the bottom for most health metrics. While there are interesting disruptors entering the market, such as Oscar and Collective Health, a for-profit system will never yield the kind of efficiency and equitable distribution of health care resources that we think are possible.

A Medicare for All system is also unlikely to result in major sacrifices on the part of providers. Various economic projections suggest that, for most physicians, transitioning to a single-payer system would not significantly impact income or satisfaction in the long-term.

We think that movement toward a Medicare for All system is inevitable. Perhaps it will look different than the current bills, but there is a groundswell of support for a system that places people over profits. The question members of the AOA House of Delegates should ask themselves is, do you want to be at the forefront of this change, or will you sit back and wait for others to lead the way?

40 comments

  1. I couldn’t agree more. Its not going to happen with Republicans running the country. They claim. Competition in the marketplace drives down costs. They’re wrong, of course, but that doesn’t keep uneducated voters from believing it.

    1. That’s untrue and unneccessary. i am republican and strongly endorse the single-payer. there is support there.

    2. Stop the partisan rhetoric and start a dialog. I am republican but have the same end goal, as many others do, better and more affordable healthcare. However, there are obstacles and one of them is overcoming big businesses that profit from the way things are. That’s just the truth, but how you change that is by explaining how this could be implemented, showing a successful example (Vermont failed) and by listening to opinions of others (roughly half the country) who are fiscal conservatives without name calling and finger pointing. Get the plan together, explain how it would work and test it…

    3. Dr. Griffin, I cannot agree with more. The problem is that there are so many uneducated voters mainly in rural areas who just don’t get it. My territory coverage is Central/SE Ohio to Kentucky. They just don’t get it.

    4. I’m sorry Ellie, but if you understood “end game” politics, you would understand that was the reason for Obamacare or ACA, or whatever you want to call it. GUARANTEED to fail. However, in the interim, it was also guaranteed to throw utter chaos into the current insurance system. Now, everyone is unhappy with their insurance or lack thereof. Bottom line is, Democrats passed a law that they didn’t understand, nor apparently read, to get to the end game which is single payor coverage. It is unfortunate that it has created a lemming mentality. I would like for anyone to tell me how this country is going to pay for it? Medicare is doing so well! Nope, reality is that it is already bankrupt without further funding. Where does that come from? The same place it always comes from, the taxpayer. So Ellie, you keep your $250,000 salary, except now you get to pay 50%, 60%, more?, taxes. I would just like to understand how that is better?

    5. Nonsense! Government interference is prohibiting competition and it’s government that drove up the price and deductibles with Obamacare. Time to get the government out!

      And it’s a big fat lie that Americans support single payer. If that were true, ballot referendums on them, such as Colorado’s, a state Hillary won, would have passed or been close. It got slaughtered! Single payer is a scam not authorized by the Constitution. Do it in your own state and leave the rest of the country alone.

  2. Medicare itself is inefficient. The problem with having one payer is then they can dictate the terms to everything. I agree that insurance companies are not efficient, but it’s good to have choices. Then, doctors can’t be coerced into accepting whatever the government wants. Medical students tend to be idealists, let’s see what they say after they practice in the real world for a few years.

    1. Private and public insurance providers already dictate the terms to our care. I have watched many patients come to the hospital with preventable results of controllable disease because their formulary switched and they didn’t understand why their vital medication was suddenly far more expensive out of pocket than they could afford. The whole concept of our choices as providers is irrelevant in those cases and this effect is magnified o-n our most vulnerable populations who lack the education, understanding or perhaps even ability to communicate when they run into these problems at the pharmacy.

    2. “Private and public insurance providers already dictate the terms to our care.” At least with a single payer, organizations like the AMA can argue medical necessity with one organization rather than the fleet of different, for-profit, insurance companies with seemingly infinite different plans. Don’t immediately dismiss students. They often have a better finger on the pulse of politics and policy than the average doc.

    3. Dr. Simelscu, Amen. Some of us medical students have had a taste of the real world and understand that 100,000 a year with our current loan burdens is financially crippling. Not to mention, what will draw students with decent grades if wages are low? Medical school will turn into the law school fiasco we have now.

  3. I completely agree with the above, the time is now for the AOA to distinguish ourselves as thought leaders in the house of medicine, as we “treat the patient, not the chart”, let us truly, as an Osteopathic Profession, put the patient first in our healthcare system. The Student Osteopathic Medical Association, representing the voice of the future of Osteopathic Medicine has spoken, it is now up to the AOAs House and its members to be the change we want to see in the world!

    1. Logic, and rational evaluation of the statistics we have seen over the last ten to fifteen years strongly suggest that our student doctors are on the right side of this issue. It’s a complex problem, that will require input from our physician leaders primarily, not the insurance providers. Let’s start a national conversation to affect the changes we want as the providers/ caretakers. Educate our state and national government Representatives and Senators, especially the ones who are our patients, friends and neighbors. It will require a concerted effort from all of us, we who are recently retired, as well as those who are presently struggling with the issues of practice of which we speak.
      All physicians must speak and act “now” to begin this process. Taking no action, is actually choosing to accept the status quo.

      1. It will require, at least as importantly, inputs from the PATIENTS, as we’re the one’s paying everyone’s salaries, and suffering the consequences of the current money-grab-as-“health”-“care”-“system”. Cheers!

  4. I’m so excited to see this article on The DO and to know that a Medicare for All resolution will be heard at the AOA House of Delegates in less than a week. It’s also great to see solid resources on a subject like this that show that there is support from medical students, residents, physicians, and the general public. I think we all know that right now our healthcare system is flawed and there needs to be a change. I hope that we can all dive into this discussion at the HoD and stand behind our osteopathic philosophy and oath by choosing what is best for our patients as human beings.

  5. As a family medicine physician with several years in practice in an underserved area, I believe both the patients and physicians will benefit from a single payer system. It will eliminate much of the waste of time and money on administration.

  6. Such naive comments from “students” who have no experience with public policy or patient care. They ignore the 23 trillion dollar cost of their recommendations and “how to pay for it”. If you travel to Europe you will see the high tax rates, and creeping socialism that diminishes economic prosperity encourages stagnation and the like. Personally, I don’t trust our government with much, and definitely with total control of healthcare. Obamacare is a case in point. There is no “free lunch” for healthcare and the government is not your savior. Read the book “Debunking Utopia: Exposing the Myth of Nordic Socialism” and you will no longer want what you recommend.

    1. I agree these social justice warrior med students stil see the world through their rose colored glasses. Who’s gonna pay for it? Have you ever been to theee countries with socialized healthcare?

      There is no such thing as a free lunch and the road is paved with good intentions. I for one do not want to pay the ridiculous level of tax required to sustain such s monumental effort run by our government.

      Liberals always trying to tax everybody else’s money

    2. So what’s the alternative? Because by almost every metric, the current health care system is failing both physicians and patients. Are we just going to accept the status quo and let the chips fall where they may?

  7. There were some positive changes from the Affordable Care Act. However, it also made health insurance unaffordable for many. It raised the cost of health care. So no, I do not think a government single-payer system is the way to improve cost of health care.

  8. I would like to respond to the following article “It’s time for a single-payer health care system in the US. Here’s why”

    The article is totally flawed and written by medical student’s who have not practiced in the real world.

    The so called affordable Care Act as been detrimental to our Hospital and Clinics.

    I am surprised that this journal has allowed medical students to comment on this topic.

    If they wish for single care system so badly then they should move to Canada

    1. As a 50 year old physician, who has also lived and worked in the UK, I find your dismissing of Healthcare for All short sighted. As is the idea that those less experienced should not comment…at the very least…or move country for daring to think outside the broken box.

      When the USA has the highest maternal/child mortality in the West…something ain’t working.

      When the vast majority of Primary Care docs (>70%), state they would not recommend Primary Care as a career…we are in trouble.

      No system is perfect, but the current one is miserable and failing so many.

  9. I agree with the writers that healthcare is a very complex issue, and that no perfect system exists. Although this is a fairly well written article, there are some glaring omissions. It talks about the likelihood of saving $200 billion in overhead and billing costs, with no mention whatsoever of the multiple Trillions (with a T) of dollars the government would need to somehow come up with to fund this. Also, with every single payer system, there is rationing of care. This is an undeniable fact. Which means care delivery will become less timely for the 91% of Americans who already have insurance. Which in a possible cancer diagnosis, can mean the difference between life and death.

    I’m glad that the writers did not try to push the extremely disingenuous notion that because our health outcomes are worse than other developed countries, therefore our system is failing. Our outcomes are worse because we have by far the highest obesity rate among developed countries, which increases the rates of everything from HTN to heart disease to sleep apnea to cancer. I am concerned that under a single payer system and “free” healthcare, the already small financial incentives for healthy behavior (not smoking, being a healthy weight, etc.)will disappear completely.

    About 8-9% of Americans do not have insurance. This is indeed a serious problem, and one we should be working to solve. However a single payer is not the answer. I’d work on legislation requiring employers of lower wage workers (the working poor, most of the current uninsured) to provide insurance, and tax breaks for doing so.

  10. Have you all heard of the DPC (Direct Primary Care) model for primary care to get patients better coverage and avoid insurance in most instances at an affordable cost? I don’t think providing Medicare for All with more government control when it is already unorganized and convoluted is the solution. The healthcare system needs to be fixed at its core and allow physicians to have a say in what their patients need and want (which varies from area to area). The government cannot possibly know that. We had the Affordable Care Act which tried to give a solution to our problematic healthcare system by getting everyone insurance – that did not work, and there are holes in the system. Ultimately, it’s the doctors who are going to fix this in conjunction with the government but not solely the government alone, and we need to try to limit insurance where we can so our patients can have affordable, accessible, and overall quality healthcare.

  11. The idea of a single payer health insurance plan in theory could work but it still does not take into account other aspects of cost that are at the table such as the high cost of prescription medications, malpractice issues, large hospital corporations owning their own health insurance plans and the current state of physician employment and the disparity in pay within the ranks of the fields of medicine. To have this idea proposed by these two well meaning students several other issues would need to occur to make the playing field level. If the program were to be federally funded there would be a need to implement a single EMR so that what the EMR was to do…allow all providers , hospitals, pharmacies etc to exchange information so as not to duplicate services thereby cutting costs. Second the cost of pharmaceuticals would need to be addressed by government to eliminate that patient who is on drug X un December but January the physician needs to prior authorize it as the formulary of the for profit insurance changed and will not allow drug X to be purchased at tier 1 copay because company Z gave a deep discount for drug Z. The next thing to change is eliminate medical malpractice…if a physician is following evidence based medicine and a bad outcome occurs why is the physician to blame after all they are following the evidence…but here is the issue with that thought and I will use treating blood pressure as an example. There is no consensus as to what the goal BP for a patient is to be as there are too many groups touting their evidence for certain patient populations to have a certain blood pressure.

    Now onto high salaries for those who are CEOs of hospital systems. Millions of dollars are being spent on salaries and stock options for these individuals to run a hospital and possibly the systems own health insurance. Why? That money comes from hospital charges created by those who care for the patient upon entering the system say in the ER and through the discharge date home not the guy wearing the CEO title…I understand that they have a great many things to worry about and make sure that the hospital runs smoothly but one payor will pay each hospital the same so why spend that money on the salary of one person.

    Finally physican reimbursement. I understand that the payment system has always been based on revenue produced by procedures and CMS with by the way the AMA who hold the proprietary rights to both HCPCS and CPT codes including E/M codes. Recently CMS has looked at paying a single fee for new and established patients to ease the burden of documentation but that documentation is how those who are not surgeons or specialists who perform procedures can show the work that they have done. If we were to go to a single payer system then create a single pay equal for all physicians…each area of training from Pediateics to Family Medicine to Neurosurgeon each plays a vital role in the care of each individual in the USA. If this is done more students may go into Primary Care allowing for less of a burden on the system and then we would be able to use the specialists for exactly that….tough cases that are not your every day case. If this means extending the length of Primary Care Residency to 4 or 5 years I do not see any issue with that…it allows for more training to take place and would allow a better trained Primary Care Physician.

    I believe something needs to be done with the system but many facets of the broken US Healthcare system need to be addressed not just creating one single payer based on taxes.

    1. Amen, it will take a group of all health care parties, Dr’s, insurers, congressmen, hospital leaders, and pharmaceutical company leaders to sort out the myriad problems attendant to some form of system, not necessarily a government “ Medicare for all”. Our forefathers wrote our Constitution. I believe our intelligent leaders can/ should figure out how to define a better USA health care system, using other countries templates of a single payer system, minus the deficiencies, but incorporating the best qualities of each, that accomplishes a “ Mission Statement” that all parties can agree on- similar to our Declaration of Independence, that established our national goals, by which we operate today. Let’s start that conversation.

      1. Yes, congress (Democrats only, right?), hospital leaders, big pharma, all the trustworthy folks who brought us ACA. Fool me once, etc.

  12. Doctors are socialised already – the best, the worst and most inexperienced are all paid the same for any given procedure. Perhaps now the obscene fees paid to doctors will drop due to market forces.

  13. If single payer is good enough for our congress,why shouldn’t it be good enough for the rest of the country?

  14. AT first I was against this but lately CAPITALISM philosophy and PROFITS being placed above the care of some patients, I can see where a SINGLE PAYOR SYSTEM would create a more balanced, less incentive/profit based system.The reward in healthcare should be in the best interest of the patient not the profit.
    There is NO PLACE in PATIENT for the capitilist philosophy
    “IF YOU ARE NOT AT THE TABLE YOU are ON THE MENU.”

  15. Single payer system would be ideal, but Medicare for all? I can’t imagine anyone that has ever tried to call Medicare would want them as their insurer. I encourage anyone in favor of Medicare for everyone to try and navigate their system as a physician (moderate nightmare) or as a patient (horrific nightmare). Most physicians never have the experience because their billers handle it and students aren’t there yet.

  16. When I interviewed in Chicago for a residency spot I was told similar stories about Canadian citizens coming to the ER, being told by their Canadian docs to tell the ER they had a 10/10 headache so they could get a head CT. 6-12 month wait in Canada. Single payor. I have s friend in Canada, took over a year to get a knee scope for a torn meniscus. In the UK, physicians (FP) make about 80000 a year, so they have to moonlight in ‘private’ clinics to pay off school loans and make a decent living. .Most citizens buy extra medical insurance to go to private clinics. So, they get ‘govt insurance’ for FREE, ( not really, taxes pay for that limited coverage) but still need outside insurance to get some semblance of full coverage. In the USA, I get paid 50 dollars to admit a patient, and 7-15 a day for rounding. Can’t pay off 250000 dollar school debt on that reimbursement. Or pay my 22 employees. Also, Medicare is the most restrictive insurance I deal with when trying to get my patients services they need. I would have to see EXTENSIVE data, pay rates, to switch. The Nancy Pelosi, ‘ we have to pass the bill to know what’s in it ‘ approach doesn’t do it for me. If you like your doctor you can keep your doctor – Obama. Nope that was a lie Pass Obamacare and your rates will go down 2500 a year. Never happened. In fact it went up.

  17. I have been a practicing physician girl 25 yrs and our system has gone from bad to worse. Universal Healthcare had worked very well in every other country that have it and it would work well here . It’s a no brainier . It would take the profit motive and decision making out of the hands of insurance companies and place it where it should belong among the physicians and patients. At the same time it would lower cost and improve healthcare outcomes not to mention the financial bankruptcies .It is a win win for everyone

    1. Thanks dude. So instead take decisions out of hands of both patient and doctors and hand it straight to government burecracy to redistribute. Fantastic idea.

  18. early in the game–I am not happy to see physicians turn over to accountants all of there earnings. Dangerous to the hilt.

  19. I just completed a rather extensive research project into the content presented in this article, as well as the socioeconomic determinants of health, and while there have been several cogent comments left with regard to said transition to a single payer system, none have struck at the core issue of why we have a “broken” system in the first place.

    Capitalism, as it is loosely practiced here in the United States, is at the root cause of the exorbitant costs and adverse health statistics that the United States posts each and every year. The problem is that plutocrats have invaded every meaningful good and service as a means to maximize profit; Thus, this form of capitalism, a form that not only requires incessant growth into numerous markets, but exponential, non-sustainable growth just to even function, is why insurance companies “run the show” so to speak in US healthcare.

    So the solution is nothing short of a revolution; stop or drastically reduce consuming the product (i.e. health insurance policies). If there is a “direct” primary clinic in your town/city, see if it will meet your (and your family’s) needs. As a physician, try to educate patients about what they are up against, and that the best way to combat rising health care costs, is to be as healthy as possible (again, reducing reliance/dependence on the system).

    As Wellpoint CEP, Angela Braly stated: “We will not sacrifice profitability for membership”. Capitalism has no conscience, so let’s stop supporting it.

  20. I agree that an American hybrid single payer system is needed. It will take time and work, but ultimately could work well for America. I practiced Radiology and Nuclear Medicine for more than 40 years in private practice in my one group and with a very large Radiology group. My practice included non profit and for profit hospitals, imaging centers and teaching hospitals, and I served in the AOCR, and on the AOBR and AOBNM.
    Whenever organized medicine, D.O. or M.D. recommended people running for office, usually Republicans, it was because they supported the best interest of Physicians rather than the public in my opinion.
    A single payer system, in my opinion, will get rid of a very expensive “middle man”. This will take a lot of work but ultimately should be worth it.

  21. There are a lot of things wrong with the current system, but new ideas do not mean they are any better. Some notes:

    – NY Times article states that physician compensation will go down, but in a rather clever way, holding down the physician compensation increase compared to inflation.
    – Fortune 500 considers the revenue, not profits. If one has to complain about excessive profits, the top companies should have been tech and financial companies.
    – Physicians in other countries may not make as much as US physicians, but they are still highly paid compared to other professions in their own countries.
    – If you reduce physician compensation but keep other professions the same, the talent would go to other professions. Eventually, you may impact the quality of health care.
    – Physician compensation is not and can not be the reason behind high cost of health care in US. If you look at the overall share of physician compensation from the total health care spending, depressing them won’t make a big change.
    – No one seem to talk about all the other jobs that can be impacted by single payer system, including nurses, technicians, insurance company employees… When you cut the “fat”, it means less food for many families out there.

    In the end, I want a system, where people do not worry about their health care, and I don’t like the current system, but with wrong decisions and ideas you can create a far worse problem.

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