By Ed Weisbart, M.D.
LinkedIn, March 20, 2017
Why do so many physicians prefer single payer national health insurance? The answer is simple: we are on the front lines, seeing the needless suffering created by our current system, and we know the evidence points to a better way. We want to do better, and we know that requires a better system.
There is little more demoralizing than seeing the patient I saw the day before I wrote this piece. This was a 30 year-old construction worker who gradually began to have trouble with balance and cognition. He lost his steady job, lost the health insurance provided by that job, and finally presented with daily seizures. He was admitted, stabilized on an expensive antiepileptic regimen, and found to have a brain tumor. The hospital sent him home with a prescription that he could not afford to fill. He was instructed to file an application for public assistance, but navigating that process was beyond his increasingly limited cognitive abilities. He saw me at another hospital’s safety net clinic one month later, still having untreated daily seizures, and with nowhere to turn for further evaluation and treatment of his lesion.
Had he been insured, the first hospital would likely have completed his evaluation and offered definitive treatment. Instead, he was sent home with an unaffordable prescription, no follow-up plan, and continued daily seizures. It breaks my heart to see someone in America unable to get life-saving healthcare due to insurance barriers.
We each have endless stories like this, we have to take them in stride, but they corrode our passion for medicine. We want to be proud of the system we’ve built, but instead we see tragedies that should never happen. And we know there is a better way.
Physicians in nations that have adopted single payer systems are shocked when they hear such stories from us. They know that medicine is hard enough without the financial barriers and confusing paperwork we impose on care.
Physicians in those nations have no need to assess the economic value or liability their patients represent to their practice, spend far less time on non-clinical administration, have comparable earning potential, and are proud of their nations’ health outcomes. Small wonder so many of us support single payer.
American physicians are an unhappy lot. Other than German physicians, we’re the least satisfied in the modern world.1 One recent time/motion study suggested that we spend 48% of our time on our electronic health records and other desk work, and only 26% of our time with patients.2 Our career satisfaction inversely correlates with the hours we spend on non-clinical documentation and communication. Our most satisfied physicians average eight such weekly hours, and it gets worse after that.3 We’re unhappy because we know this is not necessary: Canadian family physicians average 2.4 hours per week on non-clinical administrative tasks.4
It’s easier to practice in Canada, and it’s also less expensive. Our practices’ overhead average 55% of our revenue;5 Canadians’ average 28.2%.6 In part this is because we absorb extraordinary costs for insurance billing and administration,7 and in part because Canadian malpractice insurance is dramatically less expensive.8 In Missouri, where I practice, the typical single physician practice has over $200,000 in accounts receivable, averaging nearly 12 months old.9 This is unheard of in single payer nations like Canada.10 At the end of the day, the average fee for service billings per full time Canadian physician was $337,767 in 2014 (Canadian dollars), with family physicians at $271,417, Internal Medicine at $378,468, Pediatrics at $292,242, and OB-Gyne at $405,504.11
Perhaps this explains the increased migration of American physicians into Canada since 2006,12 and the net repatriation of Canadian physicians since 2004.13 Or perhaps it’s because of the broader societal impact of a system modeled on universal access as compared to one modeled on managed care. Notice that these patterns preceded the enactment of the Affordable Care Act.
In 1971, President Richard Nixon signed into law the HMO Act, creating our managed care movement. At roughly the same time, Canada’s national health insurance was fully implemented across all provinces. Prior to 1971, outcomes in our two nations were remarkably similar. We were both spending roughly the same 6% of our GDP on healthcare and following the same overall cost trends. Our life expectancies were within one year of each other. Since 1971, our paths have diverged. Canadians now spend roughly half of what we spend,14 and live nearly three years longer than we do.15 They have fewer unmet health needs than we do; theirs are largely due to waiting lists, ours to unaffordable costs. Anecdotal evidence aside, we must remember that Canadian waiting lists are generally not for life-threatening concerns or their life expectancies would not now be so much better than ours.16 We were the same, we adopted different models, and now we are quite different.
There is a bill in the US Congress, HR676, that would improve the problems with Medicare (financial barriers, gaps in benefit design, and needless bureaucracy) and provide that to all Americans. Twenty-five analyses at the state and federal level confirm that the new savings of such a strategy would easily pay for the new expenses.17 It is a matter of political will, not economics.
To learn more, join Physicians for a National Health Program (www.pnhp.org), the non-profit organization of more than 20,000 physicians, medical students and others who support single-payer national health insurance.
Dr. Ed Weisbart is chair of Physicians for a National Health Program — Missouri chapter.
2. Sinsky et al. Ann Int Med 9/6/2016
3. Woolhandler & Himmelstein. Int J Health Serv. 2014;44:635
4. 2013 National Physician Survey. CFPC, CMA, Royal College; http://www.cma.ca…
9. Private communication with Missouri State Medical Association
10. Glauser, W. Canadian Medical Association Journal. June 19, 2014
11. Canadian Institute for Health Information
14. Statistics Canada, Canadian Inst. for Health Inf., and NCHS/Commerce Dept.
16. NBER Joint Canada / US Survey of Health; http://www.nber.org… Table 12