By Judith L. Albert, M.D. and Ana Malinow, M.D.
Allegheny County Medical Society Bulletin, April 2018
Dr. Fredric Jarrett’s article in the February Bulletin, “Single-payer health care: Not an option,” offers an opportunity to correct many misperceptions about what the “single-payer option” is and to present instead, the case in favor of “expanded and improved Medicare for all.” 1 Dr. Jarrett initially suggests that proponents of single payer extol the virtues of the Canadian and British systems, a statement that is misleading since these two systems are quite different. While Canada does have coverage for all residents, it is administered at the provincial and federal levels. Health care providers are largely private. In the United Kingdom, a national health service exists, such that providers and hospitals are run by the government, and the government also pays for health care for most residents. There is, however, another option in the United Kingdom that allows wealthier individuals to obtain care outside the national health system, a factor that complicates and dilutes the potential for cost containment and equal access, and disqualifies the U.K. system as a model for a national health program in the United States.
Supporters of expanded and improved Medicare for all favor the following: “Universal coverage for all medically necessary care – health care that is publicly financed but largely privately delivered. Patients no longer face burdensome premiums, copays or deductibles, even as they gain free choice of physician and hospital. Doctors gain clinical autonomy and dramatically reduced paperwork.” 2 Any discussion of the “single-payer option” must use rigorous definitions to avoid confusion.
Dr. Jarrett voiced concerns about allowing the single payer to “make the rules” regarding medical necessity. We would argue that placing the decision-making for medical coverage with a public, single-payer option with public accountability will remove the profit motive for decision-making that exists in our current private insurance system. Do we really want health care decisions to be made by corporate insurance executives whose primary interest is their bottom line? Two current single-payer bills in the House (H.R. 676) 3 and Senate (S. 1804) 4 have explicit provisions that address accountability and transparency in the management of the health care program.
Dr. Jarrett goes on to acknowledge that the health care system in Canada enjoys near universal popularity among Canadians, due to the elimination of “medical bankruptcy,” a condition that is all too common here in the United States when lack of insurance coverage or under-insurance allows huge medical debt to accrue for individuals. 5 One of the advantages of the Canadian system is the ability of the health care program to negotiate with pharmaceutical companies on drug prices. Tremendous savings in health care expenditures would result from the ability of a U.S. national health program to negotiate drug prices and would eliminate at least one cause of medical bankruptcy. 6
Dr. Jarrett alludes to critical differences between the U.S. and Canadian health care infrastructure that make comparisons difficult, and clearly mandate that a single-payer system in the United States must be specific to the needs of our much larger population and complex medical systems. It is true that the United States is far better equipped to handle the need for necessary imaging when compared to Canada (we have three and a half times as many MRI and CT scanners). However, emergency imaging is always available in Canada without delay. While in the United States, we have the capacity, uninsured and underinsured individuals cannot afford CT or MRI scans. Millions of Americans are not even afforded the luxury of a place in line. 7
Dr. Jarrett cites the anecdotal increased mortality from abdominal aortic aneurysm due to patients waiting for approval in the United Kingdom. Compare that to the projected excess annual mortality of 36,000 Americans as a result of the 28 million people who are uninsured. 8 Lack of health insurance is bad for our health and results in increased mortality. The United States spends nearly twice as much for health care than other economically developed countries in the world, yet ranks last among 11 industrialized countries when it comes to quality, efficiency, access, equity and healthy lives. 9 Surely, with our massive healthcare resources, we can do better than this.
Finally, we would disagree that the nearest current prototype to single payer we have is Medicaid, because Medicaid is a means-tested program that varies by state. The current prototype for single payer is Medicare, which insures all adults 65 and older. While Medicaid does provide for the medical care of many non-elderly individuals, it is not universal coverage for that population in the way that Medicare is for the elderly. Dr. Jarrett neglected to mention House Bill H.R. 676, which currently has the support of 122 members of Congress. 10 The bill is 30 pages long and would create a publicly financed, privately delivered health care system that builds on the existing Medicare program. It would improve and expand Medicare to cover all U.S. residents. By replacing our nation’s fragmented patchwork of competing private insurance companies (with their wasteful administrative costs, profits and high executive salaries) with a nonprofit single-payer program, the nation would save more than $500 billion per year, 6 enough to guarantee comprehensive health care to all, with no co-pays or deductibles. Numerous surveys of physicians and health care consumers indicate a majority support the idea of expanding Medicare to provide health insurance to every American, including 59 percent of all physicians 11 and 60 percent of Americans. 12 There is even support for expanding Medicare from 40 percent of Trump voters! 12
As physicians, we have an obligation to advocate for all Americans and their health. As members of our professional organizations, we have a duty to seek evidence and report the facts. There is strong evidence that having health insurance fosters improved health and reduced mortality for all individuals. Our current system is giving us exactly what it was designed to do: increased profits for private insurance companies and the rationing of care based on the ability to pay. Improved and expanded Medicare for all: the single-payer option we need.
Dr. Albert is an obstetrician/gynecologist and reproductive endocrinologist who has been in practice in Pittsburgh since 1992. She and Dr. Malinow founded the Pittsburgh chapter of Physicians for a National Health Program with several other physicians in fall 2017.
Dr. Malinow is a general pediatrician in Pittsburgh. She is past president of Physicians for a National Health Program, an organization of more than 20,000 health care providers that support a single-payer, national health program.
The authors can be reached at bulletin@acms.org.
References
1. Jarrett F. Single-payer health care: Not an option. Allegheny County Medical Society, February 2018 Bulletin.
2. Physicians for a National Health Program, Single Payer FAQ, https://pnhp.org…
3. H.R. 676 Expanded and Improved Medicare for All Act, 115th Congress (2017-2018) https://www.congress.gov…
4. S. 1804 Medicare for All Act of 2017, 115th Congress (2017-2018) https://www.congress.gov…
5. Himmelstein DU, Thorne D, Warren E. Medical Bankruptcy in the US, 2007: Results of a National Study. The American Journal of Medicine. Vol 122, Issue 8, August 2009: 741-746. https://pnhp.org…
6. Woolhandler S, Himmelstein DU. Savings of $500 B/year. Woolhandler S and Himmelstein D. Single-Payer Reform: The Only Way to Fulfill the President’s Pledge of More Coverage, Better Benefits, and Lower Costs. Annals of Internal Medicine, April 18, 2017. http://annals.org…
7. Papanicolas I, Woskie LR, Jha AK. Health Care Spending in the United States and Other High-Income Countries. JAMA. 2018;319(10):1024-1039. https://jamanetwork.com…
8. Wilper, AP, et al. Health Insurance and Mortality in US Adults. American Journal of Public Health. 2009;99:2289-2295. https://pnhp.org…
9. The Commonwealth Fund. US Health System Ranks Last Among Eleven Countries on Measures of Access, Equity, Quality, Efficiency, and Healthy Lives. June 16, 2014. http://www.commonwealthfund.org…
10. H.R. 676 Expanded and Improved Medicare For All Act 115th Congress (2017-2018) Cosponsors https://www.congress.gov…
11. Carroll A, Ackerman R, Support for National Health Insurance Among American Physicians: Five Years Later. Annals of Internal Medicine April 1 2008. http://annals.org…
12. The Economist/YouGov Poll. April 2-4, 2017. https://d25d2506sfb94s.cloudfront.net…
