By George Bohmfalk, M.D.
California Association of Neurological Surgeons, Newsletter, August 2023
Letter to the Editor:
Reading Dr. DiGiorgio’s essays on single-payer healthcare in the previous two issues, I am pleased that he agrees that universal coverage is a worthy goal and that the current system is not praiseworthy. And I’m happy that he knows a prominent spine surgeon who favors a single-payer system. Those are great beginnings!
As a retired (Texas) community neurosurgeon with many patients who struggled to obtain or pay for needed care, I realized many years ago that we desperately need a better system. Over the past several years, I’ve become convinced that the only viable option is single-payer healthcare. We don’t need universal Medicare, as it’s currently designed, for many reasons. The solution is improved Medicare for All, as described in bills currently before Congress (H.R.3421 and S.1655).
Dr. DiGiorgio criticizes the proposal for a state-level single-payer system in California; I agree with many of his points. While states can be the laboratories for many ideas, there are many practical reasons why single-payer systems are likely to fail in individual states. As more and more Americans cannot access or pay for needed healthcare, the issue is approaching a national crisis. Only a national solution will suffice.
Space does not allow me to address every issue that concerns Dr. DiGiorgio, but I’ll touch on a few:
- Like most critics of single-payer healthcare, he worries that we can’t afford it. In fact, we’re already paying more than a comprehensive, universal system would cost. The silver bullet is that around 34% of every healthcare dollar goes to administrative overhead resulting from our hundreds of insurance companies and thousands of plans. Beyond the multi-million dollar incomes of insurance execs, we waste billions on preauthorizations, denials, appeals, and other paper shuffling that do not exist in countries with rational systems. While there’s little chance of our ever-matching Taiwan’s 1.6% overhead, we should be able to halve ours with single-payer, saving enough to cover everyone comprehensively. We can easily afford this.
- While several countries he mentions have multi-payer systems with private and competitive insurance companies, those companies are not-for-profit and highly regulated. They must provide identical coverage, similar to our for-profit “Medigap” supplemental policies. The overhead in these systems is several percent higher than in single-payer systems because of this multi-payer administrative duplication, advertising, and other expenses. Adopting such a system seems to have no advantage, only higher costs.
- Using the Medicare framework as a basis for single-payer reimbursements does not mean that the dollar amounts would be what they currently are, only that this functional framework is the logical existing system to use rather than creating one from scratch. No one has suggested using current Medicare rates, which everyone understands are artificially low as private payers subsidize them. It’s disingenuous to assume that rates would be set so low as to cause needed physicians to close their practices. While it is likely that specialist incomes may decrease slightly, it’s reliably certain that primary care incomes will increase, as that’s the greatest national need. Specialists need not worry about being able to support their families, even with modest income reductions. The general public is not likely to be very sympathetic to complaints from neurosurgeons who earn over $900,000 annually. I imagine we could all scrape by on just a bit less in exchange for providing healthcare to everyone.
- Regarding wait times and rationing, Dr. DiGiorgio’s mention of Canadians coming to the U.S. for healthcare ignores the hundreds of thousands of Americans who travel to other countries for less expensive and often higher-quality care. We cruelly ration healthcare now based on the ability to pay, with endless wait times and hundreds of thousands of families filing for bankruptcy each year, mostly due to medical expenses, most of whom have some insurance. Wait times and rationing are functions of how well a system is funded. As the wealthiest nation on earth, the U.S. has enough capacity to fund our system to avoid such rationing.
- Finally, Dr. DiGiorgio worries about who will make the rules in a single-payer system. Does he not worry about who makes the inconsistent rules now – faceless, unaccountable clerks in multiple for-profit insurance companies? A great book, Deadly Spin, gives a chilling look inside Cigna and other insurers’ operations. Single-payer rules will be made by panels of physicians, including surgical specialists, not faceless government bureaucrats. His charming notion that decisions would be best made between a physician and a patient toting a bag of money ignores so much. Namely, the powerful incentive for proceduralists to recommend procedures and that very few patients have a bag of money to offer. Policies and guidelines must be set, and panels of accountable medical experts are preferable to heavy-handed, unaccountable, profit-driven insurance company employees.
I recently heard a young physician say, “I went into medicine to help patients, not drive them into bankruptcy.” That’s what we too often do today in our dysfunctional system. I encourage you to learn more about single-payer than you can through short essays and invite you, once informed, to criticize single-payer proposals. The very readable book Medicare for All: A Citizen’s Guide is a great start. Upon being enlightened, I hope you’ll join me and thousands of other physicians in advocating for Medicare for All by joining PNHP (Physicians for a National Health Program).
Dr. George Bohmfalk is the chair of Health Care Justice — NC, the Charlotte, N.C. chapter of Physicians for a National Health Program.