By Danny McCormick, MD, MPH; Oliver Fein, MD; Christopher J. Wong, MD; Scott Goldberg, MD; Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD
SGIM Forum, Perspective, October 2018
Despite improvements in health insurance coverage under the Affordable Care Act (ACA), 29 million Americans remain uninsured and millions with coverage are also unable to afford care. Meanwhile, in our healthcare institutions, the drive for profit increasingly trumps clinical imperatives, and even in not-for-profit organizations, mounting bureaucracy drains both funds and joy from patient care. None of the incremental reforms currently being debated would fix these problems. SGIM has supported the goals of universal access to care and health equity, but has never taken a position on how to achieve these goals. The time has come for our organization to endorse and advocate for the only viable way to ensure universal access to comprehensive care at an affordable price—a single payer reform.
Current State of Coverage and Access in the USA
The ACA implemented the largest health insurance expansion since the start-up of Medicare and Medicaid in 1966. Since 2013, 15.5 million Americans have gained coverage, with larger gains among the poor, Hispanics and African Americans, although these groups continue to suffer higher-than-average rates of uninsurance.1 Yet, 9.1% of Americans remain uninsured, and 13.0%—including 16.3% of black and 20.3% of Hispanic people—can’t afford a needed physician visit currently.2
But we have likely seen all the coverage gains achievable under the ACA. Unfortunately, the current administration is seeking to undercut the law, implementing policies that will erode existing coverage levels.3 Even without these setbacks, the Congressional Budget Office estimated that no further increases in coverage would occur through 2026.
SGIM’s Mission, Previous Work, and Role in Medicine
SGIM is an association of the world’s leading academic general internists whose members have expertise in health services and policy research, healthcare administration, clinical care, and ethics. This allows SGIM to play an important role in guiding the public and policy makers on which specific policy options to select to address key policy problems. Through its committees and the Council, SGIM works hard to advance its mission “to achieve health care delivery that is comprehensive…[and] is organized and financed to achieve optimal health outcomes and maximize equity”. SGIM’s stated values include “social responsibility and equity in health and healthcare”. In addition, SGIM’s Health Policy Committee affirms a commitment to “universal health care access”.
SGIM regularly supports specific policies, even controversial ones, by issuing white papers or public statements. As an organization, we have taken strong positions against physicians’ participation in torture and in support of providing care for undocumented immigrants. However, SGIM has yet to advocate clearly on how to achieve universal and equitable access to care. We believe it should now publicly support a single-payer program for the United States.
Why Should SGIM Support a Single-Payer Health Care System?
Merits of Single Payer
A single payer reform would replace the current welter of private and public insurance plans with one public plan covering everyone for all medically necessary care—in essence, an expanded and upgraded version of the traditional Medicare program. The potential health benefits of this approach are substantial. Numerous studies, many from SGIM members, have shown that being uninsured carries mortal consequences. Covering the 29 million Americans who are currently uninsured would likely save many thousands of lives annually, and would reduce the risks borne by many more patients who delay seeking care and skimp on medications to save costs.
The economic case for single-payer reform is also compelling. Private insurers’ overhead averages 12.4% versus 2.2% in traditional Medicare. Reducing insurance overhead to Medicare’s level would save approximately $220 billion this year. Even larger savings would accrue by sharply reducing provider overhead, including the substantial costs of billing and paperwork required to deal with multiple payers. By paying hospitals lump-sum operating budgets rather than forcing them to bill per patient, Scotland and Canada have held hospital administrative costs to approximately 12% of revenues versus 25.3% in the United States.4 Further, a single-payer program could use its bargaining clout to sharply reduce drug prices. Single payer’s savings on bureaucracy and drug profiteering would fully offset the added costs of providing universal, comprehensive first-dollar coverage. Indeed, even critics of single payer estimate that such reform would cut overall health expenditures by $2 trillion over a decade.5
Single Payer and SGIM’s Organizational Objectives
Single payer aligns well with SGIM’s organizational goals. We agree with SGIM’s support of the broad principles of access and equity. However, lacking any plan for how these goals can be realized effectively undermines advocacy efforts. SGIM’s not providing specific recommendations, leaves the impression that it believes that incremental reform is a plausible way to achieve universal coverage. The evidence does not support this belief.
We are also convinced that single payer is the best way to address SGIM’s mission of “improving the work and practice environment for general internists” and reducing
physician burnout. The simplified, uniform billing procedures under a single-payer system would reduce the time and effort physicians currently waste arguing with private, profit-driven insurers and providing documentation that is clinically superfluous but essential to justify payment.
The Moral Argument
Universal access to care is, fundamentally, a moral issue. As scientists, we must be attentive to research evidence, policy details and economic necessities. Ultimately, however, we must be guided by our conscience. Access to health care should not be dependent on one’s age, employer, wealth, or zip code; it is a moral failure that we do not guarantee the clear common good that is health care. A strong body of research in the United States and experience in other nations give clear evidence that a single payer system would dramatically expand access to care, including treatments for millions with chronic illnesses, saving thousands of lives annually. As physicians, we have an obligation to advocate for policies that evidence indicates are in the best interest of the public’s health. In light of this, we believe that advocacy for single payer reform is a professional duty.
Arguments Against SGIM’s Support for Single Payer
Some suggest that advocating single payer reform would commit SGIM to supporting a fringe proposal that would isolate us from the mainstream of political debate. Yet, recent surveys indicate that most Americans favor such reform. Single-payer bills in Congress have gained co-sponsorship from 123 members of the House and 16 in the Senate. All the leading Democratic party contenders for the presidency in 2020 openly call for single payer reform.
Some may also worry that SGIM support for single payer could alienate some current or potential members, or isolate us from other physician groups. Yet, as noted above, SGIM has not shied away from taking stands on other controversial and potentially divisive issues when it was clearly in the interest of the public’s health. Moreover, past polls of SGIM’s membership have found substantial support for “a single, consolidated financing mechanism,” and recent surveys indicate that a majority of physicians—and an even larger proportion of general internists—favor a single payer system.
Others may view an incremental strategy as a more practical route to universal coverage, citing nations such as Switzerland and Germany that have retained multiple insurers while achieving universal coverage. Yet those nations’ insurers are fundamentally different from ours. In Switzerland, for example, only non-profit insurers can offer the tightly regulated mandatory coverage and are required to pay providers identical rates. Transitioning to this or similar models would entail converting our for-profit insurers to heavily-regulated non-profits, a reform that insurers would vehemently oppose. Moreover, both insurance overhead and providers’ administrative costs in multi-payer systems are far higher than under single payer. While the incremental approach may sound appealing, it would sacrifice much of the administrative savings that makes universal coverage under a single payer system affordable and it would still require a head-on confrontation with America’s for-profit insurance giants.
SGIM supports universal access and the elimination of disparities in access to care. The only plausible way to achieve these goals is through adoption of a single payer
national health insurance program. Single payer would cover 100% of Americans, dramatically expand access to care, and improve access to needed treatments for millions with chronic illnesses, saving thousands of lives annually. Popular and political support for single payer is growing. SGIM should provide leadership in advocacy for such reform.
1. Cohen RA, Zammitti EP, Martinez ME. Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2017. https://www.cdc.gov… Published November 2017. Accessed September 1, 2018.
2. BRFSS Web Enabled Analysis Tool. https://nccd.cdc.gov… Accessed September 1, 2018.
3. Collins SR, Gunja MZ, Doty MM, et al. First look at health insurance coverage in 2018 finds ACA gains beginning to reverse. http://www.commonwealthfund.org… Published May 1, 2018. Accessed September 1, 2018.
4. Himmelstein DU, Jun M, Busse R, et al. A comparison of hospital administrative costs in eight nations: US costs exceed all others by far. Health Aff (Millwood).
5. Blahous C. The costs of a national single-payer health care system. https://www.mercatus.org… Published July 2018. Accessed September 1, 2018.
Dr. McCormick (firstname.lastname@example.org) is associate professor, Harvard Medical School/Cambridge Health Alliance, Cambridge, MA.
Dr. Fein (email@example.com) is professor, Weill Cornell Medical College, New York, NY.
Dr. Wong (firstname.lastname@example.org) is associate professor, Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA.
Dr. Goldberg (email@example.com) is resident physician, University of California San Francisco, San Francisco, CA.
Dr. Woolhandler (firstname.lastname@example.org) is distinguished professor, City University of New York at Hunter College, New York, NY. and lecturer in medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, MA.
Dr. Himmelstein (email@example.com) is distinguished professor, City University of New York at Hunter College, New York, NY, and lecturer in medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, MA.