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SinglePayerSystem:WhyItWouldRuinUSHealthcare
LeighPage |September29,2015

SinglePayerWouldBeBadforDoctors
Asinglepayersystemgovernmentrunhealthcareforallsoundslikeanobleideal,butthingsquicklyfallapartintheexecution,accordingtoits
critics.

MichelAccad,MD,acardiologistinSanFrancisco,saysthatbecauseasinglepayersystemmakeshealthcarevirtuallyfree,"demandisalmost
unlimited,"andthegovernmenthastosetlimitsonwhatwillbeprovided.DrAccadwritesablogcalled"Alert&Oriented,"whichprovides
alternativeviewsonhealthcaresystems.

Becausetheofferissoopenended,DrAccadsaysthatsinglepayersystemsinCanada,theUnitedKingdom,andotherdevelopedcountries
havetoimposestrictcentralplanning.Ratherthanleavehealthcarechoicesuptoindividualphysicians,theirpatients,andfreemarketforcesthat
couldbalancesupplywithdemand,thegovernmentsetstherules.

Theserules,DrAccadsays,areusuallybasedonlargequantitiesofdatacomparingcostsagainstprobableoutcomesoronpolitical
considerations,suchastheneedtobalancebudgetswithoutraisingtaxes.Thisapproach,hesays,willinevitablymisallocateservices.When
centralplanningallocatescare,therewillbeshortagesofsomeservicesandglutsofotherservices.Inparticular,centralplannerswillhavea
difficulttimekeepingupwithcuttingedgetechnologyandimprovementsinpracticepatterns.

Centralizedsystemsalsounderpayphysicians."Inasinglepayersystem,"DrAccadsays,"plannersdecidearbitrarilywhatthepaymentsshould
be,andpaymentsfallbecausetherearenocompetitorsandnochoiceforproviderstobiduppayments."

Indeed,a2011study[1]foundthatreimbursementstoUSprimarycarephysiciansfrompublicpayers,suchasMedicareandMedicaid,were27%
higherthanincountrieswithuniversalcoverage,andtheirreimbursementsfromprivatepayerswere70%higher.Meanwhile,reimbursementsto
USspecialistswere70%higherfrompublicpayersand120%higherfromprivatepayers.

LackofCompetitionHarmsDoctors
Anotherdisturbingaspectofasinglepayersystemisthelackofcompetitionamongpayers,whichwouldreducephysicians'controloverstandards
ofcareandreimbursement.

Inapuresinglepayersystem,doctorscanonlycontractwiththeonepayeravailable.Currently,in
theUnitedStates,physicianshavesomechoiceofinsurerstoworkwith,andeveninMedicareor
Medicaid,doctorscanoptout.Buttheycouldn'tdosoinapuresinglepayersystem.

"Providersremainostensiblyindependent,butthesinglepayerexercisessignificantcontrols,"
suchasdeterminingwhatservicesare"necessary,"wroteJohnMcClaughry,founderoftheEthan
AllenInstitute,afreemarketthinktankinMontpelier,Vermont.Thesinglepayerisa"monopoly
HMO,"headded.

Criticssaythesinglepayerprogrammightstartwithacceptablereimbursementratesasawayto
getphysicianbuyin,andthenratchetthemdownbecausethereisnoalternative.AsDrAccad
hasalreadypointedout,thesinglepayercanreducereimbursementswithimpunity,becauseit
hasamonopoly.

Ratherthanrestrictchoicesfurther,opponentsofasinglepayersystemwanttoopenupchoicesinthecurrentsystem."Weshouldstrikedown
statebarrierstoinsurersandallowtheirproductstobesoldnationally,"saysJimGeddes,MD,atraumasurgeonnearDenver.

NoahN.Chelliah,MD,acardiologistinGrandForks,NorthDakota,agrees."Autoinsurancepremiumsarelowbecauseinsurershadtocompete
witheachothernationwide,"hesays."Thesamecouldbedoneforhealthinsurance."

"Whenphysiciansbecomeessentiallyemployeesofthegovernment,whichiswhathappensinasinglepayersystem,theneverythingprettymuch
breaksdown,"DrGeddessays."Onlyphysiciansarethebestpositiontodeterminethequalityofcare.We'rethenumberonepatientadvocates."

However,DrGeddesdoesnotbelievethattheUnitedStateswouldallowcompleteterminationofcommercialinsurance.Hethinkstherewould
probablybeprivateplansthatpeoplecouldpurchaseontheirown,asisthecaseintheUnitedKingdom.However,"thiswouldleadtoatwo
tieredsystem,"hesays."I'veseenitintheUnitedKingdom,andit'snotwhatweshouldhavehere."

WaitingListsinCanada

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CanadianMedicare,administeredbyeachprovinceandfundedthroughtaxes,provideshealthcaretoallresidents,withminimaloutofpocket
payments.PrivatehealthcareisnotallowedinCanada,soCanadiansonlongwaitinglistshavetogototheUnitedStatesandothercountiesto
getexpeditiouscare.

Waitinglistsareafamiliarfeatureofsinglepayersystems,especiallyforhighercostorcuttingedgehealthcare.Accordingtoareport [2]bythe
FraserInstitute,anindependentthinktankinBritishColumbia,Canada,themedianwaitingtimetogettreatmentfromaspecialisthasdoubledin
thepast20years,to18.2weeks.Canadianpatientswaitthelongestfororthopedicsurgery(42.2weeks),neurosurgery(31.2weeks),andplastic
surgery(27.1weeks).

DrChelliahwhoseNorthDakotapracticeis80milesfromtheCanadianbordersaysthatmanyCanadianpatientsonwaitinglistscometohim
andotherprovidersintheareaforcare.Hethinksthewaitinglistsareintentional."ThewayIseeit,theCanadiansystemsavesmoneyby
delayingcarebyrationing,"hesays."Thenetresultisthatpeoplediebeforetheyfinallycangettheircare.Iknowthatsoundsprovocative,butI
thinkit'strue."

Afewyearsago,henoticedthataCanadianfriendofhiswashuffingandpuffingandtoldhimheneededtogetastresstest.HisCanadian
familyphysicianwasinitiallyreluctanttoorderonebutfinallyagreed,andthenittook3monthstogetthestresstestdone.Eventhoughthe
resultswerestronglypositive,themanwasn'tscheduledforanangiogramuntilthefollowingyear.Theangiogramfounda99%blockage,calleda
"widowmaker,"andhefinallygotastent."Thispatientcouldeasilyhavedied,"DrChelliahsays.

DrAccadpointedtoarecentnewsreport [3]fromCanada,inwhichaleukemiapatienthadabonemarrowdonor,butshecouldn'tgetthe
transplantbecausetherewasn'tahospitalbedavailableforher.Thoughtheproblemsoundscrazy,"patientsinthesesystemstendtoaccept
waitinglists,"hesaid.

QualityProblemsintheBritishSystem

InGreatBritain,theNationalHealthService(NHS),operatingseparatelyinEngland,Scotland,andWales,notonlyfinanceshealthcarebutalso
ownshospitals,physicianpractices,andthepracticesofotherprovidersofcare.However,about10%ofBritonshaveaccesstoprivatefacilities
paidthroughprivateinsurance.

Thosewhowanttohaveexpeditedcarebuyprivateinsurance.DrGeddesrecallsthathisnephewhadananteriormyocardialinfarctionwhile
workinginLondon.HewasfirsttransportedtoanearbyNHShospital,buttheydidn'thaveacatheterlabtotreathim,sohewassenttoa
catheterlabataprivatehospitalcoveredbyhisprivateinsurance."HeprobablywouldhavediedatanNHShospital,"DrGeddessays.

DrGeddesbelievesstrictgovernmentcontrolsandimpossiblylongwaitinglistshavecreatedafatalisticattitudeamongmanyBritishdoctors,and
thismakesthewaitinglistsevenlonger.Manyyearsago,hetraveledtotheUnitedKingdomtowatchaBritishsurgeonoperate.Thesurgery
teamshowedupat8:00AMandhadtwocasesfortheday."Thefirstcasetookalittletoolong,andafterwardwehadaleisurelylunch,"hesays.
"Thesecondpatientwasanopenheartcaseandhadalreadybeenprepped,buttheydecidedtheywouldn'thaveenoughtime."Theoperation
waspostponed."IntheUnitedStates,wewouldhavegoneaheadwiththesecondcaseandjuststayedlate,"DrGeddessaid.

ScandalattheVA:theUSVersionofBritishHealthcare
TheunhurriedattitudeofhisBritishcolleaguesremindedDrGeddesofthetimehespentasaresidentattwohospitalsintheVeteransHealth
Administration,whichispartoftheDepartmentofVeteransAffairs(VA)."TheVAmedicalstaffhassomegooddoctors,especiallyinVAs
affiliatedwithuniversities,"hesays."Butasageneralrule,thestaffhasshorterworkhours.Theyarejustpunchingaclock."

TheVAsystemisascloseasUShealthcarecomestotheBritishsystem.Itoperates150hospitalsandalmost1400outpatientclinicsand
providescareto8.3millionveteransayear.LiketheNHS,italsohaswaitinglists,whichinvolvedascandalthatrockedtheVAinthespringof
2014andcausedthedeparturesoftheVAsecretaryandthesystem'stophealthofficial.

Foryears,theVAhassetlimitsonhowlongitswaitinglistscanbe,butthenumberofpatientshasbeengrowingwellbeyondthesystem's
capacitytodealwiththem.ItturnedoutthatmanyVAstafferswerefudgingwaitinglistnumberssothattheywouldn'texceedthelimit.Dr
Geddeswasn'tsurprised."Thisisasubparhealthcaresystem,"hesays."IfweintroducedasinglepayersystemintheUnitedStates,prettysoon
itwouldlookliketheVA."

"Asinglepayersystemisaboutcontrol,"DrGeddessays."Itisn'taboutimprovinghealthcare.Therearemanywaysofdoingthatwithout
involvingthegovernment.It'sabouttheneedtoexercisecontrol."

VermontAbandonsItsSinglePayerDream

Inthepastfewyears,Vermonthadbeenthedarlingofsinglepayeradvocates.ThestatehadbeenplanningasystemcalledGreenMountain
Caresince2011.Butsuddenly,inDecember2014,GovernorPeterShumlinannouncedthattheeffortwouldbeabandonedowingtothecost.

Beforethegovernor'sannouncement,GreenMountainCarewasexpectedtomakemoney.A2011reportbyanoutsideconsultantpredicted$590
millioninsavingsinthefirstyear.Buttogetthosesavings,stategovernmentwouldhavehadtotakeoveralltheoperationsofcommercial
insurers,withouthavinganyexperience.
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Intheend,GreenMountainCarewasslatedtocostthestate$4.3billionin2017almostdoublingVermont'stotalbudgetof$4.9billionforfiscal
year2015.Thiswouldhaverequiredapayrolltaxof11.5%anda9%taxonincome.

Vermonthasnotentirelygivenuponitssinglepayerdream.Thestateisnowreportedly[4]planningallpayerratesetting,inwhichitwouldset
paymentsforMedicare,Medicaid,andprivatepayers.ThiswouldbedonethroughauniquefederalwaiverfromtheCentersforMedicare&
MedicaidServices(CMS),butthestatehasnotyetformallyappliedforit.IfCMSgrantedthewaiver,Vermontwouldbeabletoexercisethe
pricesettingcontrolsofasinglepayersystemwithoutthecostsofactuallyrunningthewholesystem.

Butfornow,thedreamisover.Asinglepayersystemwasneverarealisticgoal,saysDavidJ.Weissgold,MD,aretinalsurgeoninSouth
Burlington,Vermont."Theplanwasnaiveandfoolhardy,"hesays."It'sthekindofsweepingchangethatplayswellpolitically.Ithasinspiredalot
ofpeople,butit'safantasy,akindofadreamstate.Ineverthoughtitwouldwork."

Theadvocatesofasinglepayersystemrefusedtofacethegrimrealityofactuallyrunningsuchasystem,eventhoughitwasthereforalltosee
justacrosstheborderinCanada,saysJohnMcClaughry.

FacedwithrationinginCanada,Vermontsinglepayeradvocatessaiditwassimplycausedby"stingytaxpayers,"hesays.WhenaVermont
singlepayerphysiciandebatedaCanadianphysicianwholistedthesystem'sfailures,herreplywas,"We'reVermonterswecanmakeitwork,"
McClaughryrecalls.

McClaughry,aformeradvisortoPresidentReaganandVermontlegislator,saysthatsinglepayerisafundamentallyflawedconcept,focusingon
theneedforhealthcareratherthanontruedemand."Demand,initiatedbypatientswhomaynotunderstandwhattheyreallyneed,willbe
replacedbygovernmentcontrolledallocationofservicesonthebasisofwhatpatientsaredeterminedtoreasonablyneed,"hewroteinapolicy
brief.

WaningEnthusiasmforSinglePayer
TheVAscandalandthedemiseoftheVermontplanwerenottheonlydefeatsforasinglepayersystemin2014.ActivistsinColoradofailedto
getenoughsignaturestogetasinglepayermeasureontheNovemberballot.AndinMassachusetts,DonaldBerwick,MD,theformerCMS
administratorwhoranforgovernoronasinglepayerplatform,wononly21%ofthevoteintheDemocraticprimary.

EveninEurope,theheartofthesinglepayermovement,theconcepthasencounteredembarrassingdefeats.InSweden,owingtoaccess
problemsinthecountry'ssinglepayersystem,about10%ofresidentshaveoptedforprivatehealthinsurance,accordingtothetradegroupfor
Swedishprivateinsurers.AndinSwitzerland,almosttwothirdsofvotersrejectedasinglepayerproposal.

IntheUnitedStates,publicopinionhasbeenshiftingawayfromsupportof"healthcareforall"eversincethebuilduptoPresidentObama's
AffordableCareAct(ACA).Gallupreports[5]thatin2000,59%ofAmericanssaidthenationhasadutytoprovidehealthcareforthepoor.The
numberpeakedin2006at69%,butinpollssince2009,aslightmajorityofAmericansopposethatresponsibility.

Singlepayeradvocatesareactuallyasubsetofthosecallingforuniversalcare,whichincludesadvocatesofmultipayerapproaches,suchasthe
ACA.AnApril2014Rasmussenpoll[6]foundthat37%ofeligiblevoterssupportasinglepayersystem.

WhySinglePayerIsStillaThreat

Eventhoughthesinglepayermovementhastakenabeatingrecently,DrGeddesdoesn'tthinkit'sgoingtogoaway.Healreadyseesmany
aspectsofitinMedicareandMedicaid,whichdependoncentralplanning.

DrGeddessaysthatjustlikeasinglepayersystem,Medicareimposesarbitraryrulescreatedthroughcentralplanning.Forexample,Medicare
dictatesthatcertainpatientshavetobeinthehospitalforacertainnumberofdaysbeforetheycanbereferredtoarehabhospital.Often,he
says,patientscanbetransferredearlier,buttheyareforcedtostayinahighcosthospitalbed."Therulesactuallyforcedoctorstowaste
resources,"hesays."That'showasinglepayersystemoperates."

Furthermore,DrGeddesthinkstheACAwillbejustatemporarystoponthewaytoasinglepayersystem.DespitecostcontrolsintheACA,
insurancepremiumsarerisingsignificantly.Hebelievesthathealthinsurancewilleventuallybecomeunaffordable,andtheUSpublicwillriseup
andcallforabolishingprivateinsuranceandestablishingasinglepayersystem.

Thatwouldbethewrongwaytogo,DrGeddessays."Ourprivatehealthcaresystemisworking,"hesays"Wehavethefinesthealthcaresystem
intheworld,anditcontinuestogetbetter."

Evenasmuchoftherestoftheworldhasembracedsinglepayerandotherformsofgovernmentcontrolledhealthcare,suchaspricecontrols,
theyarecompletelydependentonmedicaladvancescreatedbytheUSsystem,hesays.Advancesinpharmaceuticals,medicalequipment,and
manysurgicaltechniquescomefromtheUnitedStates,whereafreemarketencouragesentrepreneurs,DrGeddessays.

"Theincentiveispotentialwindfallprofits,"hesays."Butifyoutakeitaway,thewholeprocessofinnovationwillcease.Noothercountrycould
takeuptheslack."DrGeddesisaregentoftheUniversityofColorado,whosestateoftheartAnschutzMedicalCampushostsbiotechfirms
financedbyventurecapitalfirmsandothers.
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EvenwithintheUnitedStates,hesays,MedicareandMedicaiddependonthecostshiftfromprivatepayers."Theonlywayphysicianscanafford
toparticipateinMedicareisthattheygethigherpaymentfromcommercialinsurers,"DrGeddessays."Singlepayeradvocatestalkabout
'Medicareforall,'butifMedicarewerestandingalone,itwouldfallflat."

References

1.LaugesenMJ,GliedSA.HigherfeespaidtoUSphysiciansdrivehigherspendingforphysicianservicescomparedtoothercountries.
HealthAff(Millwood).201130:16471656.http://content.healthaffairs.org/content/30/9/1647AccessedAugust20,2015.

2.BaruaB,FathersF.Waitingyourturn:waittimesforhealthcareinCanada,2014report.FraserInstitute.November26,2014.
https://www.fraserinstitute.org/sites/default/files/waitingyourturn2014.pdfAccessedAugust20,2015.

3.CTVNews.Ont.teenfacingunnecessarychemoduetobedshortagemaysoongettransplant.August7,2015.
http://www.ctvnews.ca/health/ontteenfacingunnecessarychemoduetobedshortagemaysoongettransplant1.2507061Accessed
August20,2015.

4.GoswamiNP.Stategetssettoembarkonhealthsystemoverhaul.RutlandHerald.May22,2015.
http://rutlandherald.com/article/20150522/NEWS03/705229878AccessedAugust20,2015.

5.NewportF.Majoritysaynotgov'tdutytoprovidehealthcareforall.Gallup.November20,2014.
http://www.gallup.com/poll/179501/majoritysaynotgovdutyprovidehealthcare.aspxAccessedAugust20,2015.

6.RasmussenReports.37%favorsinglepayerhealthcaresystem.April28,2014.
http://www.rasmussenreports.com/public_content/archive/health_care_update_archive/april_2014/37_favor_single_payer_health_care_system
AccessedAugust20,2015.

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