Yes, I'm Sure I Want Single Payer
Recently, The Atlantic published a piece titled “Are You Sure You Want Single Payer?,” by Olga Khazan. The article details the “potentially big downsides” of single payer, supported with four experts, one of whom consults for insurance companies.
Conspicuously missing from Khazan’s piece were any interviews with experts, doctors, or patients supporting single payer, or any defense of single payer at all. The article is a particularly irksome entry in a genre of story that dates back to the beginning of the Sanders campaign. Each one says, effectively: Single payer would be hard to do, are you sure you really want it?
So let’s consider: What if, actually, single payer is good?
Among the biggest claims in the article is the frightening prospect that, under a Medicare-for-all style system, doctors will “go broke,” because reimbursements to doctors for patients who have Medicare or Medicaid are lower than for patients who have private insurance plans. That would mean, among other things, long waiting times for the few doctors that remain able to eke out a living in this barren, post-private insurance industry landscape. In discussing the prospect of a Medicaid-for-all system, too, Khazan notes that currently “not all doctors take” Medicaid.
I spoke with Adam Gaffney, an instructor in Medicine at Harvard Medical School and a board member of Physicians for a National Health Plan, who said there’s “no reason to expect waiting times to go up” under single payer. Gaffney says waiting times are “result of many factors including the number of doctors per capita, the number of healthcare facilities, there are a number of actors that influence waiting times.” But in the U.S., “we have the doctors, we have the hospitals, we have the healthcare infrastructure to provide healthcare to everybody in a timely fashion. Simply changing the way to pay for healthcare is not going to suddenly result in long queues.”
Gaffney also notes that single payer “would generate large savings for providers because they would be spending less on administration and overhead.” For doctors, filling out that insurance paperwork and making sure the treatments they prescribe are covered by their patients’ insurance is a significant burden that would be alleviated under a single payer system.
More importantly, the article assumes that reimbursement rates would remain the same as they are now under single payer. But why would that have to be true? Ari Ne’eman, who ran the Autistic Self Advocacy Network for ten years and was one of President Obama’s appointees to the National Council on Disability, said the question reimbursements is “driven by the context of purchasing power.” Medicare has much higher participation than Medicaid because Medicaid “has not been as large a program,” he says. But by expanding Medicaid, for example by allowing a buy-in, it would be in a “comparable” position to Medicare in terms of purchasing power. Now imagine if that program covers every single American. Ne’eman says it’s a matter of how the program is phased in: “if over a 15 year period Medicaid slowly becomes the dominant payer within a particular system, doctors are going to be taking Medicaid.”
And there’s no reason to assume that reimbursements would remain exactly the same under a completely overhauled system: if we’re concerned that doctors won’t take the vast majority of patients because they can’t afford to, then reimbursements could be raised. FactCheck.org noted earlier this year that states tweaking the reimbursement rates leads to more doctors accepting Medicaid: Montana, for example, “pays primary care doctors the same rate for Medicaid and Medicare, and has a Medicaid doctor participation rate of 90 percent,” whereas the national Medicaid participation rate was 68.9 percent in 2013.
Medicaid’s limits are another cudgel the piece uses against single payer. Khazan says it “limits the drugs and treatments its beneficiaries can get,” meaning “many Americans would find it stingy compared to their employers’ ultra-luxe PPO plans.” Ne’eman said it’s only a “half truth” that Medicaid limits drug choices; he pointed to the hyperlinked piece in the article, about Medicaid plans not paying for the hepatitis-C drug Sovaldi, which actually led to a rebuke to state Medicaid providers from the federal Centers for Medicare & Medicaid Services.
Generally, Medicaid providers are required to cover anything that’s medically necessary, though providers can be slippery about that. There is a real question about how to ensure low-income people on Medicaid have equal access to drugs. But there’s nothing about the current situation that makes things better for low- or even middle-income Americans in terms of access to drugs. Limits on drug choice are an argument for expanding and reforming Medicaid, not for never doing single payer. It’s certainly not an argument for keeping a private insurance-based system, where access to drugs is limited by their staggering cost.
More broadly, the article acts under the odd assumption that there’s currently no rationing of care, while simultaneously saying some rationing, like shutting down “underperforming” hospitals, might be good:
Amitabh Chandra, the director of health-policy research at Harvard University, doesn’t think it would be so bad if hospitals shut down—as long as they’re little-used, underperforming hospitals. Things like telemedicine or ambulatory surgical centers might replace hospital stays, he suspects. And longer waits might not, from an economist’s perspective, be the worst thing, either. That would be a way of rationing care, and we’re going to desperately need some sort of rationing. Otherwise “Medicare for all” would be very expensive and would probably necessitate a large tax increase. (A few years ago, Vermont’s plan for single payer fell apart because it was too costly.)
But under all but the most expensive and generous plans, there is rationing: You can’t see certain providers, you must pay a deductible before they pay for care, you can only get certain procedures or drugs, or you have to get approval from the insurance company before you visit the doctor, in itself a time-consuming process. Rebecca Givan, an associate professor at Rutgers who studies the UK’s National Health Service, said she found this part of the article frustrating:
Even people with what we think of as the best insurance have to get permission from their insurance company; everyone has complaints about paperwork difficulties, about having to wait a long time for a specialist or a referral or a physical therapist who is in their network. There’s absolutely rationing, it’s just done by for-profit insurance companies rather than a government regulator.
That’s undeniable. Healthcare is clearly rationed when people are lining up for hours for free clinics, or going without necessary medication, or suffering with broken and diseased teeth in their mouths. Waiting times are not great in the U.S.: A 2014 study found longer wait times in the U.S. than several countries with nationalized healthcare systems, like the UK.
Another reason the article cautions against single payer: Apparently, most people like their insurance plans. Khazan quotes Tim Jost saying that between “80 to 85 percent of Americans are already covered by health insurance, and most of them are happy with what they’ve got.”
Polling isn’t clear on this question. A 2010 Politifact piece cites several polls finding 80 to 90 percent were either “satisfied” or “very satisfied” with their care—you could quibble about whether “satisfied” is equivalent to being “happy with what they’ve got,” but other polls show that isn’t the whole picture. Gallup polling has consistently found low satisfaction with the availability and affordability of healthcare since 2001: In 2017, only 11 percent were very satisfied, and 28 percent were somewhat satisfied. Many more, 36 percent, were very dissatisfied. In 2016, 80 percent said they were dissatisfied with the cost of healthcare, and only 56 percent were “satisfied” with the amount they personally pay for healthcare.
And even if people think they like their insurance plans, they might not be well-informed about what those plans actually mean. After all, most people aren’t sick, and most people don’t spend a long time poring over their insurance policies until they are sick and they need coverage. Are you sure you know the difference between a co-payment and co-insurance? Your out-of-pocket maximum versus your deductible? A 2016 survey found just four percent of Americans understood all four of the most common terms related to insurance; a 2013 study found that 34 percent got premiums and co-payments mixed up, and that while 100 percent of respondents thought they knew what a co-pay was, only 72 percent actually did.
You may have noticed the pattern here: All of the problems Khazan identifies with a hypothetical single payer plan are things you would solve for when designing a single payer plan. (And some of them aren’t actually problems: Some doctors would indeed make less money under a well-designed single payer plan. This is a feature, not a bug.)
The problems of the American healthcare system are myriad, and, indeed, they can’t all be solved with single payer. The question is not whether single payer would be perfect: It’s whether it would be better than the horrible, unjust, deadly status quo. It’s also a question of who it would be better for. Perhaps people with the “ultra luxe” PPO plans Khazan describes might feel short-changed. The question is whether we think that’s an acceptable risk if the upside is expanding access to medical care, both preventative and urgent, to tens of millions of people. And it’s hard to understand approaching the question of single payer from any angle other than that, in a country that currently limits access to basic healthcare based on who can afford it, and what’s profitable.