On the surface, it sounds like a good idea. It's relatively easy to explain, and lends itself to simplistic political rhetoric, attractive headlines and good campaign slogans, but few Americans truly understand the realities of a single-payer system.
As a starting point in this debate, it's important to understand exactly what a single-payer system is. There are many variations. In a pure single-payer system, the government pays all the bills and delivers all the care, much like how VA hospitals operate.
Another variant is one in which the government pays for care and private providers deliver it, which is how it works with Medicare and Medicaid. This kind of Medicare-for-all is the brand of single-payer most often discussed for potential implementation in the US.
Here are five potential repercussions of a single-payer system in the US that do not fit neatly into the over-simplified framework lauded by many politicians and other supporters:
1. Two-tiered health system
A single-payer system would encourage and accelerate the creation of two-tiered health system divided along socioeconomic lines. Some argue that we already have such a system today, but many single-payer nations have a public system for the majority of citizens and a private system for the slim minority that can afford it. From an equity standpoint, this is far from the idealistic solution that many believe single-payer systems offer and an inherent problem that is largely ignored by many of its proponents.
It's simply unaffordable. Look to lawmakers in Vermont who passed single-payer legislation but stopped once they learned how much they'd have to raise taxes. The only way to provide current services under a single-payer system without raising taxes is to dramatically reduce payments for services or provide fewer services and benefits, which would result in further inequitable rationing of care.
3. Reduced access to care
The issue of access cannot be overlooked. There is a big difference between insurance coverage and access to care. In countries with single-payer systems, patients can wait months to see a physician, especially if they need to see a specialist. If surgery is needed, the wait can be many more months. People often think coverage means automatic access to care, but this is simply not the case. Medicaid, one of the closest relatives to single-payer in the US, covers individuals, but the reality is those with commercial insurance get quicker access to better care.
4. Staggering financial losses
Payments to providers would not meet the cost of providing care. I know this does not generate much sympathy among so-called progressives, but those of us on the front lines of care recognize the staggering financial losses that are already being incurred by hospitals and other providers that rely primarily on Medicaid or a combination of Medicaid/Medicare. A single-payer system would magnify the problem.
5. More micro-regulation
Single-payer systems dramatically increase government bureaucracy and micro-regulation. These bureaucracies move slowly and health care decisions often become political. If government assumes even greater control over our nation's health system, providers will live in a culture of compliance and outdated regulation that will strongly curtail innovation and creativity. Now is the time for more of the latter, not less.
Our system in the US is far from perfect and there are things we can learn from many of the single-payer, socialized systems overseas, such as malpractice reform, end-of-life care and expansion of targeted social services. We must build upon our successes and be guided by this fundamental principle — do not make matters worse. The government's role in health care will expand but it should not be done by sacrificing the private, commercial and market-based system that currently exists.
To expand access to care for all, we must promote competition, enhance choice and foster our unique entrepreneurial spirit. A single-payer system is no panacea — it is an expensive and unworkable fantasy.
This op-ed appeared in Becker's Hospital Review.