By Vanessa Van Doren, Augie Lindmark, Bryant Shuey, and Andy Hyatt
“There are no silver bullets, but single payer offers a way to reduce the inequalities that exist outside of the hospital.”
Health policy discussions, and the voices within them, are often minimally affected by the very crises they seek to address. It is a privilege to critique policy, yet the finer points of saving lives are secondary to the actual saving part. When faced with a health crisis—a present day example being where thousands of Americans die from lack of health insurance—it is not common that a solution, one established in evidence and efficiency, is readily available. As explained in a recent STAT article, we recognize a solution in an improved Medicare for all health system. Medicare has saved lives. Punditry and pontification have not.
We read Gondi and Khetpal’s response article, “Medicare for all? Not for us!”, with great interest. We were excited to see our peers engaged in health policy discourse and would like to use this opportunity to “sweat the details” of our support for single payer. While Medicare for all may not be for Gondi and Khetpal, it is the preferred solution for the majority of US physicians, and we are proud to include ourselves among them. It is one of many large-scale reforms that are necessary to combat the United States’appallingly poor health outcomes and worsening inequality. Single payer is a tried-and-true system that has been successfully implemented in dozens of countries around the world. When thirty million Americans lack health insurance, and tens of thousands die as a result, the time for abstract, ivory-tower repudiation with no timeline for concrete solutions is over. This is a public health emergency that requires action.
As board members of a national organization allied with many other groups fighting for social justice, we are well aware that single payer is not the unilateral solution needed to address health disparities. There are no silver bullets, but single payer offers a way to reduce the inequalities that exist outside of the hospital. A system in which everyone is able to receive medical care regardless of ability to pay–particularly given the overlap between income inequality and race, gender identity, and other marginalized groups–would go a long way towards a more equitable society.
Gondi and Khetpal accurately identify two important barriers to healthcare access: high pharmaceutical prices and the administrative bloat that contributed to increasing premiums under the Affordable Care Act. A single payer system would allow the government to negotiate for lower prescription drug prices, a currently-illegal action that would save tens of billions of dollars a year. The ACA, in its attempt to increase access at the expense of cost, exemplifies incremental reform that does not address root causes of system failure. Administrative costs, predominantly private billing and insurance-related activities, are one of the most prominent drivers of rising healthcare costs. The ACA marketplaces added needless complexity to a system already swimming in bureaucracy. Single payer addresses the root cause of our system’s lack of financial sustainability by streamlining dozens of insurers, with administrative overhead averaging at 17 percent, into a single payer, Medicare, whose overhead currently runs at 2 percent.
The authors’ response also reinforces some popular misconceptions about the feasibility of single payer. They cite a vigorously disputed Urban Institute estimate of health coverage costs to make the claim that Sen. Bernie Sanders’s Medicare for all bill is inadequately financed (while ignoring the fact that essentially all other high-income nations provide universal coverage at a fraction of what the United States currently spends). Between administrative streamlining and pharmaceutical savings, there is adequate funding to cover the cost of improving and expanding health care to all. The financing analysis of these bills will be forthcoming, but at this stage in the legislative process, it is fairly standard for bills to not include this level of detail.
The claim that the current single payer bills do not discuss cost-effectiveness evaluation is also incorrect. As Section 202 (Payment of Providers and Healthcare Clinician) of HR 676 explains, “The State director for each State, in consultation with representatives of the physician community of that State, shall establish and appoint a physician practice review board to assure quality, cost effectiveness, and fair reimbursements for physician delivered services.” Medical necessity currently guides Medicare coverage and would continue to do so if Medicare were expanded to all US residents.
Gondi and Khetpal also cite one of the RAND study’s findings–that cost-sharing is necessary to prevent over-utilization of services–but fail to mention that it also reduced necessary medical care. Additionally, families in higher cost-sharing categories had higher rates of study attrition, leading to bias in the study’s results. Forcing patients to pay a higher share of health costs will not induce them to compare prices. When was the last time you shopped around for an emergency room? Canada and the United Kingdom (which has had a universal system since 1948) have zero cost-sharing for physician and hospital care, and outside of England, other countries in the UK have zero cost-sharing for prescription drugs. Canada spends 10.4% of its GDP on healthcare, the UK spends 9.1%, and the United States spends 17.1%. To say cost sharing is necessary to “keep a universal healthcare system solvent” contradicts the lived reality of the healthcare systems of these nations.
But what about multi payer, universal systems in Switzerland and the Netherlands? The authors pose these as alternatives to single payer but ignore that these systems do not produce the administrative savings we would need to pay for fully universal care. The Swiss system, for example, is the second most expensive after the United States. The managed care practices utilized in the Dutch system, particularly insurance competition, have failed to reduce health spending and instead drove up individual costs and increased the number of “defaulters” who cannot pay their premiums. Private health insurance companies in the Netherlands and Switzerland are typically not-for-profit and highly regulated–a far cry from the massive CEO salaries and administrative overhead we see in America. Finally, if a single payer universal system works as well as or better than a multi payer universal system, and there is a growing movement for single payer yet none for multi payer, the urgent plight of America’s 30 million uninsured people demands that we move forward with single payer.
We cannot let our discussion of health policy spiral into endless intellectual debate for its own sake. The United States healthcare system is appallingly inadequate in terms of health outcomes, access, and cost. As a group, medical students and physicians come from significantly more affluent backgrounds than the patients they serve. For many medical students, our first one-on-one experiences with lack of access to healthcare happen during our third and fourth years of medical school when we start seeing patients on a daily basis. The reality is that, while many medical students have the luxury of saying that Medicare for all is “not for them,” many patients do not. In our enthusiasm to apply an intellectual eye to everything, we must be careful not to ignore these realities.
It is not enough to critique existing plans without clearly endorsing an alternative. Gondi and Khetpal’s article offers no comprehensive solution to the many issues that we can all agree plague our healthcare system. They treat single payer as a radical, untested idea and ignore the fact that dozens of countries around the world have successfully implemented single payer systems (all of which provide significantly better health outcomes for a fraction of what the United States spends). The biggest challenge to single payer does not come from lack of detail or inadequate financing; it comes from pharmaceutical and health insurance lobbyists funneling massive amounts of lobbying money to our elected representatives. A truly universal system–something that exists in all other industrialized countries–is framed as a radical idea because it threatens the wealthiest, most powerful people in our country. When we are faced with a problem this big, the potential of small-scale fixes is abbreviated.
Health policy and politics cannot be separated. Researching and vocally supporting policy initiatives that have the potential to prevent unnecessary death is not “weaponizing health care for the political left,” it’s our duty as healthcare providers. We hope that Gondi and Khetpal will reevaluate their rejection of Medicare for all and help us hammer out the details that will allow a single payer system to flourish in the United States.