Single Payer: Neither Simple Nor Smart

Published June 1, 2001

Let’s start with three facts.

First, patients are unhappy and growing unhappier with the nation’s medical care system. They want changes.

Second, there are plenty of proposals out there.

Third, this plenitude, indeed plethora, of proposals demonstrates that no single proposal has the single right answer.

These simple truths about the health care policy environment are mirrored in the practice of health care. The availability of multiple treatment approaches usually means there’s no single best treatment.

But just because there’s no best treatment, some treatments can still be worse, or altogether wrong. And so it is with health care policy.

It Sounds So Simple . . .

The search for a best solution to the nation’s health care woes has become so frustrating for the searchers that many large medical organizations are now calling for a single-payer system. It sounds so simple . . . and how could simple be wrong?

We recall, for example, a “call to action” issued in the Journal of the American Medical Association several years ago. More recently, the American Academy of Family Physicians and other groups have started advocating the single-payer solution.

One of the best reasons for a single-payer system, they say, is to free patients, medical personnel, and physicians from the paperwork burden that results from having to work through scores of insurance companies. But our federal government is no stranger to paperwork, and there’s every reason to believe the government’s red tape would be at least as strangling as the private insurers’. Remember your 1040?

Some physicians figure a single-payer system wouldn’t be so bad: The government has left them alone (so far), and they’d rather be dependent on the government for their pay than on their current employer. These physicians are in the “the grass is always greener” camp—they haven’t had trouble with the government, so they assume there’d be less trouble there than with their current situation.

Voice of Experience

We know a talented physician who spent several years in prison because he was falsely accused by the government and convicted, on the basis of perjured testimony, of incorrectly billing insurance companies. Another stopped practicing because similar accusations were made . . . based on $37 billing error made unintentionally by a secretary.

Or consider the lessons of history, which demonstrate the single-payer system cannot work.

The former Soviet Union boasted one of the most thoroughgoing single-payer systems in the world. It was developed over many years, with the advice of some of the greatest experts in the world, with minimal political bickering, and with the solid backing of the country’s citizenry. The Soviets even included a “right to health care” in their constitution.

The former Soviet Union, of course, was renowned the world over for the gross inequity and inadequacy of its medical system. Physicians practicing in Moscow were evenly divided, by government authorities, into two medical systems. One system provided medical care of reasonably high quality to the party elite, who represented about 5 percent of the population. The other 95 percent of the population was treated in very low quality hospitals and facilities by the other half of the city’s physicians.

Are further lessons needed? Consider, from our own country’s experience, managed care.

In the December 21, 1995 issue of the New England Journal of Medicine, Cambridge, Massachusetts physicians Steffie Woolhandler and David Himmelstein complained about their professional limitations under corporate managed care . . . while at the same time they pushed for a single-payer system. In a footnote, Himmelstein noted he was being terminated by his corporate employer.

Himmelstein, and others in the grass-is-greener camp, apparently don’t understand that a single-payer system is also essentially a single-employer system. And if a single-payer government fires a physician, he or she would be permanently out of a medical job, short of fleeing the country.

A Political Experiment

Any single-payer system ultimately depends on government’s monopoly on the lawful use of force. And who controls the government? Politicians, and the bureaucrats who work for them.

When there’s a change in the political winds, who knows where the system will land? Can we afford to put our health care system into the eye of that hurricane? Sure, we might enjoy a brief, calm period—but only in the transition, before violent winds blowing in one direction become equally violent winds blowing in the opposite direction.

Political control of health care payments ultimately means political control over health care decision-making. Putting health care decisions into the political arena will subject them to partisan wrangling, and it’s a virtual certainty that, in the end, the politicians will decide they don’t want to spend as much money as patients require or hospitals and physicians need to do their jobs.

The single-payer system is neither simple nor smart. That is especially true in a country like the United States, where we have long demanded the right to choose how we will meet our health care needs. (Just how much support for alternative medicines do you think there’d be in a government-run health care system?)

Freedom of choice is an essential part of the American experience. We should fight, tooth and nail, any effort to take it from us in matters of life and death.

Michael Arnold Glueck, M.D., of Newport Beach, California, writes extensively on medical, legal, disability, and mental health reform issues. Robert J. Cihak, M.D., of Aberdeen, Washington, is currently president of the Association of American Physicians and Surgeons.