Single-payer or public option, part 1 of a 3-part series

When the American College of Physicians issued a white paper outlining its support for the establishment of a single-payer or public option healthcare system, there was no hint that 2020 would unfold as the most perilous year for U.S. medicine in more than 100 years. Nonetheless, the case made by the ACP remains a compelling one—so much so that BreakingMED is offering its users as chance for a second look. This opening part of a three-part deep dive into the ACP proposals was originally published Jan. 20, 2020.

The American College of Physicians is going on record in support of either a single-payer healthcare system for the U.S. or a public option to provide Americans with access to universal healthcare.

In an 85-page supplement in the Annals of Internal Medicine titled “Better Is Possible: The American College of Physicians’ Vision for U.S. healthcare,” the physicians’ group called the U.S. health system “gravely ill.”

“…[t]he symptoms are many: Costs are too high, many people lack affordable coverage, incentives for hospitals and physicians are misaligned with patients’ interests, primary care and public health are undervalued, too much is spent on administration at the expense of patient care, and vulnerable individuals face daunting barriers to care,” wrote Robert M. McClean, MD, president of the American College of Physicians, and colleagues. “healthcare expenses are the leading cause of private citizen bankruptcies in the United States.”

Essentially, the physician group is proposing a prescription to treat the “chronically ill patient” that is, from their perspective, not being treated well. “Simple market solutions have been unsuccessful elsewhere, and we do not believe that healthcare is a commodity,” they wrote. “Issues are intensely personal, and care is not an item on a store shelf.”

Physicians for a National Health Program (PNHP) lauded the new vision from the ACP.

“As physicians, we see daily the harm that our fragmented, private-insurance based system does to our patients,” noted Adam Gaffney, MD, President of the PNHP and a pulmonary and critical care physician at Harvard Medical School and the Cambridge Health Alliance, in a statement. “Patients go without the care they need, and physicians squander time and resources on wasteful billing and clerical tasks. Medicare for All would be a much better way — for patients and doctors both.”

A spokesperson for the American Medical Association told BreakingMED in an email that the ACP had not “shared their ’vision’” with the association, but they did offer this statement: “The American Medical Association agrees that high-quality, affordable healthcare coverage should be available to all Americans to improve the health of our nation, and we look forward to reviewing the ACP proposal in detail.”

Historically, the AMA has been opposed to single-payer healthcare, and in June 2019, by a narrow margin, voted to maintain this stance.

Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD from City University of New York at Hunter College New York, called the ACP’s new vision a sea change and cited the century-old opposition to national health insurance in one of the editorials in the Annals’ supplement. Woolhandler is also a Fellow of the ACP.

They noted that when Canada first rolled out its national health insurance policy in the 1960s it, too, was met with opposition and fear particularly from the medical establishment itself.

“But despite a rocky start, most Canadians now embrace their single-payer system,” Woolhandler and Himmelstein wrote.” Everyone is covered, and all doctors and hospitals are ’in-network.”

They also noted that when the system was first proposed in the 60s, healthcare costs were nearly identical between the two countries, and are now about 40% lower.

So, the ACP asked its members what a better healthcare system would look like and focused on four questions:

  1. “Why do so many Americans lack coverage for the care they need?
  2. “Why is U.S. healthcare so expensive and therefore unaffordable for many?
  3. “What barriers to healthcare, in addition to coverage and cost, do patients face?
  4. “How do delivery and physician payment systems affect costs, access, quality, and equity?

“Despite historic gains in coverage with the Affordable Care Act, the United States is the only high-income industrialized nation without universal health coverage,” wrote Robert Doherty, BA, ACP senior vice president for government and policy at the and colleagues in a white paper titled “A Call to Action.”

Doherty and co-authors noted that the U.S. spent nearly 17% of its gross domestic product on healthcare.

“In addition, administrative costs account for 25% of total U.S. hospital spending. Complex medical billing, documentation, and performance reporting requirements for value-based payment initiatives have made the U.S. healthcare system one of the most administratively burdensome in the world,” they added.

In their “Coverage and Cost of Care” paper, Ryan Crowley, BSJ, from the ACP, and colleagues looked at the current state of healthcare in America and why it needs to do a better job addressing coverage and cost. They also looked at the pros and cons of single-payer or public choice models for achieving universal coverage.

Several models for insurance currently exist in the U.S. health system — The Beveridge model used by the VA; the national health insurance model used by Medicare; the Bismarck model reflected in employer-based insurance and private insurance; direct patient contracting models (concierge, retainer fees); and of course, the uninsured model.

While the ACP is calling for universal coverage, they admit that there are many arguments against, as simply insuring everyone doesn’t necessarily “ensure access to high-quality, affordable care — the goal should be both universal coverage and access.” They also noted that critics argue the price controls often result in long wait times or delays in care. And, since one way of providing universal coverage is through taxes, “some argue that universal coverage compromises individual freedom by forcing individuals to purchase something they may not want,” Crowley and colleagues wrote.

To this last point the ACP is clear — “’universal coverage must be compulsory….’ According to the World Health Organization, ’Because of adverse selection and the exclusion of the poor, no country in the world has managed to come close to [universal health coverage] by using voluntary insurance as its primary financing mechanism.’”

So, Crowley and colleagues looked at the single-payer and public choice models.

Although single-payer healthcare is often described as socialized medicine that is totally government run and paid for, Crowley and colleagues pointed out that this is not always the case. For example, in the Canadian model, private insurance is not prohibited — in fact, they noted, “many Canadians have private insurance to cover supplemental benefits not included among guaranteed benefits, such as prescription drugs. In Denmark’s single-payer system, 39% of people have private supplemental insurance to finance such services as physical therapy. Other countries permit the sale of complementary coverage for faster access to covered benefits or acute care services from private sector professional.”

Still, they note that opponents see single payer as government overreach that results in longer wait times for care, tax increases, and a lack of innovation.

Moving to single payer in the current U.S. healthcare environment would, Crowley and colleagues said, “cause major disruption in the healthcare industry and create winners and losers.”

The pros?

Less of an administrative burden on physicians with more time for direct patient care, and uncompensated care costs would no longer be an issue because everyone would be insured. For patients, disparities in care based on ethnicity, race, and income would be eliminated.

The cons?

Physicians would lose their autonomy and there would be the potential for increased demand for care. For patients, it would mean a lack of choice.

A single-payer system would be a hard sell to the American public, and Crowley and colleagues noted it “would be highly disruptive and could lead to price controls that would perpetuate flaws in the current Medicare payment system, including the undervaluation of primary care.”

If the single-payer system sets prices too low, then the specter of longer wait times or care shortages could ensue. It could also be costly, however, if there were not cost controls set in place.

The ACP therefore noted that the public choice model should also be considered as part of its vision for providing coverage for everyone.

“Depending on its structure and implementation, a public choice (or public option) model available to all could help to achieve universal coverage, better access, and improved outcomes without the disruption of a single-payer approach,” Crowley and colleagues wrote. “Under a public choice approach, those covered by employer-sponsored insurance can choose to enroll in the public insurance plan or remain in their existing plan. The public plan would be available nationwide, ensuring portability from state to state.”

The ACP’s vision of a public choice option is that it “be available alongside private insurance in the ACA marketplaces to inject competition into areas under served by private insurers and reduce premiums.”

They also recommend that persons age 55-64 be eligible for a Medicare buy-in.

Safeguards would be needed to ensure that the public option provides true universal coverage, such as financial subsidies and regulations to ensure affordability, and employers would have to meet “new benefit and regulatory standards to prevent adverse selection, ensure a level playing field, and promote equitable coverage.”

Disadvantages to the public option include that a more complex regulatory structure would be required and would have higher administrative costs than a single-payer option. Also, prescription drug prices would not see the same reduction as with single payer.

The ACP, while putting forth these two options, noted that it is open to other ideas, but underscored that whatever model is proposed it must be accessible and affordable to all. And, as it wrote in one of its vision statements:

“The American College of Physicians recommends that under either a single-payer or public choice model, coverage must include an essential healthcare benefit package that emphasizes high-value care, preferably based on recommendations from an independent expert panel that includes the public, physicians, economists, health services researchers, and others with expertise.”

Candace Hoffmann, Managing Editor, BreakingMED™

McLean disclosed that he is employed as the ACP’s president.

Doherty and Crowley disclosed no relevant relationships.

Woolhandler and Himmelstein disclosed that they co-founded and remain active in the professional organization Physicians for a National Health Program and have served as an unpaid policy advisor to Sen. Bernie Sanders and co-authored research-related manuscripts with Sen. Elizabeth Warren.

Cat ID: 150

Topic ID: 88,150,730,192,150,151,590,60,918