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Single-Payer Health Care? Yes and No

Duling, Reginald MD

doi: 10.1097/01.EEM.0000527817.06144.b1
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Dr. Dulingis an emergency physician in the Seattle area.

As an emergency physician with a bachelor's degree in philosophy, far be it for me to make assumptions about the undergraduate education of my fellow physicians, but I'm venturing to guess that relatively few of us pursued rigorous study in political science. I doubt scores of us excelled in comparative government or wrote theses on the sociological impact of capitalist economies.

So when surveys show that half of the doctors in the country are opposed to a single-payer system, let's be brutally honest about why that is. Our reluctance to embrace a single-payer system isn't based on a principled rejection of socialism. No, many doctors are opposed to a single-payer system for one reason: The payer.

If Bernie Sanders were touting Blue Cross-Blue Shield for all, he could count on overwhelming physician support. Instead, his call for Medicare for all makes many of us in white coats shudder.

We want to pretend that the philosophical question currently being debated is this: Is health care a right? This question was asked and answered for emergency medical care more than 30 years ago; EMTALA definitively stated that emergency care is a right. We are legally responsible for providing it, along with our on-call colleagues and the facilities in which we work.

This answer raised a crucial follow-up question: Is being paid fairly for providing health care services a right? The answer to this question is a crystal-clear, resounding no. Thus, the problem with Medicare for all.

Imagine the possibilities of a single-payer system done well. Such a system should offer the elimination of contract negotiations with multiple payers, ICD codes, billing companies, and asinine charting requirements. Throw in honest-to-goodness quality measures, improved doctor-patient relationships, meaningful tort reform, and reduced rates of unnecessary testing and procedures, and it almost sounds like we'd be onto something!

Instead, Medicare for all would only serve to pair the current soul-crushing practice environment created by government intervention with an unfathomable loss of income. Where do I sign up?

Lawmakers repeatedly claim that Americans won't go without health care because “people can just go to the ER.” Their plan is simply to stop paying for care and to thrust even more of the burden onto our shoulders.

Proponents of Medicare for all love to tout the extremely low administrative costs of Medicare compared with those of private insurers, with a straight face, to boot. Medicare imposes enormous administrative burdens on providers and facilities. How many hospital staff are required to ensure compliance with the myriad requirements of CMS, the Joint Commission, EMTALA, HIPAA, EMR, and countless other administrative mandates that have little to do with the practice of medicine? It's true that Medicare doesn't pay for these regulatory requirements; doctors and hospitals do. They remain administrative costs nonetheless.

Another favorite line of politicians: Medicare and Medicaid are able to negotiate lower rates. CMS is to negotiation just as Luca Brasi is to negotiation.

I believe that a reasonable level of health care is a basic human right that should no longer be denied to millions of citizens. It is criminal that medical expenses are the leading cause of bankruptcy in the United States in the 21st century. I also happen to endorse the crazy notion that physicians should be paid fairly for their services.

Do I support the idea of a single-payer system? I'm 100 percent in favor of Blue Cross Blue Shield for all. Medicare for all? No, thank you.

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