Once Its Greatest Foes, Doctors Are Embracing Single-Payer

By Shefali Luthra, who, covers consumer issues in health care. Her work has appeared in news outlets such as The Washington Post, CNN Health and NPR.org. Originally published at Kaiser Health News

When the American Medical Association — one of the nation’s most powerful health care groups — met in Chicago this June, its medical student caucus seized an opportunity for change.

Though they had tried for years to advance a resolution calling on the organization to drop its decades-long opposition to single-payer health care, this was the first time it got a full hearing. The debate grew heated — older physicians warned their pay would decrease, calling younger advocates naïve to single-payer’s consequences. But this time, by the meeting’s end, the AMA’s older members had agreed to at least study the possibility of changing its stance.

“We believe health care is a human right, maybe more so than past generations,” said Dr. Brad Zehr, a 29-year-old pathology resident at Ohio State University, who was part of the debate. “There’s a generational shift happening, where we see universal health care as a requirement.”

The ins and outs of the AMA’s policymaking may sound like inside baseball. But this year’s youth uprising at the nexus of the medical establishment speaks to a cultural shift in the medical profession, and one with big political implications.

Amid Republican attacks on the Affordable Care Act, an increasing number of Democrats — ranging from candidates to established Congress members — are putting forth proposals that would vastly increase the government’s role in running the health system. These include single-payer, Medicare-for-all or an option for anyone to buy in to the Medicare program. At least 70 House Democratshave signed on to the new “Medicare-for-all” caucus.

Organized medicine, and previous generations of doctors, had for the most part staunchly opposed to any such plan. The AMA has thwarted public health insurance proposals since the 1930s and long been considered one of the policy’s most powerful opponents.

But the battle lines are shifting as younger doctors flip their views, a change that will likely assume greater significance as the next generation of physicians takes on leadership roles. The AMA did not make anyone available for comment.

Many younger physicians are “accepting of single-payer,” said Dr. Christian Pean, 30, a third-year orthopedic surgery resident at New York University.

In prior generations, “intelligent, motivated, quantitative” students pursued medicine, both for the income and because of the workplace independence — running practices with minimal government interference, said Dr. Steven Schroeder, 79, a longtime medical professor at the University of California-San Francisco.

In his 50 years of teaching, students’ attitudes have changed: “The ‘Oh, keep government out of my work’ feeling is not as strong as it was with maybe older cohorts,” said Schroeder. “Students come in saying, ‘We want to make a difference through social justice. That’s why we’re here.’”

Though “single-payer” health care was long dismissed as a left-wing pipe dream, polling suggestsa slim majority of Americans now support the idea — though it is not clear people know what the term means.

A full single-payer system means everyone gets coverage from the same insurance plan, usually sponsored by the government. Medicare-for-all, a phrase that gained currency with the presidential campaign of Sen. Bernie Sanders (I-Vt.), means everyone gets Medicare, but, depending on the proposal, it may or may not allow private insurers to offer Medicare as well. (Sanders’ plan, which eliminates deductibles and expands benefits, would get rid of private insurers.)

Meanwhile, lots of countries achieve universal health care — everyone is covered somehow — but the method can vary. For example, France requires all citizens purchase coverage, which is sold through nonprofits. In Germany, most people get insurance from a government-run “public option,” while others purchase private plans. In England, health care is provided through the tax-funded National Health System.

American skeptics often use the phrase “socialized medicine” pejoratively to describe all of these models.

“Few really understand what you mean when you say single-payer,” said Dr. Frank Opelka, the medical director of quality and health policy for the American College of Surgeons, which opposes such a policy. “What they mean is, ‘I don’t think the current system is working.’”

But the willingness to explore previously unthinkable ideas is evident in young doctors’ ranks.

Recent surveys through LinkedIn, recruiting firm Merritt Hawkinsand trade publication NEJM Catalystindicate growing support. In the March NEJM survey, 61 percent of 607 respondents said single-payer would make it easier to deliver cost-effective, quality health care.

Delving further, that survey data shows support is stronger among younger physicians, said Dr. Namita Mohta, a hospitalist at Brigham and Women’s Hospital and clinical editor at NEJM Catalyst.

But it’s unclear whether these findings reflect young doctors’ feelings about the policy or whether they are tapping in to broader frustrations with the American health system.

Much like the general public, doctors often use terms like single-payer, Medicare-for-all and universal health care interchangeably.

“Our younger generation is less afraid to come out and say we want universal health care,” said Dr. Anna Yap, 26, an emergency medicine resident at UCLA, who served as a medical student delegate to the AMA until this past June. “But how? It’s different in what forms we see.”

Younger doctors also pointed to growing concern about how best to keep patients healthy. They cited research that broadly suggests having health insurance tracks with better health outcomes.

“Medical students, I would say, are very interested in public health and improving social determinants of health — one of them being access to health insurance,” said Dr. Jerome Jeevarajan, 26, a neurology resident at the University of Texas-Houston, referring to non-medical factors that improve health, such as food or housing.

Some of the shift in opinion has to do with the changing realities of medical practice. Doctors now are more likely to end up working for large health systems or hospitals, rather than starting individual practices. Combined with the increasing complexity of billing private insurance, many said, that means contracting with the government may feel like less of an intrusion.

The debate is, at this point, still theoretical. Republicans — who control all branches of the federal government — sharply oppose single-payer. Meanwhile, single-state efforts in California, Colorado and New York have fallen flat.

Also, doctors represent only one part of the sprawling health care industrial complex. Other health care interests — including private insurance, the drug industry and hospital trade groups — have been slower to warm to catchphrases like single-payer or universal health care, all of which would likely mean a drop in income.

But increasingly physicians seem to be switching sides in the debate, and young physicians want to be part of the discussion.

“There’s tremendous potential … to be at the table if single-payer becomes a significant part of the political discourse, and create a system that is more equitable,” Pean said.

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    1. 1 Kings

      No, they’re not opposed to it, but apparently ‘slow to warm up’ to single payer…along with insurance, huge monopolized hospital chains and the drug industry. Shocking.
      Hell would have to freeze over, then global warming melt it back, probably twice, before those three ‘interests’ get snuggly with it.

    2. Richard Kline

      Historically, the AMA has opposed single payer because such a system would definitely cap the ability of many physicians, especially specialists, to profit highly off their patient panels. It was a straightforward dollar decision, “I would make less under single payer.” They were, and are, correct in that conclusion. However, the growth of HMOs like toxic kudzu American health care is what has changed the calculus, not ‘idealistic youth.’ HMOs have reduced a substantial plurality of physicians at least to somewhat well-paid lackeys. HMOs tell you what they will and won’t pay for, what you are allowed to even say, effectively rationing health interventions on a least-cost-to-them basis. This is anathema to many physicians. HMOs also drop network inclusion for noncompliant physicians who keep prescribing what the HMOs won’t pay for. This is a survival issue for many physicians. The most talented specialists can go into private practice and live off of wealthy patients who will pay. The rest can’t afford to have their HMOs drop them. With many patients locked up in HMO systems, just try building a profitable private practice as a generic physician in the current environment.

      What to do? Single payer will greatly increase government involvement in coverage and administration of health care, but will all but certainly decrease intrusion into physician-patient relations. Younger physicians get this.

      Did I mention that HMO and Bamacares paperwork is simply strangling many physician practices, both in-network for HMOs and even more out-of-network physicians, who have to do all the bumpf themselves, and indeed have to hire several somebodies to do it for them? Would you rather do all that paperwork, or have a one-form single payer filing to place before payment is authorized/denied?

      Older physicians talk out of a different profit and prescriptive landscape. Younger physicians with significant six-figure certificate debt and a physician-hostile landscape would like some other options. That it is also a patient-hostile landscape allows some to take the high road in this, and believe that they act “for their patients.” Which they do, but that is not why the younger set are coming over to the other side: It’s to save their own hides. Which is fine, so long as we get single payer, and starve the health insurance industry into predating on rich folks who can afford to pay them off for elite care, which sometimes they will actually receive.

      1. Doug Hillman

        Pretender Barack Obama’s own doctor for 20+years, David Scheiner, MD, was a vocal advocate of Medicare for all. Obama snubbed him when negotiations began, and engaged in his most infamous huckster doublespeak to lock single-payer in a closet, while his cronies in crime, the insurance racketeers wrote their own bailout bill. It was a masterful heist, as was his entire regime.

        Is a 235-foot phallic monument on confiscated public land jn Jackson Park, Chicago really tall enough to commemorate the shaft he gave to his muppet voters?

        1. Etoile

          Doug Hillman, From your mouth, to god’s ears. Thank you for saying this. Now, to get the rest of the world to grasp it. Good film to see, “Now is the Time, which includes clips of what really happened in Congress during the ACA hearings. The Pretender Double Speak never intended to put single payer in the table. He has screwed those of us who had decent protection in our coverage, while allowing members of Congress to keep their golden insurance. Take that away from them, let’s see how quickly they opt for single payer.

      2. d

        The other thing not mentioned is that insurance companies pay 90 days after they approve the claim,so it could take 6 months before they get paid

  1. Livius Drusus

    Interesting. The proletarianization of doctors might be a good thing after all. My friend is a doctor and he describes his workplace as a “factory.” His time with patients is heavily monitored and he says that he doesn’t have much time or independence compared to his father. His father was an old-school independent physician.

    1. Michael Fiorill

      Indeed, that’s where Glibertarians always fail: there’s always going to be “government,” but it’s a choice between a nominally public government, able to be affected by citizen interests and actions, or a private, for-profit “government” that serves only itself and its Overclass owners.

      Doctors and other professionals are now facing the ugly realities of that “private government” that controls health care and their work, so it’s not surprising they’d give single payer, or whatever you want to call it, a chance.

    2. DHG

      As an older one retired before my time due to disability I can attest to this. My doctor has discussed this with me numerous times how his hands are tied on numerous items. He is deathly afraid of losing his DEA license to prescribe controlled substances, so much so its his own personal policy to force all of his patients on these things to have a face to face every month for which he bills my medicare insurance about 250 and causing me to have to pay a co-pay not every 3 months like it used to be but every month. I politely informed him last month that this was not going to continue and that he would be replaced if he did not do things my way. I demand from my doctors that they follow federal guidelines which allow 90 days between doctors visits or they are subsequently fired. I will get his answer next week and am prepared to can him if need be, already have someone else lined up. Doctors are hired by us just like contractors are for a home and they will follow what we decide and want (within the laws) or they are canned just like anyone else would be.

      1. Joey

        Can I charge you extra for being so bossy? That’s what your lawyer and plumber are allowed to do…

      2. Doug Hillman

        I shop for meds in Mexico or order from India w/o prescription for a fraction of what it costs here WITH insurance. Ditto for dentistry.

        Doctors are only waking up to the fact that they are being replaced by H1-B grads from Guadalajara or Bangalore. They are already being disintermediated by online docs and will likely be obsolesced entirely by autodocs, as in the movies Prometheus and Elysium. Their conversion is welcome but it is not evidence of a moral awakening.

      3. jackiebass

        Where I live all of the doctors have become employees of one of the two health care systems. Since this has happened appointments have gone from 30 minuet intervals to 20 minuets. In the past year my wife has had 4 different GP’s. They schedule her for an appointment every three mounts. It amounts to an ask the same questions session. To me it’s a wast of time. Since I see no value in these frequent visits I now change the appointment before the date to a later date.My experience with my GP is just the opposite. Instead of my usual 6 month visit the last time I saw him he said I was fine and schedules the next appointment for 1 year. In my case it is impossible to see my doctor in less than a month or two. He only take appointment for 3 days in the week. On the other two days he is assigned to other duties. My wife can get in to see a doctor the same day because the practice is staffed by interns. One doctor supervises several interns. Older doctors are hanging on until they reach retirement age. I think younger doctors realize what is going on so they are more likely to support a change like single payer. Health care where I live has become impersonal and nothing more than a money making business run by MBA’s.

  2. PlutoniumKun

    A relative of mine, who comes from a line of small town doctors in the UK, said that the NHS was something of a goldmine for them at the time. The medical establishment was historically quite hostile, but when they saw it coming the medical representatives baselined family doctors earnings on big city doctors in middle class areas – i.e. places where people who could afford to pay. The rule of thumb in rural areas or declining towns or in working class areas was that you were doing ok if you got half your patients able to pay. He talked about regularly waking up to eggs or sides of bacon left on the doorstep overnight by grateful rural patients, in lieu of the doctors fee. So the family income essentially doubled when the NHS was started. This was seemingly considered a price worth paying by the new Labour government at the time to get the medical profession on board (apparently dentists did even better as they negotiated rates per tooth, knowing that new technology meant they could go through far more patients in a day than they could previously).

    So a key problem for medicare for all is that so many US docs are so well paid – a lot more than most equivalent European doctors. If they are to be ‘bribed’ like the NHS did to get them co-operating, its going to be expensive. Good thing there is so much waste in all the other parts of the US medical system that can be excised.

    1. Musicismath

      This is a plot point in Sarah Waters’s creepy (and highly entertaining) horror novel, The Little Stranger. The (unreliable) narrator is a conservative rural GP who ends up doing very nicely out of the NHS when it’s finally rolled out.

    2. rd

      Single-payer should be coupled with subsidized medical school so the doctors don’t come out with hundreds of thousands of student debt. Doctor pay can be kept relatively low then, like most professions, because the initial large cash flow demand to service debt isn’t there.

      1. sierra7

        What the US needs is a complete social revolution. A re-thinking of our priorities. I have nothing against “capitalism” but, there have to be limits on what we consider beneficial to society and what is for “consumerism”. The for profit medical insurance entities and the for-profit medical plans available are sucking the life out of this country. The for-profit educational system is also sucking the future earnings of our graduates. We are either going to be a compassionate society or a greedy one with the bottom line, “Kill them all and let God sort them out”!

  3. gearandgrit

    I’m a pharmacist and I’ve never understood the reluctance to single payer from my peers and physician partners. Private practices and privately held pharmacies are closing their doors daily because it’s impossible to navigate the insanity that is billing and being reimbursed by thousands of different insurers. Physicians need to employee an entire billing department at which point it makes more sense to go join a large healthcare group (then you get to enjoy burning out).

    I see the exact same thing in pharmacy. I would love to own my own pharmacy, but financially speaking it doesn’t make a lick of sense. You have to carry a million dollar plus inventory even in a small/medium size pharmacy because insurer X want this drug while insurer Y requires something else. You spend all day navigating idiotic billing and reimbursement problems from the multitude of insurers out there.

    Give me one insurer and one formulary. Suddenly a ton of the overhead is gone and private practice becomes much more viable. Plus we get a lot more time to actually work on what we went to school for. Healthcare.

    1. Kent

      I have a few friends who are physicians. I’m astounded at the complexity they accept in their lives. They spent 10 – 12 years to become a physician then spend a big chunk of their day explaining why they used one billing code instead of another. While they all make good money, it would never be worth it to me. I’m happier bringing in $100K/year running a small IT shop and enjoying every minute of it.

      I tend to believe that the sheer amount of knowledge physicians have to know, coupled with the complexity of the diagnostic and clinical practices makes physicians more accepting of the ridiculously complex billing practices of insurance companies. I would bet if most physicians actually worked for a couple of months in Canada, the vast majority would demand some form of single-payer.

      I also bet there is a tier of super high-income physicians who are purely money motivated and they are the ones driving most of the opposition.

      1. Joey

        I don’t believe single payer would eliminate burn out as most of the paperwork and frustration is from money saving cookie cutter rules that aren’t scientific. I couldn’t give a lady with complex regional pain lyrica despite her being allergic to gabapentin and being on nortriptyline because she hadn’t failed duloxetine. I relented despite the dangers of serotonin syndrome warning her to stop if ill believing it was a checklist. She threw up for 3 days from the known interaction.

        Then the lyrica was turned down ‘because it was too late to appeal’ the denial based on not having failed duloxetine.

        This was Medicaid. Government insurance. Nothing to do with multiple networks etc.

        Being a subspecialist, pools of money aren’t an appealing alternative. Nothing beneficial for providers that treat the tricky cases.

    2. Richard Kline

      Yep. That’s the situation, and you get it. Single payer mostly impacts the ‘stupidity margin,’ while you might actually be able to turn a profit on it.

    3. Octopii

      I’m waiting for my very own independent neighborhood pharmacy to fade away, although I hope it does not. The difference is stark between the independent and any CVS/Walgreens/Giant/Walmart. The owner knows me by name and has always taken care of my needs with a smile and compassion. She seems much more stressed these days than a few years ago.

  4. Carla

    “Meanwhile, single-state efforts in California, Colorado and New York have been sabotaged.”

    There. Fixed it for you.

    Also, apparently the author of the piece never heard of Vermont.

    There are lots of things wrong with the article. The writer’s failure to cite Canada and Taiwan as examples of single-payer systems that work, and work well, is only one. But the general point that younger physicians are more likely to be drawn to the field by a sense of social justice is a good one, so I’m glad she made it.

    1. zagonostra

      Sabotaged by whom? The Democrats no less, just see how Anthony Rendon derailed single payer in CA…the politicians are bought and paid for in both parties

      Until there is a Party realignment or a serious third party challenge, no substantive improvement will happen in healthcare, it’s close to one fifth of the economy…too much money flowing into too many corrupt and immoral people.

    2. JTMcPhee

      Is “everyone on the same insurance plan” just an uneducated writer, or a “tell?”

    3. Brooklin Bridge

      ++ (as usual). Also, Isn’t, “polling suggests a slim majority of Americans now support the idea [of single payer]” purposely misleading? Even in the WaPo article linked to,, the phrase, polls find, is used – and not polls suggest. The actual breakdown, again from the WaPo article she links to, is:

      Nearly three-quarters of Democrats support a single-payer health plan (74 percent), while a slightly larger share of Republicans oppose it (80 percent). Independents break the tie, supporting a government-run health-care plan by 54 percent to 40 percent.

      . With friends like Luthra…

      It’s worth pointing out that this grouping by age is similar to the Sanders groupings. I realize it’s only anecdotal, but I’ve met a fair number of elderly doctors who are fully behind single payer or something similar since they loath the self defeating (in terms of care) hoops the insurance industry makes them jump through.

      1. Carla

        My primary care doc, who is on the staff at the Cleveland Clinic and is probably at least 60, has been quietly working for single-payer for decades, and I only learned this a few years ago. I also have the privilege to know many fine physicians of, ahem, a certain age, who devote countless hours to Physicians for a National Health Program. These docs are heroes, in my book.

      2. Anon

        Yes, my elderly doctor has finally had enough of the billing maize and pre-authorization paperwork (30% of his income went to front desk staff) and will retire on September 1, 2018. I asked him to delay it for 10 more days.

        He was truly the best doctor I’ve ever had and he supports single-payer; because he sees everyday the delayed health service that private insurance brings to most of the community.

      3. Richard Kline

        I was personally acquainted with several dozen physicians (worked in a hospital) who retired out rather than live in HMO Hell. Many of them were ‘in their seventh decade,’ and very clearly single payer advocates.

        Again, specialists have been the big hurdle. A good specialist in private practice could turn over $500,000 a year easy; not a few made a mil per annum. A tenured radiologist, let alone a neurosurgeon, beau coup bucks. They were never going to be for single payer as a group. But the bulk of the profession doesn’t enjoy such a high perch.

  5. Daniel A Lynch

    I do not see this as a positive.

    Just as neoliberals embraced Romney-Care to head off single payer, doctors are embracing single payer to head off nationalized health care.

    Try talking about nationalized health care with a doctor who advocates single payer, like Margaret Flowers, and you run into a stone wall.

    Single payer might be an improvement over our existing mess (though it would not necessarily fix the biggest problem which is monopolistic providers) but nationalized health care, as Finland has, has proven to be better and less costly than single payer / private provider systems.

    The “left” needs to get over its infatuation with single payer. The more logical goals should be providing free or nearly free health care to everyone and controlling provider costs. There is more than one way to do that. It could even be done with Romney-Care as some European countries have proven. “Single payer” is merely a buzzword.

    1. JEHR

      ” The more logical goals should be providing free or nearly free health care to everyone and controlling provider costs.”

      DAL, your sentence above describes single payer. Single-payer could also be descriptive of nationalized health care. The term is more than a buzzword that deserves more research and understanding.

  6. MedicalQuack

    Hey I wouldn’t mind single payer, but I’m also a realist wondering who’s going to fund and write the code for this type of a plan to work, and how many years will this take? Granted CMS has the underlying ability for the base of it, but there’s tons of code and administrative models that need to be built on top. So again, not discounting such a plan and I have written my blog covering the “business of healthcare” for 10 years and I used to write medical software and know the clouds don’t open in the sky and with a bolt of lightening all the algos and code will appear to help us out, that’s a huge problem today with people confusing virtual and real world values…I think it’s a real virus floating around in people’s head to where they choose a perception they like versus looking at the real world, and yes, healthcare today sucks, all because of the quant models that exist everywhere, not much different than tweaked financial models running on Wall Street.

    1. Kent

      Open your mind a bit. Suppose we change how we value services? Instead of writing highly complex code to manage highly complex billing procedures, we just say we are going to pay the physician $100/patient they see. We pay hospitals $1000/night per filled bed. Both just have a website where they type in provider id, and patient SS Number.

      1. marym

        Happy to report that Medicare is switching from SSN to unique identifier, and is mailing out new cards to all participants!

      1. rd

        I have been baffled that US companies don’t want to reduce the healthcare insurance expenditures. Other countries have figured out how to do it.

        1. Mel

          ISTR that when public health care started getting debated in the U.S., maybe a quarter century ago, big U.S. companies (I’m thinking Walmart, GM) were in favor of public care for that very reason — reducing expenses.
          I can only suppose that since then they invested in insurance companies instead.

    2. Carla

      In Taiwan, it took 9 years (1995 to 2004) from the inception of single-payer to covering 99 percent of the population (Wikipedia).

      And from this link: http://www.pnhp.org/news/2015/march/tsung-mei-cheng-on-the-success-of-taiwan%E2%80%99s-single-payer-system

      … here are some lessons learned:

      “The most important lesson of Taiwan’s experience is that the single-payer approach can offer all citizens timely and affordable access to needed health care on equal terms, regardless of the patient’s social, economic, and health status; sex; age; place of residence; and employment status.

      A second lesson is that a single-payer model such as Taiwan’s can control costs effectively. It is administratively simple and inexpensive and is the ideal platform for a powerful health IT system. It also facilitates global budgeting, if that is the only way to keep health spending in line with the growth of GDP.

      A third lesson is the importance of investing heavily, up front, in a modern IT infrastructure. A modern IT system such as Taiwan’s allows the government to have information about health utilization and spending in almost real time.”

      1. Carla

        P.S. In Taiwan’s single-payer system, administrative costs account for 1 percent of the total.

      2. Kurtismayfield

        Thank you for your post Carla.. evidence is not what we lack, it is the will and the whole “Giving health care to those that are not deserving” narrative. (I like to call people out on their racists overtones when they fall back on this). Which is so ridiculous on its face, since we are going to pay for them anyway when they check into an emergency room.

        1. Carla

          … and also ridiculous because each of us is probably considered “not deserving” by someone. ;-)

          But just out of self-interest, if nothing else, it seems so obvious that we all do better when we all do better.


          1. Amfortas the Hippie

            “not deserving”
            reckon hijacking Jesus was one of the smartest things the Machine ever did.
            In the feed store, one often hears small ranchers and whatnot(hanging out there til 9 or 10 am, no less,lol) complain about “welfare queens”(less, lately, which is interesting).

            when I’m asked(which is also and still interesting), I say that “there, but for the grace of god, go I” used to be a thing, and they hafta change the subject.
            This is a new thing- prior to 2-3 years ago, I would have been ignored or ridiculed.
            The dissonance between their Faith and their ranting might be becoming noticeable to them.
            The usual caveats regarding this particular place apply….as do those about the difference between online and real world behaviour.

      3. marym

        Can the 9-year timespan referenced in the Wikipedia entry possibly be a poorly worded description of the implementation? From what I’ve read, some 40% plus of the population had no insurance, and some 50% plus had coverage under various employer and government plans. These plans were were consolidated under the national health plan, and the national plan was universal from the start. The “99.9%” I think may refer to people in remote areas, for example, who may not be insured. That number still shows up with similar wording in later analyses, for example here “as of 2016.”

        They did years of study of alternatives, beginning in the 1980’s, but the plan proposed in 1993 by a commission headed by William Hsiao was passed by the legislature and implemented by 1995.

        From a 2009 interview with Taiwan’s Health Minister:

        Taiwan established universal national health insurance in 1995, bringing overnight the then 41 percent uninsured under the umbrella of national health insurance (NHI).

  7. saneperson

    In Germany as in France everyone is required to carry health insurance. Germany differs by allowing private for-profits to compete with the non-profits that dominate the health insurance market.
    The economic benefits of universal coverage are based on universal participation. “Socialized medicine” is more efficient than the US model because the efficiencies are achieved through everyone paying something in. It’s insurance in the best sense – many coming together and paying a little in order to save the individual from the financial catastrophe of serious illness. IMHO the only way around requiring everyone to pay in is to design health care financing as a tax, as the UK does.
    And many physicians in the US would earn less – first and foremost those who have porked out at the needless procedure/potential-liability-made-me-do-it trough.

  8. Disturbed Voter

    The doctors I know are going private, accepting cash only. Is that single-payer?

    They have no desire to makeover the US into Cuban medicine.

    Everyone who loves Cuban medicine should move there … sincerely.

    There is no such thing as free medicine or anything else … except in the delusion of control fraud.

    1. Yves Smith Post author

      The plural of anecdote is not data. The doctors you know are a much smaller sample than the one Kaiser Health News is reporting on.

      And I don’t know what planet you’ve been on. Every other advanced economy in the world has a health care system that is either significantly or entirely socialized. They all deliver better health outcomes at lower cost, around half the US.

      You are being ripped off and yet you defend the current system. Help me.

      1. Disturbed Voter

        Kaiser wants to be the oligopoly running the hospital administration control fraud. Don’t blame them. One health plan for all and in the dark bind them. Sauron does Medicare.

        Not defending the current system, just quoting data. Santa Claus is not coming to town. Many doctors will quit before they will put up with the bureaucracy of socialist medicine.

        We don’t have this problem in military medicine. If you want bureaucratic medical care, join the military. But you have to assume certain obligations to get it.

        The problem with political-economy is … magic wish fulfillment isn’t real. I would be happy with single payer aka Medicare for all, because in the short term it benefits me and my family.

        I don’t have to worry about the long term being old.

        1. The Rev Kev

          My daughter had a minor injury recently and it never threatened to put is in the poor house. The reason? Because we have single-payer health in this country. I would hate to think of how much we would have paid if we lived in the US (‘Is that your phone number, doctor?’ ‘No, that is the amount that you owe!’) And our system even has reciprocal rights with several other countries. More on this system at-


          The US is the only industrial country on the entire planet that does not have this ‘magic wish fulfillment’. That is, unless you count that ultra-socialist organization the US Military.

          1. Disturbed Voter

            This is because the US is predatory. Opponents of the US forget this at their peril. Think of Aleppo in Syria now vs 2010. It isn’t a question of affordability. That is the red herring.

            Different countries have different priorities. Some have better priorities. The US is in the process of destroying the EU from the start of this year using the new trade wars.

            1. Mel

              And the predators are after you. You’re offered a third choice and you turn it down. “Give me victimhood or give me death!” you say.

    2. willf

      There is no such thing as free medicine or anything else … except in the delusion of control fraud.

      Your use of the phrase “control fraud” in this context is incorrect. You seem to regard it as something that you know is bad, but don’t understand why.

      Control fraud is a term that denotes the process where the officers of a corporation (CEOs, CFOs and the like) commit fraud not just against their customers or clients but also against their own shareholders and employees.

      Read some Bill Black on the subject if you care to learn.

      1. Arizona Slim

        As I understand it, control fraud is gaining control of a company for the purpose of looting it.

        1. Carla

          Or isn’t it also gaining control of a country (the U.S.) for the purpose of looting it (by the finance/insurance industry)?

        2. willf

          As I understand it, control fraud is gaining control of a company for the purpose of looting it.

          It’s similar, although that could also be called a “bust out scheme“.

          According to Bill Black: “Control frauds are crimes led by the head of state or CEO that use the nation or company as a fraud vehicle.”

          Still no idea how that equates to what the commenter above is calling “the delusion of control fraud”

      2. Disturbed Voter

        Hospital administration in the US over the last generation, is looting aka control fraud. The whole medical insurance business is the same.

    3. Matt

      The doctors I know are going private, accepting cash only.

      Surely that’s because they’re tired of dealing with private health insurance companies?

      1. Disturbed Voter

        Yes, but that isn’t the only problem. With cash only, they have no insurance company to deal with, not even just one giant government bureaucratic one.

    4. Winslow P. Kelpfroth

      Left out of the discussion is what happens when the American semi-free medical market gets a chance to work. Seems to me that 20 years ago lasik ran something in excess of $20K per eye and was not covered by third party payment. Now it’s in the $1500 range. I’ve dropped dental insurance because the premiums barely cover the cost of routine care

      My newly licensed youngest is seriously considering concierge medical service when she gets tired of the highly overpaid locums she is doing now. Good for her.

  9. Synoia

    The UK NHS pays doctors on a capitation rate, and does not use pay-for-procedure.

    The elimination of billing system and the additional clerical overhead is one of the greatest cost differences between the the UK system and any concept of single payer in the US.

    UK: No Bills. No Billing and Accounting. No checking for overcharges.
    US: Costly Billing: Billing and Accounting are very costly. Opportunities for overcharging (fraud).

    US single payer eliminates the 30% take by the, insurance companies which would be a good start.” It does not address overcharging and medical fraud.

    The next step in the US is to eliminate the costs of becoming a Doctor. The pressing need for a new doctor to pay interest on a $250,000 student loan most certainly drive many decisions and need for high pay at the individual level.

    Once the cost of Medical education is addressed, The unaddressed cost of all higher education will come under pressure.

    A second set of costs to come under pressure would be unhealthy behaviors, driven by advertising. Yes, Sugar would be an early target (Soft drinks, breakfast cereal, fast food, etc).

    Once could call this the “Economic Domino Theory.” Knock over one domino, cost of medical care, and may others will fall.

    As usual the Devil is in the details.

    1. HotFlash

      The next step in the US is to eliminate the costs of becoming a Doctor.

      Hear hear! To that I would add, end the limits on med school entrance. And definitely promoting healthy lifestyle. Efforts to do that here are running into complications due to resistance from Big Food, of course, and restrictions under NAFTA and other ‘free trade’ agreements.

      1. Lyle

        One other difference between Europe and the US is the traditional track to med school requiring a bachelors degree and then apply to med school. A few schools in the US now admit to a medical program high school graduates, and the degree is complete in 6 years saving 2 years right there. This is how it is done in Europe. And represents at least a 20% saving in education costs.

        1. Carla

          “A few schools in the US now admit to a medical program high school graduates, and the degree is complete in 6 years” — Excellent!! I’m so happy to know this!

        2. Tom Bellhouse

          Consider alleviating the shortage of MD’s by training more advanced practice nurses and empowering them.

          1. Felix_47

            Why not just do what we have been doing. Bring in more Pakistani, Indian and African doctors on H1B visas. That should help control the costs of the doctors.

            1. oh

              It won’t. The hospitals will use this slave labor to markup up their costs and hold them captive by threatening to cancel their visa just like iT companies do.

              1. Disturbed Voter

                Yes. Innocent people simply can’t imagine someone gaming the system.

                Dr Zhivago is our future.

    2. Kurtismayfield

      Once the cost of Medical education is addressed, The unaddressed cost of all higher education will come under pressure.

      This is what I don’t understand.. the education process for doctors is already subsidized

      Princeton economist Uwe Reinhardt published an op-ed in Friday’s New York Times suggesting that the $15 billion annual government subsidy to teaching hospitals for graduate medical education — mostly for residency programs….

      Even worse, the total tuition and fees that medical schools booked in revenue was around $5B, or less than 4% of their revenues. ( You have to download the PDFs to see the data)

      Why can we just make $15 B into $20 B and take a huge pressure off doctors??

  10. HotFlash

    When single-payer came to Ontario, it was originally funded by premiums ($32 single, $64 family, per month), so , not universal. Eventually it was changed to tax-funded and universal — any legal Ontario resident qualifies.

    Coverage varied, still does, by province. Back in the beginning doctor visits were covered, hospitalization, surgery, specialists *except* anesthesiologists (they resisted for the longest time). Technically there was a lifetime limit of $10,000 but I never heard of it being enforced and eventually it was scrapped.

    Here in Ontario prescriptions were not covered, still aren’t, nor naturopathic medicine of any sort (CMA howled that they weren’t *real* doctors), chiro was partially covered, but Mike Harris, our first neoliberal premier, cut that out, along with ophtomologist visits for over 16-under 65. Liberals never reinstated it (odd, that).

    The insurance companies definitely fought it tooth and nail, but lobbying and bribery were not such well-honed skills back in the day. Big-city specialists were generally agin it, but the hospitals, mostly private not-for-profits, and often religion-affiliated were for it, as were small and rural practioners: “We’ll get *paid*!”

    Insurance companies were prohibited from insuring any portion of the fee not paid by OHIP for covered services, eg, chiro after the $25 pmt or billing over the OHIP rate for medical services when OHIP came in. Insurance companies continue to exist, writing life, long-term disability, prescription, dental and the like. It may be a coincidence that we in Canada pay more for auto insurance that you do, despite govt-pd health care and our generally non-litigious culture.

    Note to MedicalQuack re ‘wondering who’s going to fund and write the code for this type of a plan to work, and how many years will this take? ‘

    Well, Medicare was operational in 6 months, and that’s without computers. The key is simplicity. The coding gets very, very straightforward when providers do not have to deal with multiple insurance companies fighting them tooth and claw to deny or at least delay every dime, when they don’t have to itemize every aspirin, pillowcase, bandaid and graham cracker. Remember those old phone bills that itemized every long-distance call? Unlimited calling for a flat fee is more economical for the telco’s because it is so easy to administer. And, of course, they could hire some of our nice Canadian programmers. Or maybe Amazon, I hear they know how to sell things online.

  11. Susan the other

    I used to think nationalized health care would not happen in my lifetime. But I think it might. Mainly because the problems created by the other options are too insurmountable. That leaves national health care the only feasible plan standing. And nobody can squawk because we have literally tried everything else. That’s encouraging. And every day, I see more and more examples of how sensible and positive the “millennials” are. They are the generation that will change America. And if they do the nickname “greatest generation” should be theirs.

    1. jrs

      it seems it has very little individual or business downside other than the insurance companies. That’s why it will probably happen. I mean other policies like increased minimum wage have a business downside and some won’t pay it. Some policies like free college have individual downsides (it forces into much more competition with vastly more new degree holders both those currently with and without degrees). But being single payer would actually save businesses money and aggravation (at the price of giving up some control) and save individuals both of those as well, it seems there literally is NO downside except for the entrenched insurance players.

      1. Carla

        And people who work in the insurance industry have told me for years that single-payer is inevitable. They’re just getting all they can for as long as they possibly can. I’m sure the insurance folks themselves are amazed at how long they’ve been able to stretch this grift. Thanks mainly to the ignorance of the American people and (as someone else pointed out above) the criminal determination of the Democrat party to see that it “never, ever” happens.

        1. JBird

          That’s because the endless bribes donations that the leeches in the insurers’ protection racket and the extortionists in Big Pharma made to Congress ensured it. No amazement needed.

  12. leapfrog

    “Students come in saying, ‘We want to make a difference through social justice. That’s why we’re here.’”

    I love this attitude. That’s what I want in my doctor.

    P.S. Do you think we could remove some pork from the MIC budget to help fund single-payer? Yeah, I know. Heresy!

    1. Carla

      No need. The federal government can fund single-payer in the exact same way it funds the military. By creating the money.

      (I agree with cutting the military budget, but that is irrelevant to funding single-payer.)

  13. rtah100

    The picture painted of the flat fee NHS is alluring but sadly no longer true.

    GP’s (family doctors) are paid on a mix of capitation (how many patients enrolled at the surgery) and incentive schemes (how many vaccines adminstered, how many patients pushed onto statins), with the attendant misprescription….

    Secondary care is now a mind-boggling mix of a public and private providers, pricing per procedure and an insane internal market where groups of family doctors are supposed to run major procurement and forecasting exercises of secondary healthcare demand, which then determines the whole shape of public and private hospital provision in their area. This was Jeremy Hunt’s gift from the neo-liberal playbook.

    I’ve seen the system up close from the beginning. My father was the youngest consultant oncologist (in modern terms) in the NHS at its formation and it is true that Aneurin Bevan “stuffed their mouths with gold”: my father’s salary as a junior doctor pre-NHS was laughed at by my grandfather as less than he paid the cook and the NHS meant an immediate improvement for him and opportunities outside the London teaching hospitals. A contemporary and college friend is a disillusioned junior doctor turned clinical ontologist (not a typo, he is well versed in Snomed), who used to try implement it for major contractors and clinical consulting groups “reforming” the NHS. My wife was a Department of Health policy official until maternity leave coincided with Jeremy Hunt and she has gone been back to the mess he left.

    (Another college friend is trying to “disrupt” healthcare with machine learning – a fool’s errand and an privacy sink but luckily NHS IT is so bad and so much is still on paper I can be sanguine it will never happen….)

  14. JCC

    I’ve posted a few links over the years regarding my father, a surgeon, and “The Things My Father Told Me” with regards to the profession.

    When Medicaid and Medicare were first implemented, fresh out of Residency and firmly in place as a small town doctor, he hated the idea. By the time he passed away he often could be heard ranting against Private Insurers, Private Hospitals, cost and availability and was moving into the Single Payer Camp, particularly after friends of mine (and as we grew older became friends of his) died prematurely partially, if not wholly, due to lack of affordable Health Insurance.

    My point is that it isn’t just many of the newly minted Doctors supporting this, many of those that were part of the “Silent Generation” and later thought it was an idea whose time had come as early as the 1990’s. They fully understood that most of the Health Insurers had gotten very greedy even then, not to mention that the paperwork was endless, expensive, and very inefficient.

    As I’ve mentioned before, I’ll never forget when he told me in the early 90’s, “The smartest thing you ever did was to ignore me and not go into medicine.”

    1. Joey

      My father told me not to follow. I did anyway and love the actual work, but hate that neither myself nor my patients have any say. I don’t like Humana using my labor to provide stock dividends, but I don’t cherish Uncle Sam using his savings to drone bomb, either. Which is what I would be thinking with every bottom line directive from a single payer..

      Medicare, VA, ACA, all discourage or prohibit opt-out, presumptively to prevent 2 tiers. But goodrx offers better price on generics than part d. The waste in health care isn’t at the bedside…

  15. impermanence

    Reality suggests that the only sane solution to this health care nightmare is to make each individual responsible for their own health. The current sick care system is designed to extract as much money out of the ill as is possible, the only potential outcome when corporations are in control.

    Health care should be about keeping people healthy, period. If individuals make poor life choices or are just plain unlucky, that’s the way it goes. Perhaps a feedback system such as this will encourage more people to make better choices, maybe not, but just the same, why should the minority of healthy people have to pay for the majority of ticking time bombs.

    As a practicing physician for nearly four decades, I can tell you that the health of your friends and neighbors is not so wonderful. The last thing you want to do is pay the bill for their over-indulgence of every damn thing!

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