Steps toward a solution: Time to put Single Payer back "on the table"

During the health reform debate, one option we were assured was never seriously “on the table” was “single payer”, or Medicare for All. President Obama, who as a senator had indicated his support for this solution, backed away from it as fast as he could. In this he was undoubtedly encouraged by his many advisors, who have also encouraged bank bailouts, “compromise” on the debt ceiling, etc. (see June 18, 2009,“No Single Payer”: Sebelius – making policy for the powerful).  This is not to say that there were not supporters of single payer within government; there were and are. HR 676, “The Improved and Expanded Medicare for All” act, principally sponsored by Rep. John Conyers of Michigan, had nearly 100 co-sponsors in the House. Sen. Bernard Sanders of Vermont introduced a single-payer bill  in the Senate. Vermont, in fact, has become the first state to move toward a form of single payer on a statewide basis.

As anyone who has been reading this blog for any amount of time knows, I am a strong advocate of single payer. (A few of the many MSJ references: April 28, 2011 Perception and reality of economic inequality; July 22, 2010, Improving quality and access still requires coverage for all;  April 10, 2009, Does the nation need a clear policy on a right to basic health care?).

My reasons for support of single payer are several:

1. It covers everyone. No one is left out. There is no complex system of “these people get coverage this way, those people get coverage that way, and those people (too bad) are left out altogether.”


2. It provides a uniform benefit package. Everyone can get the care that they need, without concern about whether they are covered. In our current system, even many people who are insured have inadequate coverage. In addition, to the extent that the society decides to limit access to unproven or detrimental (see #5 below) or even “too expensive” care, no one gets it.


3. It saves money. Off the top, it saves the profit being taken out of the system by insurance companies and other for-profit businesses. It saves even more money by eliminating all that being spent by those companies to deny care claims and by providers of care to try to get paid (see A Modest Proposal: Bribe the Insurance Companies, August 23, 2009).


4. It puts us all in it together. This is a core method of ensuring social justice. The more educated and empowered among us will work to make sure that they get good care, and this benefits everyone.


5. It provides the basis for ensuring quality, by having a degree of control over what gets reimbursed, and therefore what gets done. It may not ensure quality by itself, but it is almost a necessary component.

In 1964, President Johnson signed the Medicare Bill in Independence, MO, giving cards #1 and #2 to former President Harry Truman, who had fought for national health insurance in the late 1940s and lost, and his wife Bess.Forty-seven years later, Medicare has proven its importance in providing a single-payer program for seniors. It is the largest payer in the country, and the rates that it pays for services determine those paid by other insurers. While expanding Medicare to everyone should be the centerpiece of health policy, it has instead become the target of proposals to cut coverage to those who already receive it, particularly from the right. This has led to a lot of bad ideas from politicians such as Rep. Paul Ryan and Sen. Joseph Lieberman (see Medicare: We need to expand it, not cut it!, July 1, 2011).

The “poster child” for a single payer system is Canada, which has had it since the early 1970s. Based on the principle of social solidarity, not often apparent in the US, the Canadian federal government set the criteria for the program (which is also called “Medicare”) and the individual provinces set the specific terms and fund it. There is local (provincial) autonomy within the boundaries established by the federal government (see December 14, 2009, Tommy Douglas and the Canadian Health System;  May 27, 2010, Universal Coverage and Primary Care: The US needs both). Several recent articles have addressed the degree to which changes in the primary care system to create “medical homes” in Ontario, Canada’s largest province, have enhanced the quality of patient care, access of patients, lowered cost, and increased the income of primary care physicians (see Rosser et al, “Progress of Ontario's Family Health Team model: a patient-centered medical home” [1]). It is critical to note that this Family Health Team program was really only possible on such a scale because Ontario, like the rest of the country, has a single-payer system.

The importance of increasing, or at least not decreasing, the income of primary care physicians relative to other specialist, has been addressed in several other posts. What about all physicians, as a group? The AMA and other physician groups were, after all, largely responsible for the defeat of Truman’s national health insurance program and were major opponents of the US Medicare and Medicaid programs. Surveys by Physicians for a National Health Program (PNHP, see especially “Single Payer National Health Insurance”) have shown increasing support for single payer among the physician community, with universal health coverage being supported by a majority of US doctors in 20 (Support for national health insurance among US physicians: 5 years later[2]).

A new study may help to persuade physicians that single-payer systems are actually in their financial interest. Writing in August 2011 in Health Affairs, Morra and colleagues report that “US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers”[3] (hyperlink to abstract). The title basically says it all. While both Canadian and US physicians spent time (translated into money!) interacting with insurers, the single payer in Canada and hundreds of payers in the US, about patient benefits and payment, the staff of US physicians spent 10 times the amount of time in such activities as did their Canadian counterparts. The authors estimate the cost to US physicians at $82,975 per physician per year, nearly 4 times the $22,205 cost to Ontario physicians. In addition, these costs fall disproportionately highly on small physician practices, which are more likely to be primary care. They conclude that “If US physicians had administrative costs similar to those of Ontario physicians, the total savings would be approximately $27.6 billion per year.”

From a financial point of view, we have an apparent dilemma in the US. The cost of Medicare is very high and creates financial threats to the economy. The reimbursement from Medicare to providers is often too low to make them a desirable payer. But there is a solution. It involves getting control over costs. First, do not pay for harmful or questionable interventions, do not pay major markups to generate excessive profit for private companies, and use the large scale of government purchasing to get good prices for drugs, unlike the boondoggle of Medicare Part D, the prescription drug program in which Medicare pays retail prices to pharmaceutical companies.

The solution is also to emphasize more primary care and prevention (October 18, 2010 Lower Costs in Grand Junction: More Primary Care, Less High Tech). The next steps will be harder, for they will involve making difficult decisions about the cost/benefit ratios of different types of care, particularly as the availability of new, expensive, high-tech interventions provide allure, if not always results.

The way not to do this is for policies restricting access for a part of the population (working and poor people) to be made by another part of the population (big businesses, politicians, and lobbyists) who will not be affected by those decisions. A single-payer system in which we are all covered by the same benefits does not automatically save money, but at least makes it possible.

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[1]; Rosser WW et al, “Progress of Ontario's Family Health Team model: a patient-centered medical home”, Ann Fam Med. 2011 Mar-Apr;9(2):165-71.

[2]Carroll A, Ackerman R “Support for national health insurance among US physicians: 5 years later” Ann Int Med 1Apr2008;148(7):566-7.

[3] Morra D, et al, “US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers”, Health Affairs August 2011 vol. 30 no. 8 1443-1450.

Universal Coverage and Primary Care: The US needs both

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In “Reinventing Primary Care: Lessons from Canada for the United States” (Health Affairs, May2010;29(5):1030-5), the eminent scholar Barbara Starfield provides just that – lessons from Canada for the United States. For decades, advocates of comprehensive health reform have pointed to our northern neighbor and suggested that a “single payer” system such as that in Canada would be a more-than-reasonable solution. In Canada, provincial governments provide the funding for health care services, under the guidance of the five principles set out in the Canada Health Act of 1972: public administration, comprehensiveness, universality, portability, and accessibility. The principle of universality means that every Canadian is covered, with the same health insurance benefit package, as every other Canadian. (In fact, because the various programs that are together called “Medicare” in Canada are provincial, it would be more accurate to say that every resident of a province has the same benefit package as every other; however, all provinces provide coverage for all essential services; more can be found on the website http://www.canadianhealthcare.org/.)

Dr. Starfield’s article goes systematically through a variety of indicators of health status and costs, comparing the two countries, citing both similarities and differences between them. Overall, the US looks much worse in health status and much greater in cost. While not the best performer among the Organization for Economic Cooperation and Development (OECD) countries (representing the most developed, “first world”, countries) in almost any area, Canada is ahead of the US in most, often significantly. A few examples from her “Exhibit 1” include Life Expectancy at birth (Canada ranks 9, the US 25), Potential Years of Life Lost at age 70 (Canada is 13, the US is 21), and Infant Mortality (Canada is 24, the US 26). Canadians have a lower death rate for conditions “amenable to medical care”, meaning that if you got care you’d be less likely to die, and the differences are not (as is sometimes asserted) due to racial differences between the two countries:

“Studies of deaths from treatable conditions also show better performance of the Canadian health system compared with that of the United States, and the differences are not a result of existing racial disparities. That is, the worse health of the U.S. population compared with that of Canadians is found even when comparisons are restricted to the white population. Longterm comparisons show that the life expectancy of Americans has been worse than that of Canadians since the beginning of the twentieth century, but that most of this difference was a result of lower life expectancy among African Americans. However, this situation changed in the 1970s, when Canadian life expectancy rose even above that of white Americans.

“Differences in death rates have increased over time, with Canada improving in rank and the United States declining in rank. Differences by cause of death for conditions amenable to medical care are on the order of 25–60 percent lower in Canada than among U.S. whites and have increased over time since the 1980s.”

Starfield attributes the difference primarily to two features of the Canadian health system, a “universal, publicly accountable health insurance system”, and the presence of a strong primary care base. The first should be a “gimme”; of course such a system would make a difference, of course it is likely to improve the health of the population and reduce the burden of disease, physical, psychosocial, and financial, on both the individual and their family and the society. It is absolutely obvious that a rational, mature, and responsible society would provide financial access to health care for its people.

Unfortunately, that is not the case for the US, the only OECD country which does not have such a system, relies on “employer-based health insurance for the nonelderly population”, and it is not going to change under the new health reform law, the Patient Protection and Affordable Care Act (PPACA). PPACA, even when fully implemented, will not cover everyone, will not control costs, will allow insurance companies to charge up to 3 times the premium for older (and note that this would be pre-Medicare; “older” could be over 40!), and will not have either the universality or public accountability to ensure quality care. We will continue to hear the pain of patients such as the woman featured in the “2009 Road Trip Video” by Mad As Hell Doctors (http://www.madashelldoctors.com/) who pulls off her turban to review her hair lost to chemotherapy, and tells us that “when I found out I had breast cancer I was worried that I might die, but I was terrified about how I would pay for it.”[1] Come on. This is simply not acceptable in a wealthy developed country. Those who do not support such a system are either incredibly greedy, selfish, and corrupt, as are the insurance companies and their minions in Congress, or incomprehensible.

The other difference between the US and Canada that Dr. Starfield emphasizes is the presence of a strong primary care base. She notes that “Several international studies have confirmed the importance of three health-system characteristics of countries that achieve better health at lower cost: government attempts to distribute resources, such as personnel and facilities, equitably; universal financial coverage either through a single payer or regulated by the government; and low or no cost sharing for primary care services…U.S. policy achieves none of the three structural characteristics of good health systems. Canada achieves all three. “

I have repeatedly written about the lack of sufficient primary care capacity, and primary care production, in the US, and clearly I am not alone. It has become almost a deafening chorus, with report after report identifying the deficiency in primary care, and the need to increase the number and percent of medical students entering primary care; much of this is presented in “Who will provide primary care and how will they be trained?”, the proceedings of a conference in April 2010 sponsored by the Josiah Macy, Jr. Foundation. PPACA does commit significant resources to supporting primary care, but we are far from having a sufficient number of primary care providers or a reasonable geographic distribution of those we have. Canada and the other OECD countries have at least 50% of their physician workforce in primary care. When Canada saw that percent decreasing, they took strong action to reverse it, and now have a majority of their medical students entering primary care.[2] The US, on the other hand, has only about 16% of its physician workforce entering primary care. [3],[4]

So how we will change this? Not by anything we are doing now. We have less than 30% primary care doctors, and we need to get to at least 50%, but are producing 16%. This is, obviously, going in the wrong direction. Doubling the production of medical students entering primary care will still have us going in the wrong direction, and we are nowhere near getting to double. Even if we produce 50% a year, on average, from all medical schools, it will take 30 years, a generation, to get to that goal. And we are very, very far from that goal. The BEST medical schools in terms of placing students in family medicine and other primary care specialties, such as the one I work at, the University of Kansas, are not close. Most other medical schools are much worse. Many, particularly the private, Eastern, “elite” medical schools highly ranked by US News do not even accept any responsibility for producing physicians who are in the specialties that are needed to meet the health care needs of the American people.

The University of Kansas School of Medicine will be establishing a rural track in Salina, KS, where 8 students per year, committed to rural health, will spend their entire 4 years. The goal is that 75% will enter rural practice and 50% primary care, and preferably both. Great idea. Except this is 8 students in one medical school! The entire KU medical school, and those of all states – “from Colorado, Kansas, and the Carolinas too, from Virginia to Alaska, from the old to the new, from Texas and Ohio and the California shore”[5], as well as those “elite” schools who feel no responsibility, all need to produce as high a percent of their graduates entering primary care as possible, to average over 50% nationally.

This will not be easy. It will probably mean taking different people into medical school, not those with the most elite educations and well-to-do backgrounds, not the children of the faculty, but those who are from rural areas and minority communities and want to go back to them; not those who want to become tertiary and quarternary care super-specialists but those who want to work in the community; not those likely to enter laboratory research (a noble career, but why take up seats in medical school?), but those who want to care for people. It will require rethinking and reprioritizing. But it must happen.

Dr. Starfield notes that “Universal health insurance alone is not sufficient to raise a country’s health levels to match those of countries with the best levels. Within the United States, there is a greater relationship between the presence of a good supply of primary care physicians and life expectancy than there is between either broad insurance coverage or affordability of voverage and life expectancy. Universal coverage alone, particularly if not organized through a single payer with uniformity of benefits, could expand access to inappropriate services.”

Well, we need both, the single payer system and the commitment to primary care. And we need action, not more words. And we need it now.


[1] Note that this comment may not appear on the abridged version of the wonderful video that appears on this website.
[2] McKee ND, McKague MA, Ramsden VR, Poole RE. Cultivating interest in family medicine: family medicine interest group reaches undergraduate medical students. Can Fam Physician. 2007;53(4):661–5.
[3] Roehrig C. Presentation to the Council on Graduate Medical Education, 2009 Nov 18. Data from the American Association of Medical Colleges Graduation Questionnaire.
[4] Sandy LG, Bodenheimer T, PawlsonLG, Starfield B. The political economy of U.S. primary care. Health Aff Millwood). 2009;28 (4):1136–45.
[5] From the late great Phil Ochs, “Power and Glory”, copyright Phil Ochs.
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Tommy Douglas and the Canadian Health System

Five years ago, on November 29, 2004, the Canadian Broadcasting Corporation (CBC) program "The Greatest Canadian" revealed the winner of that designation. According to Wikipedia, this "was not decided by a simple popular poll, but was instead chosen through a two-step voting process. On October 17, 2004 the CBC aired the first part of The Greatest Canadian television series. In it, the bottom 40 of the top 50 "greatest" choices were revealed, in order of popularity, determined by polls conducted by E-mail, Web site, telephone, and letter. To prevent bias during the second round of voting, the top ten nominees were presented alphabetically rather than by order of first round popularity. This second vote was accompanied by a series of documentaries, where 10 Canadian celebrities acting as advocates each presented their case for The Greatest Canadian.” The winner was not a Canadian prime minister, or sports figure, or show business celebrity, or even inventor (like Alexander Graham Bell – did you know he was Canadian?). It was Tommy Douglas.

Who? If you’re American, you probably haven’t heard of him, but that would likely be true of most of the top 10 (except Bell and Wayne Gretzky, who were nos. 9 and 10, and maybe Pierre Trudeau). Douglas, who died in 1986, was a prime minister of the western prairie province of Saskatchewan in the 1940s and 50s. In 1961 he became the first national leader of the New Democratic Party, a post he held for 10 years. I’m sure he was a fine leader in many ways, but what won him this honor was the fact that he was the father of the Canadian national healthcare system, called Medicare. First introduced in Saskatchewan in 1962, the program became federal in 1966 with passage of the Canada Health Act, and was fully implemented by 1971.

Canadian Medicare is a “single-payer” system, such as that advocated by many, including myself, for the United States. It is actually administered by each of the country’s 13 provinces, with much of the funding coming from the federal government through a match. While there are some differences in the coverage in the different provinces, they all must meet five principles: they must be publicly administered, comprehensive, universal, portable (i.e., residents of one province must be covered in other provinces), and accessible. In Canada, doctors and other medical practitioners (mostly in private practice) provide services and submit the bill to the “single payer”, the provincial health ministry, and are then reimbursed at rates annually negotiated between the ministry and the medical associations. Hospitals are provided funding on an annual basis (a “global” fee) rather than fee-for-service, and importantly capital budgets are separate from operating budgets, so that a hospital cannot scrimp on patient care services in order, for example, to build a new building or buy an expensive piece of equipment. Everyone is covered. Everyone can get care. Administrative costs, for both providers and government, are kept down because there is only one payer. Costs for healthcare continue to rise, but at a much slower pace than in the US (see figure).

Are there complaints? Sure. There will always be complaints from people in any system not built specifically around them and their individual needs. Are waiting times sometimes longer than in the US? For elective procedures they might be, provided that you are a person who has excellent health insurance in the US. If you are a person without, or with poor, health insurance you might never get elective surgery in the US. And the waits in Canada, most recently, are certainly not excessive...4 weeks for elective surgery, 3 for an MRI scan. We hear stories of Canadians coming to the US for health care, and undoubtedly there are well-to-do people in Canada who do not wish to wait in line with everyone else (a common characteristic of many of the well-to-do), so come to the US. A 2002 study published in Health Affairs by Katz, et. al. (“Phantoms in the snow: Canadians’ use of health care services in the United States”) revealed, among other data, that in a survey of 18,000 Canadians only 90 had received any health care in the US in the last year and of those, only 20 had gone seeking it (hey, Canadians do go to Florida in the winter and get sick!). And there are many more uninsured Americans who cross the border in search of health care; so many that the Canadian provinces have now put photographs on their Medicare cards so that US citizens cannot borrow them from Canadians.

The system works quite well. Most Canadians (over 80%) are very satisfied with it, and a very small % would wish to trade it for a non-system like that in the US. But this is not what is going to happen with US health reform. Despite the support of nearly 100 representatives for Rep. John Conyers’ “Medicare for All” bill, and the work done in the House by him and others such as Anthony Weiner and Dennis Kucinich, it was not part of the House proposal. And a similar proposal from Sen. Bernie Sanders will likely not be voted on in the Senate. Instead, we are getting sausage – liberally spiced with financial input from the health insurance industry.

Most Americans do not know who Tommy Douglas is, but Canadians do. And they believe that spearheading their single-payer universal health system earns him the title of “Greatest Canadian”. I don’t see any of the leaders of the current effort to “craft” health reform in the US earning a similar honor.
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Poverty and Uninsurance Diverge: So let’s solve the problem!

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Wyandotte and Johnson counties form the Kansas side of the Kansas City metropolitan area. Wyandotte, mainly Kansas City, KS, where I live, is an old “rust-belt” inner city, packing-house industrial city, and is the poorest county in Kansas. Johnson, to its south, consists of older inner suburbs and newer, were-recently-farmland suburbs, and is the richest and most populous Kansas county, with more than 3 times the population of Wyandotte. In Johnson County, only 14% of the population is below 200% of the poverty level, compared to Wyandotte County’s 44%, but it actually a slightly larger absolute number (73,200 to 67,400) because of Johnson County’s larger population. More interesting is the uninsured rate; while it has fewer than 10% more people under 200% of poverty, Johnson County has 2.5 times as many uninsured people as does Wyandotte County.

This means, obviously, that there are many non-poor uninsured people, and this is a national phenomenon. For most of this century, poverty and uninsurance rates tracked together. But in the late 1990s, with poverty rates decreasing, uninsurance rates continued to rise. With the recent recession, both have climbed, but uninsurance is rising at a higher rate. (See graph).

This dissociation between poverty and uninsurance is a very troubling phenomenon; while it is bad enough for poor people to not have financial access to health care, more and more of the uninsured are not poor.

Thus the case for health reform: let’s do something about this. Let’s dissociate the “privilege” of having health insurance from being employed by an entity large enough to afford to provide it, and make sure everyone has financial access to high quality care. Unfortunately, the current plans in the Congress will not do so. The recent assurance by Senate Majority Leader Reid that the Senate bill will contain a “public option”, as will the House bill, obscures the fact that the public option it contains will be weak; in an ostensible effort to not give the public option an “unfair advantage” over private insurance plans, it has been given an unfair disadvantage – it will not be able to use its public status to set rates for provider compensation, as does Medicare, or for drug prices, as Medicare (under the bad restrictions of Part D) also does not.

This is, of course, bizarre: why should anyone, other than the insurance companies themselves, care that they can continue to make money hand over fist while providing inadequate coverage, and not be held accountable by having to compete with a public option that provides comprehensive coverage and does not have to make a profit? Oh yes, the senators and congressmen who get contributions from those insurance companies, yes, but the rest of us? Why should we care? And why should we not insist that our representatives represent our interests, and not those of the insurance companies?

Much of the opposition – not only to single payer, but to a “public option” has been based on, not to put too fine a point on it, lies spread by opponents who are mostly on the payroll of insurance companies. These lies have led people to think that they will lose the excellent medical care, and extensive freedom of choice that they have under the current system (oh, whoops, forgot, they don’t!) if we have a government program. Writing in the Oct 28, 2009 issue of JAMA, Joseph S. Ross and Allan S. Detsky look at “Health care choices and decisions in the United States and Canada”[1], choosing Canada specifically “…because the Canadian health system, with much greater government involvement, is often publicly portrayed in the United States as limiting choice.” They review the restraints on choice of insurance plans, hospitals and doctors, and diagnostic testing and treatments, and conclude, modestly that “…there is clear evidence that for Canada’s health care system, less choice in insurance coverage (although guaranteed) has not resulted in less choice of hospitals, physicians, and diagnostic testing and treatments compared with the United States. In fact, there is arguably more choice.” More than “arguably”, I’d say, based on the evidence provided in their piece.

The fewer obstacles that are placed in the way of services to people, the more efficient they are, the more they are appreciated, and the less they affront the dignity of the people receiving them. When comprehensive services are provided to everyone, there is no need to put people through rigorous screening to see if they are poor enough, or don’t have other insurance, or are deserving enough to receive them.

Ironically, or maybe not, the same legislators who decry government bureaucracy are those who demand that bureaucracy through establishing restrictions on programs that help people. This includes, of course, income and citizenship verification for those seeking help with health care; after all we wouldn’t want people to “cheat” and avail themselves of public services when they didn’t “need” them, when their incomes exceeded the 200% of poverty, or 100% of poverty, or 38% of poverty* that we require. If there were one program for everyone, a single-payer or Medicare-for-all program, then all this bureaucracy could be eliminated. We wouldn’t have to screen people, because everyone would be eligible. It would be everyone’s program.

I have written before about the enormous administrative cost involved in both insurance companies (payers) and providers having huge teams of people to try to deny payment or get paid; in one more way, a single-payer plan would eliminate administrative waste and bureaucracy. Funny that those anti-government-bureaucracy folks can’t – or won’t – see it this way.

*38% of poverty was what one's income used to have to be to get financial assistance in Kansas if you were a childless adult -- and it was $100/month. Now it is not available at all.

[1] Ross JS, Detsky AS, “Health care choices and decisions in the United States and Canada”, JAMA, Oct 28, 2009;302(16):1803-4.
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