I Am A Republican… Can We Talk About A Single Payer System?

I am a Republican. For those who know me that is not a surprise. I live in a red state. I have never voted for a Democratic presidential candidate. I can field strip, clean and reassemble a Remington 12-gauge pump blindfolded. And on top of it, I think we should talk about having a single payer national health care plan. The reason is quite simple. In my view, we already have one; we just don’t take advantage of it.

Firstly, Medicare and the Center for Medicare and Medicaid Services (CMS) are de facto setting all of the rules now. They are a single payer system. When we go to lobby the Hill, we lobby Congress and CMS. Talking to Blue Cross, Aetna, Cigna and United Health care is essentially a waste of time. All the third party payers do is play off the Medicare rules to their advantage and profit. They have higher premiums, pay a somewhat higher benefit and have a significantly higher level of regulation which impedes the care of their customers. This is no longer consumer choice but effectively extortion, a less than hidden shake down in which the “choice” for a family of four is company A at $900 per month or company B at $1100 per month. The payers are simply taking advantage of the system, playing both ends against the middle.

Secondly, in order to move forward with true health care finance we need complete transparency in cost and expense… and we need it now. As was noted in a recent Time magazine piece on the hidden cost of health care, our current system is a vulgar, less than honorable construct more akin to used car sales than medical care, cloaked under the guise of generally accepted accounting principles and hospital cost shifting.

Thirdly, with a single payer system would potentially come real utilization data, real quality metrics and real accountability. The promise of ICD-10 with all of its difficulties is that of a much more granular claims-made data. We could use some granularity in health care data and we will never achieve it in big data quantities without a single payer system.

Lastly, I think that the physicians should be in charge of health care and not the insurance companies and hospital systems. With a single price structure, it becomes all about medical decision making, efficiency, the provision of care to our patients, and shared decision making, all of which we do well.

How, you might say, could a Republican come to such a position? The simple answer is I really think it is quite Republican. Oh, I know there will be many raised eyebrows and many critics. I accept that. I understand the fact that no single payer system is perfect, that it is “socialist,” that it is “un-American.”

I would submit to you, however, that it is un-American to allow many of our citizens to be uninsured, that it is un-American to shunt money away from a strong military in order to support a bloated, inefficient and fraud-laden health care system, that it is un-American not to be open and above board with the cost of what we do, the expense of that service and the profit that we make. Mostly, it is un-American to let this outrageous health care injustice continue.

I would be interested in hearing your thoughts in the comment section below.

Addendum: Listen to Dr. May’s interview about a single payer system with Arnie Arnesen, host of “The Attitude WNHN 94.7FM” here.

95 thoughts on “I Am A Republican… Can We Talk About A Single Payer System?

  1. Dr. May provides an important lesson for those who think that the single payer concept falls on the far left of a linear political spectrum. Society is not linear; it’s four dimensional. If we look at all dimensions, single payer clearly prevails. Thanks to Dr. May for shattering the traditional but flawed construct of health care ideology.

  2. In response to Tim Logeman: Why do you assume we will "lose that drive" for new products, etc. under a single payer system? The products, therapeutics and services would still be compensated under single payer. Removing all the layers of inefficiency we have now would leave plenty of room for profit.

  3. Thank you for having the foresight to recognize that Single Payer, in a sense, is MMedicare for all and is cheaper in every country that has taken on Single Payer in some form.

  4. bravo is all i can say, it is about time someone stands for what is ethically and morally right for ALL AMERICANS – not only the middle class and high end takers.

  5. It is with great relief that I read the author’s comments and input on the possibilities of Single Payer in the USA. He is correct on all counts. I have been researching health reform policy for many years and I keep coming to this same conclusion. The recent Brill article in Time Magazine was an unexpectedly bold expose on the accounting/finance practices of our current billing system. The profit-motive of skimmers in the Wall St. insurance cartel are obviously not in favor of MDs or patients. As for whether or not we will "kill" innovation without our so-called Free Market, the answer here is No, we will not kill innovation. As it is, bench-science research, which leads to products, is often grant funded at early and important stages — by Taxpayers. The Pharmaceutical and Med Device Mfg industries piggyback off the research and development projects which have been Taxpayer funded at US universities. Their marketing (and whining) about R&D would say otherwise. We can do Single Payer. As the author most eloquently points out, we are already nearly there.

  6. You are absolutely correct that a single payer system is the only way to contain costs and provide access to health care based on need and affordabilty. Another virtue of single payer is its abilty to demonstrate and implement system health system reforms. This has been hampered in the past by direct appeals to Congress by self interest groups that have inhibited purchase of services and devices through open bidding and more recently forced EMR expenditures without the necessary requirements that provide national benefits (see above). Data and feedback to providers is essential to assure qualty care but so is use of cost effective technologies and development of system changes that permit cost effective care to be provided and concerns for the health of people over the health of institutions to be achieved. Full implemementation of the Independent Payment Advisory Board, diminishing congressional intereference with care, and full funding of the CMS Innovation Center and public health education funds, all threatened now by congressional resisitence to these worthy provisions of the ACA are necessary. A single payer system is the best way to pay for care but we have an imperfect system of providing for care – both have to be addressed to attain affordable, sustainable, universal care.
    The medical profession can never achieve our professional goals of providing the best care for all at a sustainable cost unless the financing of care is focused on those goals and not on profit maximization. Some form of single payer is essential for this to occur but we as a profession do not yet understand that and as a result are becoming manipulated tools subservient to private corporate interests

  7. Bravo, Dr. May! I have been working to advance the cause of single payer for several years now. I don’t recall having heard or read a more concise, more elegant statement of the facts. I am particularly struck by your reference to politics: "How, you might say, could a Republican come to such a position? The simple answer is I really think it is quite Republican." Outstanding. I never thought I’d have to admit that (at least in this regard) I’m a Republican! Thanks again.

  8. What difference does it make if it’s a single payer or multiple payers.

    Fee-for-service, for profit health care is the problem. When the motivation is to make a profit, all we get is increased care, not necessarily the care we need. (You might be interested in this article – http://www.fiercehealthcare.com/story/hospitals-profit-post-surgical-complications/2013-04-17?utm_medium=nl&utm_source=internal)

    Europe learned that long time ago, and the VA also does a good job of providing needed care.

    Unfortunately the majority of Americans have been brainwashed into thinking the free market system is the answer to all our ills, and as long as our political leaders are bought and paid for by the health insurance industry, pharmaceutical companies, and health care providers nothing will ever changed.

  9. And I’m a Yellow-Dog Democrat (I’d vote for a yellow dog before I’d vote for a Republican), and I couldn’t agree with you more! Thanks for making such an articulate argument for a single payer system.

  10. Our current health-care "system" is a violation of the Hippocratic Oath, which states, in part, "First do no harm!" In spite of this noble statement, our for-profit health care system does grievous harm to many Americans. It requires them to purchase health care insurance when a full 30% of their purchase price does NOT go to paying for their health care, but into the insatiable pockets of some in the health-care insurance industry. Health care insurance is so expensive that low-income folks frequently cannot afford it at all, or if they can afford it, can only afford inadequate insurance plans that will not protect them from a catastrophic illness. David May is right – the only way to actually make sure that everybody is covered is to extend Medicare to cover everybody, and eliminate any and all reliance on private for-profit health care insurance. The overhead costs of Medicare are less than 1/10th of those of the private health care insurance industry, so at least 97% of the taxes we pay to support Medicare For All will actually go to pay for the health care of Americans. Medicare "Advantage" plans should be eliminated as they, too, are an unnecessary monetary drain on the system. Instead Medicare should be expanded so that it covers everything that is currently covered by these plans, including all medications, and more. Will this mean an increase in taxes? Yes it will, but the increase in taxes will be LESS than we currently pay for our health care "insurance", so it will be a huge net bargain for the American People, and this should be the basis on which the argument for it is made. We should do this NOW!

  11. Thank you, Dr. May, for your fine impressive accurate letter. I’ve sent it on to the rest of my colleagues in my group prcatice! I rejoice in your promotion of patriotic, all-American health care! Thankfully and sincerely, S. Milton Zimmerman, M.D. (Graduate of the University of Pennsylvania School of Medicine, Class of 1954, and practicing family medicine in New York State for over 50 years)

  12. I think we do need to compare what we can deliver in health care in the U.S. with what the rest of the industrialized world has delivered in health care. Yes, we have many accomplishments. What we fail to acknowledge, I suspect, is how the rest of the industrialized world also has made contributions in health care and to not acknowledge this is to practice hubris. In the name of science we have allowed our prejudges and misconceptions to rule the market – a market that has not really been "free" since nearly the beginning of the twentieth century. So why cover our language with words like "free market and socialism" while the rest of the industrialized world is laughing behind our backs?

  13. At last, common sense is prevailing. ALL PEOPLE NEED HEALTH CARE @ SOME TIME; SO PROVIDING IT WILL COST LESS IN THE LONG RUN.
    THERE IS NO SOLUTION EXCEPTING SINGLE PAYER!!!!!!!!!!!!
    Thanks.

  14. To T. Logemann: Instead of having less of a driving fore about which you are concerned, we will have more of a driving force by all of us, especially anyone associated with health care. We will be both proud and happy to be associated with the most efficient, most productive universal health care in the world: a truly pure single-payer health care: 1 fund, 1 plan, 1 payer.

    Health care professionals will be more satisfied with their jobs due to spending less time on administrative functions and activities and more time with patients. The net income of family physicians and many specialists will increase and the amount of time caring for patients will increase.

    About two weeks ago a physician, a single man, moved from our community in Michigan to Canada because he wanted to work in a better environment, one which cared for everyone. Several years ago a young woman in our community went away to college, but soon after decided to become a veterinarian instead of a physician when she learned about all the administrative burdens. And specialists? I found it interesting just two weeks ago when a specialist told me he’d never recommend that his son go into medicine.

    Local medical professionals practices are EACH being forced to spend tens of thousands of dollars on a non-standard medical information system that is being implemented at our area hospital. I have heard some VERY STRONG FRUSTRATION about that; a single payer system would undoubtedly consider the common sense action of efficiency of one system, perhaps building on the excellent VA electronic medical records system.

    Many of the innovative products that benefit Americans came from countries with universal health care: Gamma Knife for radiosurgery (Sweden, 1968); CT scan (computed tomography) (England, 1972); Laparoscopic surgery on humans (Sweden, 1910).

    But the list goes on and on. The above multi-part response provides you with examples of how we’ll have MORE drive to excellence, not less.

    – Bob the Health and Health Care Advocate

  15. The mills of the gods grind slowly but they grind exceedingly fine. Thanks to you, Don McCanne and Physicians for Single Party Payer we will eventually have Medicare for all or some form of universal "free" health care. I have Medicare, I am 85, and have Blue Cross High Option. I am totally disgusted with the routine care I get from most MDs. When you call you get, "If this is an emergency go to the ER or call 911". Their office staff make an obstacle course when you try to get an urgent appointment or phone call to the MD. I learned to do a history and physical. My MDs, with 2 exceptions, don’t do a through history, don’t listen and only examine their area of specialty. None of them use email. I hear horror stories from most of my friends about their healthcare. Patients tell me they are very pleased with Kaiser/Permanente of Southern California. From what they say it is how medicine was and should be practiced.

  16. My wife and family are from England. They, and I, can tell many horror stories of inadequet care, and long wait times for vital services in the National Health Care system.

    Additionally, as more of the money supply of a country is allocated to a national health care system, the less opportunity is available to the populace for investment in new business that create jobs. England, France, Italy, etc all are having tremendous financial difficulties.

    The rest of the industrialized world is imploding under this burden of Nationalized health care and large Social systems. The nationalized systems worked for many years for a reason. In Europe, a large portion of the older population, or what would have been the older population, was killed in WWII. Additionally, for many years, like in our country, people’s life expectency was much lower. The next generation of Europeans, and immigrants, is now getting older, and those countries now are having to finally take care of an aging and sicker group. We have always taken care of this group in this country.

  17. There is one glaring omission to this otherwise reasonable article: there is no mention of the benefits of preventative care that could ameliorate a large percentage of ailments, including cardiac, pancreatic, reproductive, pulmonary, etc. But there is little profit there, so it is ignored as a subject of consideration when it comes to "health" care. Simply put, prevention is "before the fact" and intervention is "after the fact". I have chosen the former, and at nearly 88 years of age, am healthy and lead an active life, with the help of nutritious organic foods, nutritional supplements and the physical activity of helping create an organic vegetable garden for the 500+/- residents of the senior apartment complex where I live.

  18. Single payer, while not perfect, is the way to go. Conservatives should support single payer. Unfortunately, too many Americans are still quite confused about what single payer is and what it isn’t. With everybody in the same system and nobody out, then all of us have incentive to keep quality high and costs as affordable as possible. No more cost shifting to the "other guy." We could truly focus on prevention and move from a sickness system to include wellness. It would end job lock because health insurance wouldn’t be tied to employment any longer. No one would get a "free lunch" because all of us would pay into the health system either directly or indirectly (when the health care tax is included in the cost of goods and services). Thanks for speaking up. That’s what it will take.

  19. This former Pepublican endorses Dr David May as a sensible Republican. Maybe I don’t oppose the party, but what has become of the party. Even as a Republican I was for a single-payer.
    Whether single-payer or some other way; we must make sure nobody has to be uninsured. The one who loses his job due to company downsizing, or even if he got fired, his fault; must not have to lose his insurance. I mean "period"; not if he can afford the Cobra. I had plenty that would argue with me about that.
    Okay, if I am ASKING TOO MUCH to be protected if you lose your job;WHAT IF YOU LOST YOUR JOB BECAUSE YOU GOT SICK? Happens often with cancer, you are spending too much time in the hospital and not able to keep up the premiums. Now the insurance elapses, which you have paid for to protect you from medical debts in case you got sick. Furthermore, sometimes people get fired because they are not performing as well do to a NOT-YET-DIAGNOSED illness.

  20. Thank you for posting. I couldn’t agree with you more. Effective change towards a single payer system won’t happen without significant buy-in of the medical profession with financial support. It was the AMA and payers, in collusion, that stopped the single payer initiative that Clinton tried in ’92. Over time, doctors are seeing the fruit of that concern that government could control their income – they can’t serve their patients.

    I work for a payer – they are not going to just lie down or go away. You are talking about a trillion dollar industry. How do you propose to buck that? Rational argument hasn’t worked and won’t work as long as the money is there to buy Congress, popular media, and scare the general public into thinking they will somehow have less than they have today if we went to a single payer system.

  21. I join the many others who are congratulating Dr. May. Single-payer (Medicare for All) is the only healthcare system that ever made sense, and we are the only industrialized nation not to have it. My one little disagreement is that I don’t feel sorry for the military, which I think is too strong and should be cut on behalf of things we really need. But you are so sensible about single-payer, Dr. May!

  22. A single payer system will give the government COMPLETE control to dictate BOTH services provided and the reimbursement rate medical service providers will receive. Would this truly be beneficial to either the Medical Services industry or consumers.

    ABSOLUTELY NOT!!!

    Decades ago the government began to jettison the interests of the people in favor of their campaign financiers. It has been said that ‘Power corrupts. Absolute Power corrupts absolutely!’

    A single payer system would be laden with far greater corruption than the system that is in the process of being systematically destroyed.

    Ask any doctor their opinion of the American Medical Association and they will quickly point out that this organization in no way represents the interest of the independent physician. Who do they represent? The ‘Mega-Hospital Conglomerates’.
    These organizations are striving diligently as their goal to eliminate private physicians and establish organizations of hospitalists. Ultimately, this is an essential step in establishing their ultimate goal of monopolizing the medical industry.

    I do agree that one major problem with the established healthcare finance industry is their is a complete lack of transparency. We have a system dominated by clandestine PPO network negotiated pricing and regulations that prohibit physicians from discussing their fees. Indeed, service prices are all over the map and consumers haven’t a clue as to what services costs until after delivery. The answer of government is to legislate more. After all, more laws with greater complexity benefit everyone, right?!?!?

    The public only expects two things from government standards and protection. The government sets standards as to the quality of gasoline. The government provides law enforcement. For these things the public is grateful.

    I find it remarkable that government has failed over the years to define what constitutes comprehensive major medical coverage for instance. Purchasing health insurance for consumers has been like a wild, wild west shoot out with the result being that many have purchased plans which substantially limit the liability of the insurer while placing UNLIMITED liability on the insureds of these plans. Carriers like Reserve National and Mega-Life and Health in a free market should be allowed to sell what they want, BUT… STANDARDS should be set so that the PUBLIC clearly could see the contractual crap they are buying instead of compelling them to read all the fine print. Why has this not been done???
    Because every time someone has tried to get legislation introduced to set a quality standard people can count on the sleaze ball politicians have sold the public up the river and accept funds from these kind of companies.

    Free markets should reign. The people need a less complex system, not more legislation. They simply need standards they can count on. They need market competition, not monopolies.

    If Medical Service pricing were to be predicated upon a basis (say Medicare as the floor) and service providers would be freely allowed to adjust and POST their fees as a tiered percentage of the set basis, insurers could designed policies to pay accordingly. However, this would cut out the PPO Network fees collected by the Mega-Hospital conglomerates (this is generally a per insured charge of $5.00 to $15.00 per person assessed added to the premium of the insured). Most PPO networks are OWNED by Mega-Hospital Conglomerates.

    PPACA is designed to funnel all affairs toward a Single Payer System. It is currently over 15,000 pages long and GROWING.

    While I understand that as a physician, you would like nothing more than to be able to simplify your life (because insurance processing is a nightmare thanks in large part to all the legislative rules and mandates that all parties have to abide to), a Single Payer system merely provides a means for legislators to get further into the pockets of everyone.

    PPACA is a prime example of this. This acronym is officially defined as the ‘Patient Protection and Affordable Care Act’. Now, the more I learn and read of its provisions, the more convinced I am that this definition is a complete oxymoron as it has little or nothing to do with either.

    PPACA is more appropriately defined as the ‘PERSONAL PROPERTY APPROPRIATIONS COMMANDEERING ACT’.

    It does nothing to protect the public, but creates a plethora of new faucets of cash flow for the Federal Government to collect. A Single Payer system would definitely make this far easier for the government to accomplish.

    As a surgeon, you know that before wielding your scalpel the first thing you would do is stop the bleeding and stabilize the patient. We have had a healthcare finance system that has been hemorrhaging profusely. The governmental response is… "Now let’s cut out the heart!"

  23. Some important features I think should include:
    Management of the system by an organization outside the government. This will help eliminate the horrible influence of lobby and reelection concerns. ? the Robert Wood Foundation?
    A parallel no fault legal system set up to automatically compensate injured parties for their injuries avoiding the miserable expensive damaging tort system for the vast majority of medical injuries. This would very likely decrease the massive defensive medicine practiced in our ER’s and offices all the time now.
    Aligning incentives. There has to be a meaningful “co pay” to help eliminate the overuse of testing and treatments that “entitlement” encourages.
    Probably paying for it by both sales tax (so everyone pays into the system and everyone’s covered) and income tax (so the wealthy pay a higher percentage than the poor).
    Properly use the “market” to get value for prescription drugs. Eliminating that gift to the pharmaceutical companies and eliminating involvement of insurance companies will save hugely.
    I know we may need to phase in a few items…..however…..by taking control of the system away from government and insurance companies we can massively reform (? eliminate?) coding and charging and
    huge amounts of personnel now needed to fulfill all the documentation demands to receive insufficient reimbursement. Imagine restoring EMR’s to be a medical instead of 90% a billing tool. Coding,
    and the massive documentation demands have nearly ruined medical records. We are diverting caregivers from giving care by the demand to flesh out all the elements of history, exam, etc etc and then find codes that hopefully will be accepted—a huge waste.

  24. Dr May,
    Since the government isn’t going to get out of health care, I would propose a different solution, First networks should be abolish and payment for services to go to the patient unless they assign them direclty to providers. Fees should be based on a % about medicare and medicade system should be abolished. If fees were about the same for all in the system, ptivate care fees could come down. Networks may of have been a good idea in the beginning but they do not work. Care should be between the person and physican, paying for care should also be between the person and physician. Insurance companies should just pay a flat rate for services and send the cash to the people and let them shop the best place to get it and competition would start and prices would come down. Free market solutions always work, not a Governement run plan for all.

  25. Thank you Dr. May for pointing out that it is un-American to allow so many of our citizens to be uninsured. I agree with you and it implies that health care should be considered a human right in our country and we should have a national health program. Bravo!

  26. I totally agree!!! After reading the article in Time I wrote a letter to
    the President. Both Republicans and Democrats should act as Americans
    and fix the shame full Health Care System. It seems our elected
    Representatives are Chills for the Industry Lobby.

  27. Thanks Dr. May, I’m a semi-retired cardiologist who chide my Republican colleagues that I’m too fiscally responsible to vote Republican! As I see it most of the deficit came from Reagan and Bush. All that aside, Single payer is the only way to get quality healthcare to everyone at an affordable price. I’ve been advocating for Single payer and been a member of PNHP.org for nearly 10 years. If you are not already a member, check out their website. I would be happy to meet with you at one of their annual meetings. Bill

  28. Thank you for this articulate and excellent review of the current health care situation. But, what will it take to get our politicians to make the right move. State Democratic organizations, are you listening? Smart Republicans, are you listening?

  29. What an excellent, articulate letter, and from a Republican, no less !! Thank you ! May I have permission to submit it for publication in some newspapers ?
    Also, to those reading this blog… are you aware of Physicians for a National Healthcare Program, PNHP ? Please look at their website and consider joining, so we can make a louder sound about single payor ! Thanks.

  30. When this is so obviously the way to go, what’s wrong with the AMA, the state medical associations and the hospital associations that they wont champion meaningful healthcare financing reform. I’ve tried working with the Washington state medical association and they basically limit their sphere on involvement to "local" state issues. It’s like they’re attending to a few trees while the forest is burning. The legal profession certainly would not let government and insurance companies trash their finances and ways of doing business. How do we progress to getting this accomplished?
    Dick Lynn

  31. To T. Logemann: You wrote of the drive to innovate that is "… motivated in some way by profit …" We are going to replace that selfish drive of the desire for money with the unselfish drive of the desire to care for everyone in our society. Health care professionals, including the innovators, will be happier and more productive in an environment which focuses more on patients due to a dramatic reduction of time spent on administrative functions and activities. One of the options for my acoustic neuroma removal was Gamma Knife radiosurgery, which was developed outside the USA in 1968. The more well-known CT scan was developed in England in 1972. Many innovative products that benefit Americans came from countries with universal health care.

    – Bob the Health and Health Care Advocate

  32. The current fragmented healthcare is bloated,centered towards acute care and expensive diagnostics with many times not leading to therapeutic decisions.Dr May has succinctly dispelled ideological divides and put "politics" out of our most important duty of taking care of our patients.Granted that single payor system may not be ideal on day one and will need enhancements and on going evaluation and will evolve as it grows.It will save millions from administrive costs and layers,lobbying costs for various providers in the delivery of care and allow them to deploy those funds for R and D and patient centric innovations.Physicians will be free to practice medicine like they do in many other developed nations without getting roped by beurcratic maze and achieve better outcomes.Cardiosource and all similar educational and organizational sites should provide URL link to TIME magazine’s article,so we wake up the physician community at large and bring about the change our republican leader Dr May is talking about.

  33. Excellent points Dr. May and respondents. I am very conflicted about this issue. Despite many recent "failures", I remain a believer in the merits of a properly regulated free market system (even in an area as complex as healthcare delivery).

    While I agree with DLJ’s points about whether our system is "free", it is difficult to reconcile the comments about the world’s opinion of our system, when many individuals with means will gladly travel from the ends of the earth to receive care in our system. Admittedly, those patients may be still be ‘laughing behind our backs’ about what our system is doing to our economy.

    I wish I could be as optimistic about the VA as a model for a future single payer system, but as a resident and fellow between 2003 and 2009, I have worked in 2 different VAs in this country. I wouldn’t wish this system (in its current state) on my worst enemy, never mind our nation’s heroes.

    I agree with many respondents that the problems we face are largely related to a corrupt political system, stymied by the enormous lobbying power of the insurance and pharmaceutical industries. I for one may be prepared to abandon my belief in free market principles if only to "free" ourselves from their death grip. However, it would be more productive to "free" ourselves from our corrupt political system.

    I would also like to see more transparency in our billing/accounting system combined with shared responsibility for expenses. While I would never support abandoning Medicare, I am reminded every day that most of my government-insured patients have little if any financial stake in my diagnostic or therapeutic interventions. I often find myself discussing the "costs to the system" with my patients. Some are intrigued, but many are more focused on getting out of the system what they put into it through income withholding and premiums.

    Physicians can never be absolved of any blame here. As reimbursement is continually reduced/threatened, there is an unfortunate but very real pressure towards over-utilization. Call me a starry-eyed optimist, but I still believe that the vast majority of physicians are focused on doing what is right (and necessary) for their patients. Many of my colleagues disagree, but I see an integrated EMR as a practical first step to address this problem. Private data reporting (i.e. feedback to physicians) on utilization and outcomes is a very simple way to influence practice patterns, without the need for punitive action or public reporting (which is fraught with problems).

    This was intended to be a 200 character response. Oh well. Let’s work together towards a practical solution for our nation’s health.

  34. SOME REPUBLICANS GET IT. Thank you for your insightful comments, Dr. May. The most efficient way to take care of the health of a population is with a SYSTEM. Today we have CHAOS FUELED BY PROFITS. While not utopia, SINGLE PAYER sure beats what we have today.

  35. As a registered nurse, I talk every day with people who can’t afford their medication, and who complain that their doctors spend most of their time staring at computers, not talking to them. People can’t even afford the copays, so skip medical care, don’t get their medicine, and end up in the emergency room at much higher cost.
    I recently had to deal with my insurance company, when my husband needed a new wheelchair. The company assured our vendor 4 times that the vendor was an in-network provider, 4 different representatives said that, then sent us a bill for the whole $4000, stating that our vendor was out of network. If I were a person with less experience in healthcare, I might have buckled under and paid it, but fortunately was able to appeal – then the company lost the paperwork. We submitted it again, and this time they paid what they had agreed to cover, 80%. But it is clear that the for-profit insurance companies are doing all they can to gouge the consumer, and they need to be out of the picture.
    I vote for Republicans, because although they are often cowardly and lame, they are not as bad as the pro-death Democrats. I have always failed to see why a single payer system is considered a liberal stand — providing health care to everyone goes along with being pro-life, decreasing government interference in our lives, and immigration reform. I hope Dr May can persuade other Republicans to see his logic.

  36. Thank you Doctor May. The current system is indeed a scam. I hope that you find a way to break through the willful blindness of our current commercial media, which is happily avoiding this issue.

  37. Dr. May,
    Thank you for sharing your thoughts. I also agree that lack of coverage, increased cost, and inefficiencies in delivery are, to use your term, "unamerican." However, single payer is neither necessary nor sufficient to achieve all the goals we wish to accomplish, and many of the goals you desire can be accomplished in the absence of a single payer system. Universal coverage can be achieved with a competitive and diversified payer system, and can be uncoupled from employers as well. Fraud is present in all complex systems-military contracts, housing, and banking to name a few-and its presence does not justify nationalization of an entire sector of the economy. By your logic, you would also be a proponent of nationalized defense, banking, and housing sectors- ideas which would surely set you apart from your fellow Republicans. It is also unclear how creation of a single payer system would afford any budget protection for military spending, and there is no evidence that our military needs more money in order to project and protect our interests abroad.

    On the other hand, there is no durable example (meaning more than 40-50 years) of a complex system which thrives on lack of diversification-not in biology, agriculture, or economics. We would never use a single chemotherapeutic agent or antibiotic to treat a complex disease. We would never fill our portfolio with a single stock. And we would never base an food supply on a single crop. A single payer system is a monolithic system-when it fails, the system collapses. Over the past 24 months, it has become fashionable in certain circles to compare our economic situation to Greece’s. Those who would do so then advocate for a single payer system would do well to revisit how their single payer system is doing (it’s not doing well).

    I would submit that one thing America excels in is innovation-and forsaking innovation to emulate a system which is showing signs of failure is truly unamerican. Rather than jumping from one sinking ship to the next, we should strive to create a system which is a model for the world, not modeled after it.

  38. That is well put and I agree in principle. But politicians will run it, that’s the rub. Watch them at work and realize that MDs have no comparable lobby and we will always be at the mercy of the lobbyists for the drug companies, hospital organizations, and commercial payers. United Healthcare will lie down for this? The AHA? Lions and lambs and it wont happen. Political power and money will doom the vision. We are doctors not lawyers and will always enter battle with politicians without armor.

  39. Why the comment linking the military to healthcare? It seemed to me that this serves only to reinforce the author’s conservative credentials. Every other industrialized/civilized country on the planet has a form of single payer with better outcomes and lower costs. Are their populations unhappy? Are the physicians in those countries unhappy? An ACC poll of US cardiologists suggested a high level of unhappiness. It was recently reported the the the rank of the US in the metric of longevity has dropped from #9 to #51 in the world as a reflection, I presume, of all the other poor outcomes data and the increasing poor economic reality for a large percentage of the US population. There would have to be some sort of reform in CMS, FDA, VA etc, since they have evolved into institutions more interested in their own existence than serving the wider good.

  40. I was pleased to see another cardiologist join the public advocacy for a single payer national health insurance program. I am a retired cardiologist who joined Physicians for a National Health Program in 2002 near the end of my active practice. i did this because I saw how complex and costly health care access had become since I started medical school in 1960. Looking at the research that PNHP has done over the past 25 years, i am convinced that the easiest solution for America is to switch to an improved and expanded Medicare for All. If we don’t do this, our current supply driven medical market will collapse. We’re already seeing that the PPACA Law of 2010 is already leading to more complexity and cost. A single payer system would help us control long term costs, and further more, would be good not only for our patients and everyone in our country but would be good for our medical profession in our efforts to improve the quality of health care delivery and promotion of population health. Let’s do it!

  41. I greatly appreciate your article. In the current health care environment, too much cost is shifted directly or indirectly to the taxpayer. I also would add, that it is un-American to employ workers as part time employees and have them work 35 hours without benefits. Under current rules and customary billing, the people, who can least afford it, will be stuck with the highest bills, because nobody negotiates on behalf of so-called "self payers".

  42. Dr.David May, congratulations on your insight.
    I am with Heatlth Care for All Oregon. You can visit our web site at http://www.hcao.org. We are just getting started organizing for single payer in oregon.
    We could use a few more Republicans like yourself in the legislature. If our own representatives won’t give us single payer then we are planning to start an initiative petiton and vote it in. We would love to have your help. Furthermore, we would like to have your permission to submit your letter to the House Health Care Committee at the May 13, 13 hearing.
    Thank you.

  43. We should not have a single payer system because it will not solve the problem in healthcare. It wont improve care and it wont save money unless the government rations care. It certainly hasnt solved Europe’s and it is one of the main reasons they are in far more serious financial trouble than we are.

    We will lose our drive to innovate…take a look at other countries. The US does most of the R&D and produces most of the innovative products. And since when is having a profit a bad thing? Profits encourage innovation and growth. Ask ACC, a "non-profit" what will happen if they dont take in more money than it spends.

    The answer is to bring true market forces to healthcare, which in reality has never existed. YOU will pay for your healthcare, the question is who is in charge of the money.

    Single payer will be paid for with your taxes. But do you really want politicians in Washington making decisions about what your health plan will look like and what it will cover? For example, Medicare is going broke, doctors are reducing the number of Medicare patients they see yet — it is the single-payer system so many people on this list serve are advocating for. Why would we want to expand that?

    If you get your insurance from your employer, you pay for it with a lower salary because you are receiving a benefit instead. But your employer decides the plan you will receive, not you. People may over utilize their healthcare because after all "the company is paying for it."

    But if we encourage more health savings accounts (HSA) for routine expenses and a catastrophic plan for emergencies and serious illness, you still pay for the plan but you are in charge of the money. You pick the plan you what you want. You pick the doctors you want. HSAs have proven to lower healthcare costs because people shop around for the best deal for routine expenses like xrays or a check-ups. They ask what tests are for and if they are necessary. They do a better job of keeping themselves healthy. But if they have an emergency, the catastrophic plan kicks in.

    Dont be fooled by the siren song of single-payer healthcare. Utopia doesnt exist.

  44. I am very disappointed that the ACC is turning from a representative organization to an activist organization that does not represent its constituents. I am also concerned by the probable coordinated response to a single payer system. I have a difficult time accepting that so many are so willing to cast their lot with the federal government. When it comes to cost containment, the cost will increase with a marked decrease in supply and quality. Single payer will be medicare on steroids with both physicians and patients being held hostage to the whims of politicians.

  45. Thank you everyone for your discussion and comments. Just a reminder that these views are my own and do not reflect the official views of the ACC.
    -David May, MD, PhD, FACC

  46. I have practiced medicine in the private sector from 1950 to 2000, when I closed my cardiology practice and now teach first year medical students. I am a Fellow of the American College of Cardiology, an Associate Clinical Professor of Medicine at KECK/USC School of Medicine, and a BOD member, PNHP California.

    The overriding principle, in my opinion, is that humane health care is a human right. I started working for this goal in 1946 while I was in medical school. In 1965, we finally achieved Medicare. Medicare is a not for profit system that operates on three percent overhead. You become eligible when you are 65 or are totally disabled. For profit HMOs operate on 15-25% overhead. In addition, physicians commonly spend up to 30% of their practice income trying to get paid by the HMOs.

    The drug industry so praised by "political girl" and a few other respondents to Dr. May’s letter inserted a provision into Medicare Part D preventing Medicare from bargaining on drug prices. the VA is able to bargain for drug prices and gets much lower rates in many instances.

    In the fight for Medicare, the horror scenarios promulgated by opponents included a prediction that, with Medicare, we would find a government employee in our consultation room between us and the patient. Of course this never materialized and soon we were doing very well simply billing Medicare for our services and being paid promptly. Medicare premiums have enabled us greatly to expand research and development of therapies we could only dream of before the advent of Medicare. We have greatly increased the number of slots for residents in family practice and all specialties. In addition, Medicare has provided several million skilled jobs which cannot be exported from the US.

    It is time to expand and improve Medicare and extend it to the entire population. For profit HMOs and big Pharma now extract about 600 billion dollars from the total US medical expenditure of 2 trillion dollars for health care annually. They provide no services but are simply middle men. With these hundreds of billions of dollars saving, we can pay for health insurance for all.

    Assertions about unique US commercial health insurance providers doing our RND are baseless. Much of that work is provided by NIH, and is also done by other countries including the UK.

    When I have traveled to Canada and to France, I have found a high level of health care provision and a high level of physician and patient satisfacation as compared with the United States.

    Thank you, Dr. May, for opening this discussion in the ACC.

  47. An ideal single payor system is neither a Republican nor a Democrat view, but rather a pragmatist and empiricist view. What COULD make it ideal is to get government out of the mix. The system could be facilitated by the feds BUT managed at the regional/local level. There are ways to do this if we can get the politicians and the business people to let go.

    There is one point with which I disagree – and it shows how Dr. May is still too much of the “establishment” to finalize the idea. ICD-10 codes are more “granular” only for the institutions and large practices which will have the $$ to hire coders, for everyone else will be LESS because we’ll select a subset we can work with (to begin with, LESS info). I spoke with the CEO of the coder consultant company hired by our hospital who agrees wholeheartedly – but is happy no one at the federal level is enough of a pragmatist to see it so his company can make a killing. [another example of extra costs for LESS benefit for patients].

    Deychak – Agree on the EMR – we need ONE, the holy grail of the EMR is interconnectivity (IT business folks are some of the people who need to let go – too many dream of a DOT.COM type venture to make their fortunes).

    DiJustica – You are correct – that is why government has to facilitate a single payor system then get out of the way (as a realist, not likely to get the politicians to let go).

    Lynn – Because of Dr. DiJustica’s comments RIGHT ON.

  48. I am relieved to see physician discussion of the financing of the medical industry taking place. However, I am afraid we are still not looking at root dynamics: whether one is a gun-toting Republican or card-carrying ACLU member may not have ever been the fulcrum upon which the logic of this issue rests. I will illustrate my point with two anecdotes: 1) I have a lay friend who thinks medical insurance should stay in the private sector because "that is the American Way" of doing all business, including insurance; however, this friend is furious about physicians taking any incentives from pharmaceutical companies, as this practice, in effect, divides our loyalties, causing us to serve two masters: the patient and Big Pharma; 2) Julia Roberts voices over some snappy new commercials for Farmers Life Insurance, in which she soars through the phrase "because we don’t have share holders…" These six words are the most powerful, provocative words of any advertisement I can remember, and they go straight to the heart of the medical insurance crisis in this country: the crisis is not about a single payer; it is about insurance companies serving two masters–patients and share holders. We, as health care providers, should be as outraged that insurance companies are arbitrarily carving out massive executive salaries and stock holder benefits from monies that should be going to patient care, as my friend was enraged that Big Pharma is paying for lobbying, patient advertising, and physician inducements from monies that should be going toward R&D. The "For Profit" in the private insurance industry is not the profit that health care providers and institutions see; it is the profit that CEO’s and stock holders see. The fact that discussants in this conversation are not aware of that fact shows how clueless we are about the actual medical insurance crisis we are facing. I understand that electronic medical records is a major pain for everybody, but in the big picture, it is so far from the pit of the financial/business/congressional lobby stranglehold on medical reform as to barely be a blip on the screen. We simply have to begin to look at the big picture: medicine has long since been bought, leveraged, bankrupted, and sold off in chunks. We need to change our paradigms entirely if we want to effect changes in the financial health and well being of our patients.

  49. Why do you think adding more laws, more layers of bureaucracy, more complexity and more money into this system will result in something better?

    Do you have any examples of the US Government doing this well?

    When you try to organize something like this at the Federal level, EVERYONE will get input. EVERYONE will try to tug on it to benefit themselves the most. And even if a miracle happens, and a perfect diamond of a system is created, it will be corrupted as everyone tried to get money out of it.

    Look at how incredibly basic our Constitution is, and where we are now. Unable to even pass a budget.

  50. @Tim Logemann: I’m curious if you could present any examples of profit driven innovations that the healthcare insurance industry has provided to Americans. Aside from coming up with the idea of denying healthcare for "pre-existing conditions" I can’t think of one.

    I believe what you’re thinking of is the medical technology industry, which the author is not suggesting we nationalize. Single payer is only the idea of replacing private insurance companies with a single government insurance program that takes its payments through the tax system.

    So considering those facts would you reconsider your position?

  51. The author is clearly not a Republican if he believes in Socialism. Less government spending, not more!!! If poor people can’t pull themselves up by their bootstraps, we shouldn’t be forced to do so. If people want to help the poor, it should be their choice, we shouldn’t force it on everyone.

  52. Excellent article, thank you. Some seem to confuse the innovations in medicine that come from developers and the loss of ‘profits’ for private industry. This notion is not correct, a single payer will not stifle innovation, there will still be a market for innovations. The private industry that will get hurt is the insurance industry, and frankly yes they should be hurt. The insurance industry does not contribute to healthcare, they take a cut of the top for all services that are rendered, while not contributing in any meaningful way. The savings available in a single payer system come from taking the third party out. Nobody has ever been cured by an insurance premium.
    We need this as a country to remain competitive. Our industries have to compete with other countries where healthcare insurance is not a benefit they must provide to employees. We need this because covering everyone is actually cheaper than covering no one.

  53. How about a combination of a single payer system and health savings accounts? This would make the insurance side simpler and take away a significant part of healthcare costs that are going to insurance companies. But what it leaves is the opportunity for those providers that put more into the patient experience to charge more for those services and for those that appreciate a better experience to pay the difference in those fees and what a single payer insurance would cover. If companies want to take better care of their employees and offer them better benefits, they can give them company paid-for health savings accounts to cover those additional fees. This puts some ownership on the patient to put a value on what their health care provider is offering them and "shopping around" for the best bargain or value. It also puts more incentive on the patient to invest in preventative care and follow the advice of their provider.

    Maybe everyone deserves access to healthcare, but not everyone deserves access to the same healthcare experience. Those providers that are paid more can offer more up to date technology, less double/triple booking for appointments, shorter wait times, more time spent with the patient, a nicer facility, and on and on. Once we get to a single payer system, whoever controls the fees is going to set them at what they think should be paid to someone running a "bare bones" operation. It would be like the government offering food stamps for each item of food (instead of a monetary value) and saying it’s good for one steak at the grocery store or one steak at Ruth’s Chris Steakhouse, but reimburse the facility the same set amount based on the cheapest steak possible. Let both places accept it, but the one that puts more into the service and experience gets to charge the difference to the patient, while the other just accepts the single payer rate.

    There also needs to be more flexibility given to the providers in how to run their business to either turn a profit or operate efficiently, including broken appointment fees, deposits, and a more clearly defined policy that both the provider and patient can understand (and be on the same page). Currently the insurance company sets the rules and leaves the provider and patient to blame one another.

    I think there’s a lot of upside potential to a single payer system in driving down healthcare costs, but there are also a lot of dangerous side effects that may keep the United States from remaining the leading country in the world when it comes to healthcare options.

  54. David,

    You miss the point. It’s the entire health care system that is flawed. Read further: http://market-ticker.org/akcs-www?singlepost=3149840

    Here’s an idea: How about everyone pays for their own health care so there is an incentive to stay healthy?

    Why should health insurance cover routine maintenance when other forms of insurance (home, auto) only cover accidental/unexpected losses? If maintenance was excluded, we would start to see a competitive market emerge for certain services – and prices would come down.

    Why can’t most hospitals provide an accurate quote for services and when they do, the rates vary by as much as 10x between them? http://archinte.jamanetwork.com/article.aspx?articleid=1569848
    Answer: They aren’t used to bidding in a competitive process. Who in their right mind would spend $125,000 for the same surgery they could get for $11,100? No one would. But most people just hand over their insurance card and let the insurance company deal with it. But if prices for services were displayed and insureds were incented to shop for the best rate, prices would come down!

    We no longer have a competitive market in health care and the more government gets involved with health care by hiding the true costs involved, the more expensive it will become. The industry protections MUST be removed.

  55. Health Care should not be on the backs of America’s employers. Remove this burden and watch hiring skyrocket.

  56. I don’t think single-payer system is a good idea for NOE REASON the government wants it’s paws all over it and they are corrupt enough, when will we realize that the best way to save the American way of life is to get rid of all the corrupt junk in our society and get money out of the government. These Globalists (and yes, they ARE GLOBALISTS) are the main problem. Globaiizatio isn’t the problem, GLOBALISM is and this is what we need ot get rid of. This is not a "conspiracy theory" it’s been proven to be conspiracy FACT. Can we cut to the chase and stop the evil in this country on BOTHSIDES OF THE AISLE PLEASE?????

  57. The first President to propose single payer health care was a Republican.

    His name was Theodore Roosevelt.

    I guess the Republican Party broke the mold. Pity. We could use more like him.

  58. I’m turning 30 this year, didn’t have family backing for college and was pretty much forced into the work industry. I’m working full time and going to school again. My wife has a BA and working in her field, and we don’t make enough to provide healthcare for ourselves, only our daughter. It really comes down to a choice of saving for the future or living month to month or even going into debt for healthcare for ourselves.

    We are lucky we’re healthy, but now I have some dental issue’s I honestly have no idea how I’m going to pay for. Just how ridiculous is that? I’m almost a middle class American and can’t afford basic dental care for myself?

    Makes me wish I was born 500 miles north.

  59. At one time, fire services were mercenary operations. Now, in most communities, they are "single payer". Further back in history, military affairs were handled as the private property of individuals who had government ties. Officers bought their commissions, and the practice was heavily defended. Individual men could finance and run military units as private property, under a government license. Now, at least in theory, militaries of civilized countries are "single payer".

    Ultimately, it comes down to whether or not the "single payer" model helps or hinders overall profitability.

  60. As a social liberal with oddly conservative fiscal leanings, I applaud any attempt to break the Us versus Them deadlock between the parties. Universal health coverage is something I have been pushing for my entire life, because I see it as a way of protecting people while ALSO bringing down costs. As our pharmaceutical giants pump out one useless vanity drug after another, we are currently running out of antibiotics that work. We do not need another "erectile dysfunction" drug, we need the vaccines and antibiotics that actually save lives. However, those don’t make the fat profits that vanity drugs do, so they aren’t a priority.
    Thank you for thinking about human lives and well being over political stubbornness. If more people would agree to do what is right for the most people, instead of what is financially beneficial, or politically expedient, then the US would be a better place.

  61. Thank you David May. I believe in being both fiscally responsible AND socially responsible. They do not need to be mutually exclusive. Creative solutions are necessary to achieve both of these goals and I am sure with open minds we can find them.

  62. http://brontis3rdrail.blogspot.com/search?updated-max=2012-06-29T15:59:00-07:00&max-results=7

    Well, this makes 2 of us! It’s a start, I guess.
    I’m a libertarian-leaning conservative who recognizes that our present healthcare system is appalling–the worst in the industrialized world. It’s too late for any market-forces to fix it. Replacing it with a single-payer system is the moral equivalent of war, IMO. I have been blogging on this for years. The link above is my most recent. There are several others on the same site.

  63. Good piece. However, I would take issue with your contention that healthcare is siphoning away defense spending. Congressnisnliterally shoveling money down the military’s throats, for instance insisting on buying tanks that the army doesn’t even want, but which provide jobs for Workersmin Ohio. And while we’re at it, let’s not forget that healthcare provided by the VA also falls under the heading of single-payer.

  64. Here’s one thought that (in my view) doesn’t get enough exposure … a single payer system is good for an entrepreneurial ecosystem. It would encourage people to create new companies because they wouldn’t have to worry about losing their HC insurance or having to provide such coverage for potential employees. It would encourage workers to join fledgling companies, who in our current system may not be able to provide full HC coverage.

    In short, our current system that ties HC to your employer discourages new/risky ventures.

  65. To those worried about a "loss of innovation," many new cutting edge treatments have come from the military and from university research, not private companies. Most of the new products put out by private companies are just "ever-greening" new patents of already existing products that don’t actually improve care outcomes.

    Here’s another thing – my first job back in the 80s was to setup doctor’s offices for their brand new computerized medical office management systems. This was back when electronic submission of HCFA 1500 forms was first going online and Medicare and Medicaid were toying with requiring electronic submission of claims, and everybody had to learn ICD and CPT codes whether they wanted to or not. The gaming of the of system began literally immediately. They learned quickly that some codes brought in more money, and used them whether they were accurate or not.

    Fast forward a decade or so, and my young son falls and gets a small cut on his forehead, requiring two stitches. Of course, the ER had no idea that I was reasonably familiar with CPT codes, and back them they put them on the printed bills. (Not sure if they still do that.) I was shocked – to put it in non-technical terms, at that time there were basically 5 levels of coding or ER visits, with one being silly stuff that shouldn’t be there anyway at the lowest level all the way up to you were just in a plane crash and are in pieces, near death. The ER billing department had coded my child’s two stitches at that highest level code. Since the company where I worked then was self-insured, it was money out of our pockets so I called both the HR insurance coordinator and the ER to complain. Most people never realize what those numbers mean and literally billions of dollars are wasted every year because of that type of thing.

    The other issue, of course, is that when you pay your premiums for private for-profit health insurance, money that you spent for healthcare ends up going for CEO salaries, perks and golden parachutes that are literally in the hundreds of millions of dollars at each health insurance company. Then there are the stock dividends paid to shareholders – more hundreds of millions of dollars. All together, that is tens or hundreds of billions of dollars they are sucking out of the healthcare system. I am not against anyone earning living wages, but those compensation packages for all the executives and vice-presidents are way, way out of line. It’s pure greed – and it’s death panels in disguise. Every for-profit health insurance company decides to let some of their customers die every year so they can pay those compensation packages. That is immoral, sinful, and disgraceful. A single-payer non-profit system would provide reasonable living wages for administrators and still have plenty of money for patient care.

    And in spite of what you might have heard, the US does NOT have the best healthcare in the world. In fact, on every possible measure of patient outcomes we aren’t even in the top 20.

    And finally, this is supposed to be a democracy where everyone is treated equally – then why has congress voted themselves a cushy single payer system that is not available to the rest of us? Since when do we have one law for the rulers and one for everyone else? It’s time to overthrow the moneyed elite and re-establish equality under the law. Single-payer healthcare should not be a privilege of the wealthy – it should be everyone’s right. Your right to "life, liberty, and the pursuit of happiness" means nothing when your health insurance company can decide to kill you for fun and profit.

  66. I think that it is possible to have market forces within a "single payer" system. I define single payer as a system that covers everyone, collects premiums on an ability to pay basis, and provides reimbursement through one pipeline. We can create this system such that it coordinated care that controls costs by providing the greatest level of disease prevention and chronic disease control. I’d love your feedback on my ideas found here: http://www.couniversalhealth.org/
    Senator Irene Aguilar, MD
    Denver, Colorado

  67. Every single point made in this presentation is spot on and well thought. Having worked administratively and in an ICU for 28 years, I always wondered when and if the medical profession would finally take the bull by the horns and be REAL healers (even of the system)

    The medical profession has been laden with extensive regulations for decades…because it never quite got its act together to do what is measurably right for the whole.

    Kudos Dr’s May and Harold.

  68. I am and have been an insurance agent for 14+ years and I can tell you from where I stand the system is a complete and total ripoff with medicare and underage health insurance. I was a phone sales agent for the last 2 years off and on until recently I had to give up my job making 17 dollars an hour plus commissions because i could stomach my job anymore. I worked in a building with about 400 employees and was told to sell sell sell a product that took 2 to 3 weeks of training to understand and still had my own questions on what it covered and didn’t cover. The deductibles and copays and networks and so on and so forth.The last few clients I talked to that did me in was when a veteran’s wife was calling about getting insurance for herself and her husband who because of his many tours in Iraq and Afghanistan was physically unfit for duty so they kicked him out. She said that the VA wouldn’t cover them because the fell thru the cracks. He could not get insured thru any private insurance she told me as she wept after I told her what she already knew. The last was when a mother who had struggled for yrs to get off welfare and had a child. She was told that her son would be covered even tho he had some physical problems and was quoted a certain amount but would be rated because of her sons problem’s. Her first bill was over $600 dollars! She desperately needed to have her son insured she cried over the phone to me and realized her only option was to quit her job and go back on welfare. How friggen sad is this pound of flesh mentality when the CEO of AETNA makes 1700 times more than the average employee? I was pushing a product that made me feel sick and disgusting to people who were dealt a hand of misfortune while parasites "like myself" fed on their misery.I wanted no part of it. I am looking for a new line of work. And just think how many thousands of middlemen such as agent’s, supervisors, managers, facilities and the list goes on and on of people that make a living on selling this shit. When I look at the statistics of people that are insured and see that 67% of them go into bankruptcy if they fell ill. And the many 60 to 65 yr olds that finally make it to medicare age and cost the system so much more because they couldn’t afford to see a Dr. untill they received help and were so much more sick by then. We are better than this.

  69. I am a stock investor who does his own research. Examining the stocks of publicly traded health providers and health insurers, I read their quarterly reports (10-Qs), proxy statements and dividend histories.

    I am shocked at the huge dollar amounts of bonuses, stock options and dividends disclosed in those documents. This is all money that is taken out of the premiums and fees that were supposed to pay for "health care". It does not go to you, the providers of health care, but to the profit-seekers in "management" and investors.

    Our current, for-profit health care system feeds the 1% at the expense of the 99% by making sure that money which should be used for health is siphoned off to make wealthy people even wealthier.

  70. Bravo! SIngle payer (or tri-care) for all is a basic human decency and common cents no brainer. Although I am neither Democrat nor Republican I have to quibble with your more money for military reasoning. As a doctor you should consider your do no harm oath before suggesting the already insane amounts of money we spend on military is in need of a raise and even further just how horrific our use of military has been across the global board for decades on end.

  71. It’s very encouraging to hear a conservative thinking about the common good. (As a very left-like liberal, I nonetheless would support capitalism if it had stuck to serving a free-market economy by producing goods and services, and not devoted itself to producing money for stockholders.) The health insurance industry provides very little actual service to anybody. Unlike other insurances, its main activity has come to be producing as much interference as possible against the provision of health care. As a mental health care provider, I can tell you I am no fan of Medicare — which serves me very well as a .subscriber — because it is so very dismissive of the provider; somewhere around 2008-2009, for instance, it entirely stopped reimbursing solo psychotherapists for a full year. There were apology letters from them and we all made lots of phone calls and yes, we all did get our money (with no interest, of course)in the fullness of time, but I think frankly they couldn’t have gotten away with this if there hadn’t been a precedent set by the regular health insurance industry that we who merely take care of the subscriber-patient come LAST. I don’t think that is as likely to be the case if there is only one game in town, and everybody knows who is and isn’t following the rules.

  72. I see some of the upsides of this. It does seem that a lot of the innovation in health care has come from private industry, motivated in some way by profit, especially the profit of the US market. If we lose that drive with a single payer system, will we lose the new products, new services, new therapeutics, that bring so much benefit to our patients?

  73. It’s too bad that the provision of health care in America has become a partisan issue, as illustrated in the title of this piece. Unfortunately, having a single-payer system implies that the government will control health care–every country in which this has happened as led to diminished health statistics. Our health care is expensive and duplicative only because the federal government and the insurance industry meddle. We need a system wherein people are responsible for basic care and nave insurance only for “catastrophic” expenses, wherein both provider and recipient of care KNOW THE COST of that care and wherein employers have nothing to do with either health care or insurance. Having a single payer will eliminate those aspects of the market which have (formerly) made this country great!

    A retired MD.

  74. Bravo Dr May. I also support and have been an activist for Medicare for All HR676 for a few years. I was a solo neurologist, but insurance on the income and overhead balance sheets squeezed me out. My book The Other End of the Stethoscope explains, for lay people, how the health care crisis is leading to the growing dropout of physicians in practice, and suggests a three fold solution: 1. single payer health care system-but physician run quality control and standards of practice; 2. malpractice reform similar to workers comp. where injured patients can actually get fair compensation and the centerpiece would be a retraining/educational approach to outlying physicians or hospitals;3. free choice of physicians by patients- true competition at the most appropriate level. Currently, patients have very little choice in health care. #1 would save est. $400 billion from admin costs of insurance companies, plus the incredible stimulus of truely small businesses and entrepreneurs who are stuck in jobs they hate because of the insurance;#2 another $30 billion from the trial lawyers who prey on the public and drive good doctors out of practice with frivolous lawsuits, not to mention the savings from reduced defensive medicine; #3 the free market should mean free for patients to choose their doctors, not free for big corporations to monopolize health care and make us all pay for thier huge profits while giving us little to no choices or information (withholding their big data)about our health.

  75. Dr, May,

    Thank you for your lucid article. Even courageous.

    I have one question about what you wrote: You referred to a Single Payer system as “socialist.” How can that be so? I thought “socialist” meant that the employees work for the government. That the checks are cut by the government is not “socialist.” Medicare is not a “socialist” system, and, unless I am mistaken, you are recommending a similar payment method to “private” health care deliverers.

    Am I missing something? If not, then you did your article a great dis-service. Most Republicans, even Democrats, think Single Payer is “socialist.” But it is only a method of taxdollars paying for the services of private health care deliverers. They do not become government employees. Single payer elimates the middleman, the health insurance companies. Since the US government pays them, is that “socialistic?”

    Respectfully,

    L. G. (Sandy) Welton

  76. Yes indeed, Dr. May’s analysis makes sense and his approach should be the beginning of a in depth discussion between legislators without interference of the corporate world. That’s where the trouble starts and (for the time being) ends. On the whole the legislators “depend’ in more ways than one on the monetary contributions of the corporate world, which precludes an honest and open debate. Convince me that I am wrong! In the mean time, “Thank you, Dr. May!” and let other authorities in the field of medicine add in large numbers to his comments. With an overwhelming number of like minded people changes are possible.

  77. We need reform in healthcare IT implementation. Too many EMR’s not talking with each other. I’ve gone thru NexGen, GE Centricity and now EPIC. Our culture of "documentation and data entry" needs to change, as well as reimbursement rules for E&M. With every patient encounter, we should spend 95% of our time listening to and talking with our patient’s and families, and 5% of the time punching data into computers. Unfortunately , with current "meaningful use" EMR rules and billing and coding, physicians, nurses and other provides are spending over 50% of the time taking care of the EMR and ignoring the patient. An office visit shouldn’t require 30+ separate mouse clicks… Our patients tell us we stare at our monitors, and are distracted from them. We need to document for patient care and safety only, and minimize it…to the bare bone essentials. The signal to noise ratio in many EMR generated notes is very low… The folks in CMS who have dreamt up these processes and policies need to understand what it is like "on the ground"…. I’m all for EMR and for us selecting truly meaningful data, not "decorative" data for data’s sake… We should have started with a "singe unified EMR for all Americans, analogous to the VA… We cant allow documentation to interfere with care of the patient.

  78. Single party where the recipient of the services is the payer. that is the only way to control costs. Simple and eloquent like it was before insurance companies ruled the health care universe. ie: don’t go to the doctor when you have a hangnail because he will give you a cat-scan. Oversimplified in this example but this is the root of the problem.

  79. I am generally conservative and strongly support single payer. I have used it. It works and there is no good reason why Americans are left out of that option. My 30 years in the military was a godsend. I am 66 now and never have had to deal with a private insurer, except for auto insurance. The military uses one government-selected contractor who enrolls families, collects modest premiums, and pays claims. That is for doctors you select yourself off base. On base, is the true “socialized medicine” where the doctors, nurses, staff, equipment, and medicine are government owned and run, like our supermarkets, fitness centers, dept stores, etc. Outstanding care where profit is NOT a motive yields happy people. In fact, one of the reasons many of us held out for a full career was the promise of this medical care. Fortunately, I can use Medicare…second best to the miltary system, but superior to what people who have to use private insurers have. With Medicare, I choose my own doctor. In the government hospital, they usually allow that as well. I’ve used the British NHS and it was very good. My Canadian military colleagues and I compared notes—-their citizens pay less in medical tax for complete care than the unlucky Americans who prop up private insurers. Single payer is the only sane way to go…as every other industrial country has determined.

  80. Now that we have all been re-educated about the meaning of the Golden Rule – those who have the gold make the rules – we must regain our integrity and autonomy. The doctor-patient relationship must reign supreme. We have been co-opted into satisfying our paymasters not our patients. Indeed, the greater third parties interfere the greater is the damage done to Medicine. We must refuse to satisfy and therefore starve the beast of private insurer/government crony capitalist system that continues to enslave both patients and their physicians.

  81. This is a response I left on a different website. It was due to this person, that I am at your blog. I have read some of the responses and I am sure I am duplicating some of what they said, but for what it is worth, here is my rebuttal.

    First off, what he laid out is utopia and like all utopian things it sounds wonderful. The problem is in the details. The goals he lines out are very laudable and clear; however, they will be administered by men. My experience in Germany and with the US Military is the system looks good on paper, but in practice does not work.

    All of these goals could be obtained with the proper legislation, but they are not because (congress)man does not allow it to happen. So while I found the article enlightening, it is my opinion and I am not a doctor, doomed to fail just like the other SP countries.

    I would love to eliminate all but catastrophic medical insurance, but if not make sure insurance companies could write policies across state lines. Encourage MSA’s so people could save up tax free for medical expenses. Allow the drug store chains and Walmart type stores to offer basic medical services. Eliminate frivolous medical lawsuits and establish a peer run arbitration panel. These are just a few ideas that will increase supply, use the profit motive positively creating more jobs and providing better health care to the citizens. It removes political parties out of the process and returns the government to an arbitrator roll instead of a service delivery role.

  82. A push into single payer will reduce the ability of the physician to make decisions. An example is the VA medical system. Anybody that has trained there well understands the reality of a fixed budget. I was on a cath lab rotation there, the govt shutdown occured a few years ago, and the cath lab closed. It was very simple…..if you were dying at the VAMC of a STEMI on the floor, then we could lyse you or more appropriately could transfer you under the road to Shands Hospital at the University of Florida. We had no autonomy on what medications to write, because very few trade name drugs were on formulary. If they were generic, then ok. This is already happening in todays medicine, not to that extent yet. The patients hated it, the docs hated it, and when 4:30 came in the afternoons, don’t be in front of the exit doors or you would be trampled just like you would by the bulls in pamplona. That is single payer, that is our govt running it, and that would be the model. Anybody who wants that and thinks it is an improvement over what we have now is, unfortunately, either uninformed, or very flawed thinking. I do not mean to be ugly in my terms but I have a very strong opinion. With these governement changes that we see today so many fewer people are effectively insured than even last year, and most are seeing much higher deductibles and premiums. Access is lower because of loss of specifically IM docs that can not financially survive this atmosphere. I can go on, but am at work today. Hopefully by the end of 2014 most of us will have seen enough to convince even the cheerleaders for this disaster called ACA that the right path is reduction of govt influence in the financial side of medicine.

  83. Ideally a single payer system will work ONLY if it is implemented correctly!! That is where the problem is. Various entities like hospitals, pharmaceutical industry will want to have their own interests protected. Even the quality assessment system is fatally flawed. I know my hospital held a session to “teach” physicians to document differently that made it look like we were much better than the national average. Any system that DOES NOT give incentive to the patient to make lifestyle changes will never succeed. It has been proven that a vegan lifestyle if adopted by all Americans will save 85% of the health care costs. It is a FACT. It is also a fact that our current system does not give incentive to the patient to get better. Health Savings Plan is one that gives patient incentives to live healthy.

  84. So the number one premise is that we already have (de facto) a single payer system. Yet things could hardly be worse. As a colleague of Dr. May we have had many discussions on the regulatory and coding systems that dictate much of the efficiencies fostered on practicing physcians. How exactly will removal of those in the middle, both insurance companies and indedepndent physicians trying to pay for and pay attention to regulatory expenses and mandates, make medical care more efficient? Will it be magic or just “the law”? Or is the problem the regulation itself?
    Let’s walk through some of the benefits of single payer.
    Transparency.
    Nothing the governent does is transparent except its deceit. Patients will not get billed if we do single payer like the British, so patients will have no idea what medical care costs. Likely the doctors will be employeed and will have little insight as how to price medicine. It should not be hosptial or insurance administrators according to Dr. May. Maybe HHS will be the answer. I saw this breaking news about the new HHS Secretary:

    Undoubtedly, new Secretary Burwell, who served under Bush and now Obama, will know if grandma got a good knee replacement or not. We can’t even get a straight answer from the IRS on how to file our actual taxes until the audit. Transparency: count on it.
    We will have better and consistent data with single payer.
    Dr. May calls on Big medicine and Big government to join hands with Big data. This arguement is a little too obscure to develop in a paragraph, but it has become fashionable to claim that Big data knows more than local or Little data. To wit records of all prescriptions in the US filled for, say, cold medication can predict a new epidemic of the flu before even the CDC. (The CDC is biggish medicine and government together-anyone failed to note that medical societies and governement have worked together for a while?) However Big data seen from “universal access” doesn’t know what exactly is “out breaking” until the CDC or local doctors do the field work. Medicine is unfortunately down and dirty actual field work. Operations and interventions happen one at a time. So do outcomes. Why not just get rid of the doctors, if protocols and data can tell us all we need to know? Have a mid level care giver or even a medical assistant with a good vocobulary and
    understanding of protocols treat all patients. How about a call center in foreign country? Does an experienced doctor add anything or not? Our evidence medicine its data and its regulations and statistics are not medical care it seems to me. They are virtual medical care. Walk onto any medical service area and just note whether the medical and nursing staff are looking at a patient or a computer. It is not rocket sceince to see what is going on. I am not saying these other resources have no role just that either doctors as nonartifical intellegence are real resources or not. We don’t all get the textbook or last case cause of illness or possible death. Call me a skeptical thirty year veteran of surgical practice.
    Doctors should run health care.
    It’s hard to argue with that one. I am a doctor after all. If Big government is my least favorite solution, I find Big medicine equally flawed whether it is the political version like the AMA or the so called academic versions. The AMA, who makes hundreds of million of dollars in administration of ICD codes, or the specialty societies such as the ACC, who make the same amounts “creditialing” their peers seem a little short in the cost reduction departments. The ACC and its academic leaders have come to the government funding table to promote “research and development” (and academic notoreity) spending billions of dollars in trials to prove “noninferiority” to standard surgical therapies which translates into “inferior devices” that cost tens of thousands more than standard products like a percutaneous aortic valve. The tax payers thankfully have not payed all the up front costs for this regulatory approval by the FDA, but undoubtedly will pay on the
    back side.That is what single payer do. It pays on the back side for therapies that Big medicine works through Big government. About the only thing on which all (or most) doctors agree is that Big lawyers should not be ib charge of legal medicine. But trust us doctors with medicine itself, we are doctors. Trust us more when we run single payer medicine.
    We could use a little granularity.
    Geez. Dr May has a Phd in some area of molecular biology to go with his MD. All I could muster was an AB in religion in college before I went to medical school. Let me say naively that this might be the most fruitful part of the discussion or talk requested by Dr. May. However, I have no actual idea what he is talking about. My best guess is what George Gilder calls “the materialist superstition” -Dr. May was formally trained in “molecular stuff” after all- in Gilder’s book Knowledge and Power. Or check out James Gleik’s more popular book Information: A History, A Theory, A Flood. Or maybe the Old Testament, which addresses knowledge and power and superstition over a millenium. We do live in the information age. Lets talk about information. Evidence is so 1800’s, except in medicine where it is still the vogue. Evidence like granularity and heresy has no meaning scientifically. Information does. This understand is THE really “big” topic. Or so it seems
    to this observer.
    Republican.
    Does this response make me a Democrat? Shall I match Dr. May a shot gun for Glock? I think the population is splitting on different lines like freedom not as in flag waving but as in Wiki-leaks, NSA, and government spying. We are all using and being used by information. Why woud we design a system where people as patients are left out of the question of medical cost-what is their own cost and interest- we might as well tell them what music can be heard. Let the experts decide everything. I can hardly tell the difference between the Republican Ryan “you can keep your Medicare” and Obama’s “you must have it”. If it doesn’t matter to you who your doctor will be that will be the doctor you get. Think we are all alike? Choice is not merely about deadly birth canals.
    Information is choice. Evidence is determinism.
    You pick.

  85. Thank you for your insightful views! Your argument that single payer health care is compatible with both republican and democrat party values is very compelling. I hope more republicans (and democrats) begin to see the value of a single-payer system, that would likely improve American’s healthcare and be a lot more fiscally sane than our current, wasteful multi-payer system. And yes, providing universal health care is patriotic and very compatible with American values.

    In addition to your arguments, I would add that single payer would save private businesses money, by relieving companies of the responsibility of paying for their workers’ healthcare.

    Single payer also lowers the cost of healthcare to consumers by getting rid of administrative costs associated with the complicated multi-payer system which have required huge billing staffs in doctor’s offices and hospitals. We’d also all save money if our health care dollars were not going to paying the private health insurance middleman.

  86. re: Dr.Scott Vasconcellos MD on April 28, 2013 at 2:19 pm
    What he said then about VA system has proven to be even worse as the current VA scandal is unfolding.
    There must be a balance between bureaucratic bottlenecks and unbridled profits. All I know is the current healthcare is not serving patients well and burning out caring providers.

  87. Dear Dr. May,
    Thank you for an insightful presentation. As far as being a Republican, well… we’re people first and our country’s strength is our diversity. I just wish that people were more civil in their political differences.
    I would like to point out that health care is already publicly funded at roughly 60% when you consider Medicare, Medicaid, CHIP, etc. it’s not a stretch to extend it to 100%. Further, the fact that several studies have shown that 30-31% of health care costs are consumed by wasteful beurocratic paperwork that is also very labor intensive. We spend enough on health care; roughly double what other developed countries spend. The primacy of the doctor-patient relationship is imperative and third parties should not trump the ten or so years of training you spent to honor the virtues of the Hippocratic oath you obviously aspire to achieve in your practice. We have publicly funded schools, libraries, roads, bridges, police departments, and fire departments to name a few. I don’t look at it as socialism. I call it part of the social compact…consent of the governed. I support a single payer system. Thank you again.

Leave a Reply

Your email address will not be published. Required fields are marked *

86 − = 84

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>