Single-payer system is better – but not for physician income or quality of care, survey says

A small margin of physicians favor a single-payer health care system over a multiple-payer system (48% vs 45%)—even though most also predict that a single-payer system would reduce their income as well as lower quality of patient care, according to a new MDLinx.com survey of nearly 900 physicians and advanced practice clinicians in the United States.

The survey asked participants to compare the multiple-payer system with a single-payer system, such as the “Medicare for All” model proposed by Sen. Bernie Sanders (D-VT). About 887 health care providers responded. Here’s what they said.

Single-payer vs multiple-payer

• Single-payer: 48.4% of respondents said they support (22.2%) or strongly support (26.2%) a single-payer system.
• Multiple-payer: 45.0% said they support (18.0%) or strongly support (27.0%) a multiple-payer system.
• Neutral: 9.7%

“As a CPA and an MD, I believe strongly in a single-payer system that removes the insurance industry from the medical delivery system. We must restore the sacred relationship between patient and physician, and only when we move toward a single-payer system can we ever restore it,” said pediatrician Craig M. Uhl, MD, of Palm Desert, CA.

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To read the original article upon which this survey was based, click here.

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But a multiple-payer system grants autonomy to the patient, said Elizabeth Blasuci, RN, of Toluca Lake, CA. “Single-payer breeds dependence and strains resources that are already depleted and limited by regulations and overseeing panels,” she said. “One-size-fits-all is a Potemkin village on steroids.”

Quality of care

• Decrease quality of care: 45.6% of respondents predicted that a single-payer system would either lower quality of care (20.9%) or "significantly" lower quality of care for patients (24.7%).
• Improve quality of care: 35.2% said that single-payer would improve (25.1%) or "significantly" improve (10.1%) quality of patient care.
• No change: 19.1% think it won’t change the quality of care.

For quality of care, many respondents said that the devil is in the details. “If done correctly, as is done in Europe, care would be better as there would be community health clinics where patients would get care from their PCP,” said psychiatrist Fares J. Arguello, MD, of Salt Lake City, UT.

Others respondents said the writing’s already on the wall. “Just as in the VA system, a single-payer system would be overwhelmed by rules and regulations and paperwork,” said cardiac anesthesiologist Thomas Russell, MD, of Dallas, TX. “Quality and service would be evident only in slogans.”

Effects on physician workforce

The survey asked participants what effects a single-payer system would have on the US physician workforce. Respondents could choose more than one answer.

• Mostly negative effects: 40.0%
• Mostly positive effects: 36.1%
• Make the business side of medical practice more manageable: 48.7%
• Accelerate physician retirements: 41.3%
• Decrease the number of students choosing a career in medicine: 33.2%
• Increase the number of students choosing a career in medicine: 12.7%
• Little or no impact: 6.1%

A single-payer system could make medicine more attractive to students if less paperwork and bureaucracy is involved, several respondents said. Retired professor Ralph Hale, MD, of Kailua, HI, also noted, “My experience with students over the last 30+ years is that very few go into medicine based on how health care is paid.”

“A governmental program with basic insurance paid by income taxes and contracted out to insurance companies by the individual states with standard forms, denials, and expected payments would simplify medical practice,” said OB/GYN and professor emeritus Selman Welt, MD, of Johnson City, TN. “Despite all the complaints against Medicare and Medicaid, they pay promptly and you know how they will react and how to make appeals. Then if some people want a more deluxe plan, the insurance companies can provide that with a second tier of standardized services.”

Not everyone agrees that Medicare is quite so tolerable; for them, a Medicare For All system just won’t cut it. “The two most burdensome insurances are Medicare and Medicaid. Government would soon start dictating medical decisions based on political and economic concerns,” said internal medicine physician Richard Kolchin, MD, of West Hempstead, NY.

Some physicians say the US simply can’t afford to have a single-payer system: “A single-payer health system or ‘Medicare For All’ is absolutely unfeasible after crunching the numbers,” points out Ob/Gyn Tara Solomon, MD, of Coconut Creek, FL. “Our country already spends 16% of GDP on health care. If all 330 million US citizens were to receive health insurance, this number would double to 30%. Implementation would cost trillions of dollars in a country that is twenty trillion dollars in debt.”

Other physicians say the US can’t afford not to have single-payer. “The overhead for private health insurance companies is ridiculous—20% to 30%—compared with 3% for Medicare. None of this goes for health care,” said retired pediatrician Walter Ector, MD, of Charleston, SC. “We spend more, and have worse health statistics, than almost every other developed nation. We need Medicare for all.”

Physician income

• Decrease income: 67% of respondents said that the single-payer system would slightly lessen (26.0%) or significantly lessen (41.0%) annual income for physicians and advanced practice clinicians.
• No change: 25.3% expect that annual incomes under a single-payer system would stay about the same.
• Increase income: Only 7.6% of respondents anticipate that single-payer would either slightly increase (1.5%) or significantly increase (6.1%) physician income.

Many respondents fear that a single-payer system would require physicians to see more patients for less money, and ultimately undermine medicine overall. “I do not care about the money,” said osteopath and family medicine physician Harold Kornylak, DO, of Virginia Beach, VA. “It would destroy free choice, individual responsibility, innovation, and make medical care like working for McDonald’s.”

Internist Andrew Gurien, MD, of Naples, FL, noted, “If you lower reimbursement too much, it will pay for us to find another line of work.”

Others agree that a single-payer system would mean more patients and less money, but efficiencies in the system could balance it out. “We would probably earn less per patient, but more people would get needed health care so it would average the same,” said psychiatrist Jed Shapiro, MD, of Boulder, CO.

Many respondents predict that the salary range would narrow among all physicians, and then general practitioners might find closer parity to specialists. “Currently, medical and surgical subspecialists are overpaid (and ideally should earn less) and generalists are underpaid (and ideally should earn more),” said cardiologist Wade Martin, MD, of St. Louis, MO.

Some respondents look toward single-payer systems in other countries but, interestingly, respondents’ views of single-payer health care differ. “It is not just the [decrease in] income,” lamented gastroenterologist Narayanachar Murali, MD, of Orangeburg, SC. “It is the professional debasement and dispiriting influence of central planners that will destroy medicine. Look at the mess created by NICE in the UK.”

On the other hand: “I have physician friends in Canada, and their yearly income is similar to mine without the administrative burden of my practice,” said Ob/Gyn Tomas Hernandez, MD, of Pasco, WA.

Your ideal health care system

The survey asked respondents: What would be the ideal scenario for US health care?

• Single-payer: 37.5% favor a single-payer “Medicare For All” plan
• Affordable Care Act: 17.6% chose the ACA program—a mix of employment-based and government subsidy
• Graham-Cassidy: 7.2% would repeal the ACA and replace it with the Graham-Cassidy proposal
• Something else: 37.7% said they want something completely new because none of these options are feasible

Many respondents chose the “something else, completely new” category and, of these, many envision a two-tiered system that allows all individuals to receive basic coverage and then pay extra for better or more convenient services. Internist Robert Lin, MD, of Warrenton, VA, describes it as: “A basic insurance for everyone with the option for an employer or individual to purchase higher-end insurance.”

Additional questions and answers

“How would single-payer likely impact efficiency in the health care system?”

• Increase overall efficiency: 45.6%
• Decrease overall efficiency: 40.0%
• No change: 14.4%

“How would a single-payer system likely impact the per capita spending on health care in the United States?”

• Decrease per capita spending: 50.5%
• Increase per capita spending: 33.6%
• No change: 15.9%

“What effect would a single-payer system have on the number of patients admitted to hospitals each year?”

• No change: 37.0%
• Fewer patients admitted to hospitals: 35.8%
• More patients admitted to hospitals: 27.1%