In the United States, medical costs have been increasing inexorably for many years, as have the numbers of the uninsured; the latter is currently estimated to be as high as 47 million persons. A single-payer system has long been suggested by some as the most logical solution to the current crisis in health care access and affordability (1). Under a single-payer health system, the federal government would ultimately be responsible for reimbursement of most medical services provided by clinicians and hospitals. The hope is that a single-payer system will both improve access to health care and reduce health care costs. By definition, under a single-payer system no one would be without health insurance, and cost savings might be achieved through a reduction in administrative expenses coupled with an emphasis on preventive medicine and the universal adoption of electronic medical records. However, I have substantial concerns over whether these potential benefits can actually be accomplished. It is the history of government bureaus to become large and complex rather than lean and efficient. Furthermore, access to preventive care does not equate to individual adherence to the precepts of such care. Finally, I fear that the ultimate toll of a single-payer system will be a reduction in the quality of health care that Americans may be unwilling to bear.
Proponents of a single-payer system argue that government-sponsored insurance would save money by reducing wasteful administrative costs. Yet comparisons of administrative expenditures between private and government-run insurance programs are misleading (2). For instance, the cost of administering a private insurance plan includes the expense of collecting premium dollars, which also applies to government insurance programs such as Medicare. However, this expense does not register on Medicare's budget insofar as a separate government agency (the Internal Revenue Service) performs this function. Furthermore, many states tax premiums paid to private insurers, and also tax their profits; government programs are not so encumbered. Finally, Medicare spends approximately twice as much on claims than most private insurers (older patients consume more services), and administrative expense is expressed as a percent of claims paid. Thus, Medicare looks more thrifty than it really is (2). Estimates of the bureaucratic cost savings under a single-payer system do not account for the expense of administering a greatly expanded Medicare-like program or the price of collecting new employer and individual taxes.
Additionally, administrative costs are only a small portion of health care costs in this country. The main problem is overuse of health care, particularly that involving expensive new technologies and drugs (3). Even within Medicare, which functions as a single-payer health system for elderly Americans, there are wide variations in health care spending across regions, with little or no gains in quality in regions with greater expenditures (4). Over-attention to administrative costs distracts us from the real problem of wasteful spending due to the overuse of health care services.
A single-payer system will subject physicians to unwanted and unnecessary oversight by government in health care decisions. With the newfound power to benchmark physicians and regulate payments, the government will inevitably restrict the use of potentially beneficial therapies and pay differentially for perceived differences in quality, with potential unintended consequences such as increased health care disparities (5). Without price competition from private insurers, the government will be free to pay whatever it wants for health services. Physicians are already inadequately reimbursed for services provided under Medicaid (6), and reductions in Medicare reimbursement over the years have demonstrably affected access and quality of care in a variety of health care venues (7–10). Even lower physician payments under single payer will drive many physicians out of business, further restricting access to care. Decreased reimbursement will also prevent hospitals from investing in new health care technologies or trying innovative new therapies (11). Allowing government, rather than the free market, to set health care prices is a dangerous proposition.
Despite the general perception, health insurance alone will not overcome the problem of access to health care in this country. Many patients with adequate insurance do not come to their appointments or do not adhere to recommended therapies. Part of what we perceive to be medical problems can actually be traced to societal conditions. How can we ensure, for example, that all pregnant women receive prenatal care? How can we force patients with asthma to use their prescribed inhalers regularly? How can we stop patients from smoking and eating an unhealthy diet? Health coverage and medical advice would yield little or nothing unless patients do their part.
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