Best Arguments Against Single-Payer — and Rebuttals

No less a sage than Socrates said that — to paraphrase him — every good argument deserves a good counter-argument.  Here are the best counter-arguments against single-payer healthcare financing.  All are well intended. Some are well taken.  Some require hard choices. But some are based on faulty logic.

The counter-arguments against single-payer financing fall into five categories:

• 1. Long wait times and other access problems in countries with single-payer systems.
• 2. Other administrative turmoil
• 3. Predictions of other severe secondary consequences
• 4. Cost overruns
• 5. Unaccountable power grabs

The next two posts for Fixing U.S. Healthcare will look at each these counter-arguments.  We will draw primarily on the cases made against single-payer financing by Sally Pipes in her 2018 monograph, The False Promise of Single-Payer Health Care and by Chris Jacobs in his 2019 book, The Case Against Single Payer.  

Let’s start in this post with the first two counter-arguments — long wait times and administrative turmoil. In the next post, we will then cover secondary consequences, cost overruns, and power grabs.

Long Wait Times and Other Access Problems

Pipes spends the first one-third of her 2018 monograph on long wait times in Canada and on the Canadian system’s other failings.  She quotes Danielle Martin, a Canadian physician, who admits, “We do have a problem with wait times for what we call elective or non-urgent procedures.”  Pipes cites a median wait time of 21.2 weeks from time of referral by a primary care doctor until seen by a specialist.  Chris Jacobs’ 2019 book cites the same data.  He also cites wait times in Canada of 10 months for orthopedic surgery and other similar statistics.

Jacobs and Pipes also both cite elderly patients in U.K. and Canada stuck in hospital beds after an inpatient stay for lack of enough nursing home beds to receive them. And they cite the 2016 scandal at the Phoenix Veterans Affairs Center, where staff maintained one public log of cancer patients receiving treatment “on time,” but another off-the-record log of their real wait times, during which many died.

Comments:

First of all, Pipes and Jacobs are guilty of “reverse cherry picking.”  Their data comes largely from OECD (Organization for Economic Cooperation and Development) in 2011, ranking the 11 industrialized members.  Canada was 10^th overall, and was indeed 11^th worst for timeliness of care. That same study showed the U.S. was dead last among the 11 for overall ranking (behind Canada!), and U.S. 5^th worst for timeliness.  Switzerland, with a public-private hybrid system — comparable to an “improved” version of Obamacare — was 1^st in timeliness.  U.K. was 2^nd in timeliness, with its fully socialized, government-financed, -owned and -operated system. Netherlands was 3^rd, with its version similar to Medicare-for-all single payer.  Here’s the chart from that study. Pipes and Jacobs’ criticism of Canada amounts to a weak “straw man” argument, which falters when rebutted with “best practice” evidence from Switzerland, U.K., and Netherlands.

Second, the trade-off between staffing and wait times is a universal conundrum in all healthcare organizations, no matter what the payment system, from the highest system level down to the clinic level. For example, should a clinic hire one more doctor so that not even minor emergencies need to wait on Monday mornings? Or should the clinic just block out extra time on Mondays for a nurse manager to do “triage” juggling?

Third, Americans do wait less for knee replacements than Canadians, but that’s not a big deal, since often arthritis patients on both sides of the border have usually been putting off their own semi-elective surgeries for years until they finally decided to go ahead with a procedure.

On the other hand, delaying cancer treatments at the Phoenix VA is quite another matter. And fudging the wait time numbers was not only deceitful but also destructive of trust! Those delays and cover-ups were unconscionable, even though some of the veterans, in truth, had such advanced cancers that even more timely treatment would not have saved them. However, the root problem, in my view, was “bonuses.”  The VA department heads received bigger incentive bonuses if all their wait time numbers were good, and the VA Medical Center Director received the biggest bonus of all. After the scandal broke, the VA did away with those kinds of bonuses. (On a personal note, I worked at one of the better VA Centers with no fudged waiting lists discovered by the Inspector General’s follow-up audit. But as a geriatrician I had always refused to participate in the bonus system as a matter of professional principle, because those bonuses would have given me a “perverse incentive” to overtreat my frail elderly veteran patients!)

Elderly patients stuck in the hospital after an acute illness is another universal variation on the theme of the staffing-versus-wait-time conundrum. Not enough nursing home beds exists in every health system. As a geriatrician, I have been gratified that several of the current Medicare-for-all proposals are finally recognizing the connection between acute care and long-term (nursing home) care, and bringing them both into the reformed system together.  It’s about time!

This blog claims that a single-payer system would allow planners to monitor wait times and then distribute resources rationally with full public accountability. Does anyone really think that private hospitals and for-profit systems are not concealing wait times and other statistics? No one can excuse the Phoenix VA cover-up, but on the other hand it tells me that whistleblowers came forward, were heard, and launched a system-wide correction under public scrutiny. Do private systems do that?  We’ll never know!

In summary, the problem of wait times which Pipes and Jacobs attribute to single-payer systems actually pertain to all health systems. This blog claims that problems of access can be managed more rationally within an integrated system, with aligned incentives (the health of the public), and with transparency and accountability.

Administrative Turmoil

Pipes and Jacobs predict administrative turmoil both during transition to a single payer system and continuing even after full implementation. 

During the transition all health insurance would change.  The 181 million people covered by private employer-based insurance would switch.  Even those currently on Medicare would switch to a new version of it.  Only persons currently receiving care exclusively under federal health delivery programs, like Veterans Health and Indian Health Services, would keep their coverage unchanged. A daunting prospect for all concerned!

Then, after the transition Pipes and Jacobs foresee shortages of doctors and hospital due to increased demand and lower payments. They foresee restricted access to new expensive treatments, diagnostics, and drugs due to budget constraints.  And they foresee logistical problems, for example those attendant on electronic health records and quality monitoring.

Comments:

Pipes and Jacobs are correct, of course, that big changes – like re-financing one-sixth of the entire U.S. economy! – would bring big turmoil.

Some turmoil would be entirely predictable and thus controllable. Well and good. By the same token, some turmoil would turn out to be less than feared by Pipes and Jacobs. Remember that single-payer would change only the payment system (at least at first), not the delivery system.  Medicare and Medicaid already pay 40% of America’s total healthcare bill. Also, remember that Medicare and Medicaid already have established billing relationships with virtually every doctor and hospital in America.  Regards the possible dislocation of a half-million employees of private insurance companies, many would continue their very same jobs, only now as public employees or public contractors.

On the other hand, predictably some turmoil would be unpredictable. In that regard, Medicare has a good track record of implementing changes. Medicare has a system of rolling out new procedures, training partners, proceeding region by region, monitoring the process, supporting staff, and, importantly, making mid-course corrections. Medicare, in my experience, does pretty well in managing change and uncertainty, as discussed in a previous post.

Once the billing and payment system were fully in place, then the New Medicare would be in a position to begin reforming the delivery system.  A good place to start would be to implement a uniform inter-operable digital record system.  Then, in time, the comprehensive, reliable data generated could be advantageously used for targeting further initiatives for optimizing quality and value. 

Through it all, the New Medicare would need to maintain a rigorous system of accountability. And it would need to communicate diligently with the healthcare community, with the public, and with other stakeholders to provide explanations and, most importantly, to maintain public support.

Pipes and Jacobs warn that the New Medicare might ultimately engage in cost-benefit analyses. They fear that cost-benefit analysis could be misused against the elderly (since their “quality-adjusted-life-years” gained per dollar of cure would be fewer than for younger patients) or against the disabled (since their “quality” would already be implicitly discounted).

Pipes and Jacobs’ admonitions are well taken. However, in my opinion, these concerns should not prompt the New Medicare to eschew cost-benefit analysis altogether. Rather, their warnings should remind New Medicare reformers to ensure the ethical utilization of these cost-benefit methodologies and explicitly to avoid unethical biases. And the New Medicare should also engage the public to monitor and critique any policy decisions flowing from cost-benefit analyses. This kind of public common-sense reality check was done under the Oregon Health Plan in 1994. It was also stipulated in a little-recognized provision of the Affordable Care Act (Obamacare), namely Section 6301 (See “What Can I Do”). Thus, I see cost-benefit analysis as a golden opportunity under single payer, not as an argument against it. This blog has consistently supported use of cost-benefit analysis to flush out low-value services. (See post and post.)

Over time, system reforms and cost-benefit-guided policies likely would result in increases in some personnel and services (like primary care) and decreases in others (like futile last-ditch surgeries in very high-risk patients). I agree with Pipes and Jacobs that heavy-handed, rushed implementation of sweeping changes in the healthcare system could be disruptive if mishandled. But I think the new Medicare would have the know-how to heed their warning and thus proceed more slowly, thoughtfully, and deliberately. That would give phased-out healthcare workers time to shift to new jobs and would give expanding programs time to recruit or train need staff.

More Counter-Arguments Next Post

In this post, we have addressed long wait times and administrative turmoil. In the next post, we will cover secondary consequences, cost overruns, and power grabs. And we will also provide general conclusions to be drawn from all of these counter-arguments. Please re-visit us soon.

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References

Jacobs, Chris. The case against single payer, Alexandria, VA: Republic Book Publishers, 2019

Pipes, Sally C., The false promise of single-payer health care, New York: Encounter Books, 2018

Commonwealth Fund, OECD Ranking:

http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

 

Image Credit

Title:  Plato and Aristotle in the School of Athens (Detail)

By:  Raphael (Fresco in the Apostolic Palace in the Vatican)

URL:  https://commons.wikimedia.org/wiki/File:Plato_and_Aristotle_in_The_School_of_Athens,_by_italian_Rafael.jpg