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Single Payer's Advantages and Disadvantages

April 23, 2018

Single payer healthcare will not save the world. It won’t even save Oregon. But it will save Oregon’s rapidly imploding healthcare system.

Realistic expectations are mandatory. While single payer will produce significant benefits for Oregon, we must also appreciate what it won’t accomplish.

Single payer streamlines the flow of money into Oregon’s $36 billion healthcare pipeline using fundamental principles of all universal healthcare plans: Everyone contributes and receives care, everyone is covered by a single benefit schedule, and any patient can see any provider. These principles (single risk pool, single plan, single network) generate enormous savings. The recovered money no longer spent on insurance administration exceeds the amount needed to address the unmet medical needs in Oregon.

Single payer provides unexpected benefits in other areas. Employers need no longer pay the medical portion of Workers Compensation: injured patients receive care regardless of cause. For the same reason, insurance premiums for automobiles, homeowners, and businesses decrease because none require medical riders.

Single payer eliminates medical bankruptcies in families paying for treatable conditions. Medical debt is the leading cause of bankruptcy in the US. Medical bankruptcy does not occur in nations with single payer programs.

Single payer eliminates the leading cause of labor-management disputes in the US: healthcare benefits. Labor-management disputes over healthcare do not occur in nations with single payer programs.

These advantages are in addition to providing better to more people for less money than the US produces right now.

That’s quite an achievement.

But in a recent opinion piece, Dr. Michael Rohwer notes this is only part of the story.

Single payer will not remove patient demand for unneeded care. It may even provoke more patients to expect experimental treatments, unapproved drugs, and perhaps even dangerous therapies.

Single payer will not stop unscrupulous practitioners from providing unneeded care solely for financial gain. (However, the FBI estimated a 5% reduction in costs with universal care plans because common billing through a single agency makes fraud harder to commit and easier to detect.)

And while single payer allows more patients to access care at a lower cost, there is no intrinsic mechanism to determine what care is appropriate for individual patients or how to deliver care to maximize community health.

This shortfall illustrates two different aspects of how healthcare dollars flow through Oregon. How money enters the healthcare pipeline raises financing questions: Who participates? Who pays? How do we collect? How money exits the pipelines raises delivery questions: What providers are paid how much to provide which care to what patients?

Single payer addresses only financing, not delivery. Without additional work, single payer leaves our delivery system intact, for better and for worse.

However, single payer enables delivery options that are currently impossible. A single provider network, using a single electronic record, using a single billing format, and paid through a single agency allows statewide creation of Dr. Rohwer’s real-world community health networks as well as localized, networked programs for continuous improvement. Single payer also allows monitoring of regional healthcare needs and practices that are required to produce improvements in individual and community health outcomes. These are impossible without single payer financing.

Single payer healthcare is not the final step toward better care to more people for less money. But it is the first step, and the most critical.

Samuel Metz, MD, is an anesthesiologist who lives in Portland. He is member of Oregon Physicians for a National Health Program and a founding member of Mad As Hell Doctors, both of which advocate for single payer healthcare. His opinion pieces have appeared in the New York Times and most major newspapers in Oregon.