A single-payer health care system? A flawed treatment

AMA Leader Commentary. By Donald J. Palmisano, MD, Sept. 15, 2003.

AMA LEADER COMMENTARY

A few words about current events in medical practice

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A message to all physicians from AMA President Donald J. Palmisano, MD:

I was surprised recently to read an article in the Aug. 13 Journal of the American Medical Association written by a small number of physicians and medical students who advocate a single-payer national health system.

It wasn't that the article ran in JAMA -- the journal is editorially independent from the AMA, and is free to publish articles at odds with AMA policy. My surprise was directed at the authors of this article who don't want market competition, but instead seek a rigid, coercive, government-controlled system.

The AMA has long-standing policy in support of pluralism, and against a single-payer system because it would create long lines for services, is slow to adopt new technologies and maintain facilities, and generally is less adaptive, less responsive, more bureaucratic. Such a system is bad for patient care because it invariably leads to rationing.

Just this past July, I attended a meeting of the British Medical Assn., where Dr. Ian G. Bogle, BMA's chair of council, characterized his nation's single-payer health care system as "the stifling of innovation by excessive, intrusive audit ... the shackling of doctors by prescribing guidelines, referral guidelines and protocols ... the suffocation of professional responsibility by target-setting and production-line values that leave little room for the professional judgment of individual doctors or the need of individual patients." His words come from long experience with a single-payer health system that has increasingly been criticized for not keeping up with the needs of its patients.

Unlike the United Kingdom system where private insurance can co-exist, Canada's single-payer model forbids the existence of competing private insurance. No wonder I recently heard a delegate speaking on the house floor at the Canadian Medical Assn. annual meeting state that her patients are "suffering and dying on wait lists," and the only escape for them is to go to the United States.

For those who do advocate a socialistic system, remind them that our current Medicare system, based on centralized, government control, is crumbling. Why take an already visibly flawed system and apply it to a larger national system?

The authors of the JAMA article have issued a challenge to those who reject their "solution" -- present a better and stronger one as an option. The AMA has a better and stronger solution -- it eliminates the monopsony power of abusive managed care, creates true choice and competition, and puts the patient in control.

The AMA health insurance reform proposal, applicable to public and private insurance, advocates a mix of private- and public-sector financing, where the provision of both coverage and care remain firmly in the private sector. We support replacing the current tax exclusion of employer-provided health benefits with a system of refundable, advanceable tax credits that are inversely related to income, consequently empowering those who need it the most: lower-income Americans, who are most likely to be uninsured. Read more about the AMA's plan on our Web site (www.ama-assn.org/go/insurance-reform), and learn how we can cover uninsured Americans.

The right of private contracting is the hallmark of America's free enterprise system. Americans are too diverse and selective to be satisfied with a "one-size-fits-all system." Empowering people with tax credits and freedom of choice will dramatically transform today's health insurance markets. Our proposed system will make health plans more responsive to patients, rein in premiums and costs, and stimulate the development of new forms of health insurance that better meet the wide range of needs of individuals and families, and, yes, unshackle medical savings accounts so that option is available to everyone.

Why consider replacing our whole system with one that, when used in other countries, elicits such disgusted responses as Dr. Bogle's -- when by applying our proposal, we can get coverage for all with fewer disruptions and true competition?

The AMA's proposal builds on the strengths of our current system and allows individuals choice among plans and selection of their own physicians. This puts patients -- not bureaucrats -- in control. Our analyses show it can work -- and it is gaining support. As we approach an election year, let's give our well-thought-out plan an even bigger push.

The JAMA editorial responding to the single-payer proposition ends with these words: "No one should sit back and bemoan the existing state of affairs. The 'health care mess' is too real for anyone to ignore it." That, the AMA agrees with. And the AMA has been taking action on some of the issues that contribute to "the health care mess" as we know it.

On national medical liability reform, we are still working hard to overcome the minority of U.S. senators who on July 9 thwarted the will of a majority of the American public on the Patients First Act (S 11).

The most recent action on the Medicare physician payment front has been the Aug. 8 announcement by the Center for Medicare & Medicaid Services projecting estimates of a 4.2% cut for 2004. This development underscores the importance of including a positive physician update in the Medicare bill now in conference, something which we strongly support.

Every time CMS announces a cut, we go into crisis mode, taking our time and energy away from other important issues. This is a prime example of arbitrary decision-making by our government, using a flawed formula that ties rates to the gross domestic product, and not the needs of our patients. Most importantly, such cuts jeopardize access to medical care -- not just for seniors, but for the disabled, and for military retirees and active duty military families who are covered by the TRICARE program, which ties its rates to Medicare. Our brave military members don't need this kind of response from their government. Neither do we. There is no reason the flawed formula cannot be fixed for good.

For more information on AMA policy, visit our Web site (www.ama-assn.org/go/policyfinder) and review the policies created by the AMA House of Delegates: Opposition to Nationalized Health Care (H-165.985); Right to Privately Contract (H-380.989); and Government Controlled Medicine (H-165.916).

Let me know what you think on these issues. Join the battle. And, if you haven't already, join the AMA. Together, we are louder; together, we are stronger.

Dr. Palmisano, a general and vascular surgeon in private practice in New Orleans, as well as an attorney, was president of the AMA during 2003-04.