Michael S. Victoroff, MD

The current debate over a single payer system calls to mind the parable of the blind men describing an elephant.

Michael S. Victoroff, MD

"And Moses said to Pharaoh, 'Let my people go!' And Pharaoh said, 'You don't seem to understand the implications of a 'single payer' system.'"

When I was little, there was a movement to adopt a universal language called, "Esperanto." This was supposed to solve all the world's problems, which were believed simply to be due to the inability of people to communicate with each other. (Now that we have global communication, we realize the world's problems are more than semantic, and Klingon is growing faster than Esperanto.) But, let's talk about a single payer health system.

I support two ethical goals that have been advertised for a single-payer system: Make broader access possible to certain types of care, and expand tax-funded, public health services. However, neither of these requires, or would be facilitated by, an SPS. My main problem with an SPS is, I can't figure out what people are talking about.

Picture a hundred allegorical blind men, groping the anatomy of an elephant. This gives you an idea of the debate over a single-payer system. The phrase has been bandied about for a long time. But, it can't be called an idea, until we find two people who agree on what it means.

Like the current health care ecology (I avoid calling it a system because that would be misuse of the word), SPS proposals have two radically different formats. Call them wageworker and pieceworker.

To some people, the SPS would follow a "wageworker" model, like military or academic medicine. It would involve the creation of a giant federal "Monolithic Health Service," like a V.A.-for-all. Everybody who performed health care services would need to become a salaried employee of the MHS, which would be responsible for all medical care in the country.

To other people, the SPS would involve the creation of a giant federal "Monolithic Insurance Co." that would replace all existing health plans. It would collect taxes, rather than premiums. There would be one fee schedule, one Post Office box, and one medical director to resolve any policy question not legislated by Congress. Unlike the MHS, the MIC would be a pieceworker system, based on a coding-for-dollars model like Medicare.

Exactly how is that going to work?

In the "MHS" fantasy, you'd have to make "practicing medicine outside the service" a crime. You couldn't allow practitioners to take payments under the table, or you'd foster a black market health system bigger than the official one. Unless you strictly outlawed extracurricular practice, you'd have what we've got today — a multi-payer ecology.

"Everything must go!"

Likewise, in the MIC fantasy, you'd have to make all forms of health insurance illegal. Not just commercial insurance, but state programs like worker's comp and Medicaid, employer-funded plans, Tricare, FEHBP, and everything else — including Medicare. "Everything must go!"

I suppose that, in a voluntary SPS, you could shift some covered lives from one plan to another with the usual carrots and sticks. (Been there, done that.) And, you might induce providers in a voluntary SPS to drift a bit from one compensation arrangement to another, with strong enough incentives. (Ditto.) But, if you allowed patients to buy medical services outside the system, a side market would persist (like what the Canadians come to the U.S. to get). Then, inevitably, coverage plans would spring up to pay for it, employers would be forced into making non-MHS care a benefit (thus expanding the definition of affluent), and providers would drop out of the MHS for jobs in the private sector. You'd end up where we are today. As far as I can see, state control of an industry requires state exclusivity. Government does not compete.

Furthermore, neither of these models promotes fairness in provider compensation, which is the dream that recruits practitioners to support one SPS or another. Each is worse than the other, in that respect. Witness the panic of private practitioners when a single commercial insurer begins to dominate a given neighborhood. Can you imagine a single, take-it-or-leave-it contract that governs every eligible patient in the country?

Likewise, neither model provides universal access. The problem with caring for the indigent isn't the lack of insurance — it's the lack of money! This won't change by simply sliding the chips across to a different dealer. I could personally fund all care for the indigent if I got a nickel every time somebody said, "Reduce administrative overhead." This is just an MBAism for abracadabra. Who thinks clerical burdens would be reduced in a single-payer system? The power to pay is the power to demand that forms be filled out.

What lunatics imagine that physician incomes would increase if they became public employees of an MHS, competing with people who actually have unions?

Imaginary benefits

Private practitioners tend to envision an SPS as nationalizing the insurance industry, rather than nationalizing the health professions. They imagine fee-for-procedure reimbursement continuing, using the AMA's doomed CPT system but with more generous relative value units. How can they believe this would happen in a total buyer's market? Forget "any willing provider." You're talking, "any provider that wants a job."

There are a million other problems with any definition I put on the label single-payer system. I'd love to share them. But, don't take this skepticism to mean that I wouldn't like to see the current ecology reformed. Two terrible drawbacks of the current multi-payer system are:

  • It is wasteful and resource-intensive to deal with multiple claims systems, each with different policies, standards and practices.
  • It is wasteful and unconstructive to deal with multiple accountability and quality measures, like precertification, referral oversight, utilization review, and quality audits, with different measurement systems and standards.

These can certainly be improved by some kind of uniformity without falling into the tar pit of an SPS. I'd like to see the effort currently wasted on single payer directed at creating a uniform reimbursement policy, with nationally standardized, legally enforceable interpretations of a clinically relevant procedural coding system (not the tattered and proprietary CPT), with a national board of appeals. And I'd have the National Institute of Standards and Testing administer it, rather than the FBI.

With more talk about single standards rather than single payers, we could all save valuable breath, and maybe accomplish something constructive.

People who advocate "single payer" simply haven't paid enough attention to those evil jokes that begin, "This guy picks up a magic lamp on the beach, and a genie pops out and gives him three wishes..." You know what he always wishes at the end: that he'd never touched the lamp.

Michael S. Victoroff, MD, is a family practitioner in Denver who has also been an HMO medical director.

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