The arithmetic behind Bernie Sanders’s single-payer health care proposal is the subject of much dispute. Whether or not the numbers add up at the federal level was one of the contentious points in the most recent Democratic debate, and it is far from a settled question.
What is not disputed to any great degree is that Sanders would reduce payments to doctors and hospitals. His “Medicare for all” plan would result in a substantial reduction in revenue compared to what most private insurance plans currently pay. As a pediatrician in private practice, I have grave concerns that implementing a rapid transition to a single-payer system would be far more disruptive to many Americans’ health care than Sanders cares to discuss.
An incremental increase in Medicare eligibility would create a de facto public option, the lack of which was my single greatest objection to the Affordable Care Act. But in order for Medicare to become a single-payer system for everyone, patients must be left with no option. Sanders’s plan, presumably accomplished through legislative action, would require the summary voiding of every contract medical providers have with all the insurance plans they accept. Even in the unlikely event that Sanders gets this plan through a recalcitrant Congress, it is anyone’s guess whether it would withstand the wave of lawsuits that would doubtless ensue.
But even if the plan survives these practical challenges, it makes a mockery of the notion that people can keep the plan they have if they’re happy with their current coverage, one of the ACA’s biggest selling points (for which President Barack Obama got into some trouble when those promises fell short). Whether or not I could still refer patients to the specialists I typically prefer, chosen because my practice trusts the quality of care they deliver, would be in question. Controlling medical expenditures is a necessary goal, no matter what health care system we have, but putting everyone on the same plan without acknowledging restricted choices as an inevitable consequence isn’t telling the whole story.
Compared to the lustrous ideals that inform the pursuit of a single-payer system, talking about profitability seems downright grungy. But businesses need to stay profitable in order to stay afloat, and medical practices are no different. Even not-for-profits need sufficient revenue to keep the doors open. Talking about substantially reducing payment to medical providers in one fell swoop, as though doctors and hospitals will say, “Alrighty then,” and carry on providing the exact same services without any appreciable change to patients strains credulity.
For my practice, it would immediately put pressure on us to eliminate services we provide that do not generate any revenue. As it stands, every patient of ours who gets admitted to the hospital is seen by one of our providers, even if they’re not admitted to our service. We visit our patients in the hospital every day because we believe strongly that doing so keeps us informed about and involved in the management of our patients’ care, even if we’re not ultimately in charge of that care at any given time. It generates no income for the practice when we do this, and it’s hard to see how we could keep paying providers for this service when they could be in the office seeing patients instead.
Further, every well-child exam at our practice is scheduled for a full 30 minutes, and for medically complex patients we dedicate an entire hour. Giving ample time to discuss each patient’s care thoroughly, answer all the parents’ questions, and offer guidance about important health and safety issues is a value we hold strongly. But the pressure to maximize patient volume could put that value in jeopardy.
And despite pressure to see as many patients as possible, it’s still very likely that we would need to reduce payroll costs to stay in the black. Even if you factor in a reduction in our already-thin billing personnel (a prospect I don’t greet with any joy, as these are employees I care about), and even with the substantial haircut my partners and I would doubtless take to support our staff as much as possible, we’d have to pay our providers less. This may be a matter of blithe unconcern to advocates of Sanders’s plan, but it would almost certainly mean we’d have to make compromises in what we ask our providers to do.
We’re currently open seven days a week. Even on major holidays, we make a provider available for urgent sick visits to the office. If you call our number outside regular office hours, at any time of the day, it’s one of our physicians or nurse practitioners who gets the page. It’s hard to see us maintaining that level of availability while simultaneously cutting the pay of people who show up on Sundays and take those two o’clock in the morning phone calls.
Could we make all the changes necessary to make it worthwhile to stay in business? I hope so. It would be a grimmer place to work, to be sure, but we’d try to make it happen. However, I have no doubt many offices would see the writing on the wall. Some may try to sell to hospitals, which certainly won’t keep them open at a loss, and others will close outright. Who will assume care for the thousands of patients these closures would displace is not a question I see answered in Sanders’s plans. The government can provide insurance, but providing care directly is an even more ambitious change than Sanders is already proposing.
A phased-in approach to expanded Medicare enrollment, while allowing other payers to remain intact, would obviously be far less disruptive. Gradual shifts in the multiple-payer system are much easier to accommodate than a sudden large reduction in revenue. Given the choice between “adjust next year’s budget” and “batten down the hatches,” I’d just as soon pick the former.
But these incremental changes are not the revolution Sanders is advocating. Fans of single-payer may well be willing to make sacrifices in terms of patient choice or provider availability. However, it does not withstand scrutiny to say that hospitals and doctors will take a big decrease in compensation without patients feeling the burn in a painful way. As with all things in medicine, a full discussion of risks and benefits must be had before a truly informed decision can be made.