Why you should care
Doctors could decide whether presidential candidates touting single-payer sink or swim.
Wayne Goldner is a staunch Democrat who has penned op-eds criticizing conservative health care laws for threatening coverage for preexisting conditions. “Universal health care is a human right, and it should not bankrupt a family to have an illness,” he says, while attending a New Hampshire primary event for California Rep. Eric Swalwell. Yet after having led a medical practice in Nashua for 35 years, the OB-GYN doesn’t understand the plans being bandied about by many liberal presidential hopefuls. “My litmus test is that if a candidate wants ‘Medicare for All,’ then they are too stupid to understand the complexities of the medical care system,” he adds.
As Democratic contenders have raced to the left to attract their base, with many of them endorsing Medicare for All and even a single-payer system, there are some within the rank and file — particularly medical professionals like Goldner — who are less excited. And while universal health care has become a nearly universal plank within the party, the much more complex question of how to get there is far from settled among these voters. That divide is now beginning to find reflection in the positions adopted by Democratic presidential candidates as they prepare for primary debates starting in June.
Senators and presidential candidates Kamala Harris, Elizabeth Warren, Kirsten Gillibrand and Cory Booker all co-signed a Bernie Sanders single-payer bill in 2017. Meanwhile, Minnesota Sen. Amy Klobuchar stopped short of that, with only a promise to make health care “more” universal and affordable, and California Rep. Swalwell has proposed raising capital gains taxes and reducing the defense budget to fund a universal system with a public option.
You don’t have a right to demand that I work for you.
Jane Orient, Association of American Physicians and Surgeons
Meanwhile, the biggest hurdle to actually passing single-payer will not be hospitals or the insurance industry. It will come from doctors, many of whom fear an exodus from the profession unless presidential contenders are thoughtful with their prescriptions. “Best-case scenario is that everybody gets covered and gets access to care,” says Steven Schroeder, a medical professor at the University of California, San Francisco. The worst case? Expanding access and leaving payment the same could place primary care physicians under such great demand that they would have to “triage and close their practices.” That could lead to a boom of “concierge” practices, where physicians prioritize the needs of wealthier patients over poorer ones, creating a new 1 percent problem out of what was supposed to be an equity-based solution. Single-payer could also skew toward primary care, rather than technology-intensive specialities as it does today.
“The devil is in the details,” Schroeder cautions.
The American College of Physicians has yet to endorse single-payer but has said it supports public options and the ability for those between 55 and 65 to buy into Medicare under an idea supporters call “Medicare Buy-in” and opponents deride as “Medicare for Some.” The American Medical Association, the nation’s largest doctors’ group, supported the Affordable Care Act but has opposed single-payer and Medicare Buy-in. The American Academy of Family Physicians, representing more than 131,000 doctors and medical students, has suggested it would support Medicare for All public options that still preserve a private marketplace.
While studies specifically targeting Democratic doctors aren’t available, the polling on doctors, in general, is wildly disparate. When the Association of American Physicians and Surgeons conducted an online survey in September 2017, it found that 90 percent (of 1,208 respondents, most of whom were medical professionals) opposed single-payer. That came on the heels of a Merritt Hawkins survey in August 2017 that concluded 56 percent of respondents “strongly” or “somewhat” supported single-payer, while 41 percent “strongly” or “somewhat” opposed it. “There is going to be a huge debate. Doctors are already split,” Schroeder says.
Doctors are split by region, with rural practitioners (with smaller patient bases) currently getting shortchanged the most, which may lead them to support changing the system. And they are split by age, with younger practitioners most supportive of single-payer. “I prefer a hybrid system,” one physician who identified as older than 50 years wrote in the AAPS survey’s public comments section, “where the federal government pays for nationally recommended preventive care for all, and provides reinsurance for catastrophic expenses.” The strategy for getting to single-payer “should be done in steps,” wrote another physician, suggesting Medicare become an option on exchanges for those in their 50s. An anesthetist in his 40s put it more bluntly: “Single-payer = career change.”
For those who supported single-payer, the administrative burden of insurance and fairness were among the top reasons cited. “We physicians spend so much of our time not seeing patients as a consequence of the administrative nightmare we are facing,” says Dr. Ed Weisbart, chair of the Missouri chapter of the Physicians for a National Health Program.
Complicating matters are worries of an impending physician shortage, with the Association of American Medical Colleges reporting a national shortfall of as many as 120,000 doctors by 2030. Rural areas will likely be hit worst. With the significant time required and increasing cost of medical education (the median medical school graduate carries nearly $200,000 in debt), skeptics of single-payer wonder if decreasing earning potential would drive doctors further away from the profession. Governments are having trouble convincing doctors to accept patients with Medicaid, which pays less on average than Medicare or private insurance. One proposal, briefly considered in New Hampshire, included fining health care facilities $10,000 per full-time employee if they didn’t accept their fair share of Medicaid patients.
While that effort was killed in a state legislative committee, it gave physicians like Jane Orient, executive director of the open-market-touting AAPS, a glimpse at what they fear would be an indentured servitude-like future under single-payer health care. “You don’t have a right to demand that I work for you,” Orient says.
More than a dozen health care groups that banded together to protect Obamacare before the midterms are now forming the Partnership for America’s Health Care Future to preserve a private option and oppose single-payer. The Center for American Progress, a left-leaning think tank led by Hillary Clinton confidante Neera Tanden, and the United States of Care, founded by former Obama administration health official Andy Slavitt, have published Medicaid Buy-in proposals. A number of legislators who backed Medicare for All before Democrats won control in the 2018 midterms are now proposing similar half-measures. This intraparty schism is sharpening — well beyond the emergency room.