By John J. Seidenfeld, MD

Repairing a Broken System:

A New Vision for American Health Care from the American College of Physicians

By John J. Seidenfeld, MD

COVID-19 infections have been more prevalent and more deadly among people living in the southern parts of the city of San Antonio, where the population is 81 percent Hispanic, according to Laura Garcia of the San Antonio Express News. 1 The data indicate more people dying from COVID in the Southside zip codes when compared to Northside code areas. Flaws in the US Healthcare system were more obvious because of the pandemic, and showed a system that fails marginalized people. These failures result in shorter life span, higher infant and maternal death rates, higher rates of chronic illness such as diabetes and heart disease, and poor or no health coverage in vulnerable communities compared to others.

In 2020, the American College of Physicians (ACP), the largest organization of American Internal Medicine specialists, with over 160,000 members described their new vision for American Healthcare and called for systemic reform. Currently they endorse single payer reform. Why would they embark on this path when many U.S. Medical organizations have opposed this change?2

Major reasons to familiarize yourself with this discussion include the vulnerable Americans who lack health maintaining nutrition, childcare, education, potable drinking water and health insurance coverage. Other problems are expenses of the current system that result in a high rate of personal bankruptcy, and a healthcare system that costs as a percentage of gross domestic product (GDP) more than 1.5 times the cost of healthcare systems in other developed countries. There are serious concerns about access to services, and disparities evident during the pandemic, and equity among citizens.

Many of us are troubled by the administrative costs of a multi-payer private health insurance system. Specific issues are excessive payer profit margins and executive salaries, high administrative costs in each practice devoted to filing claims with over 100 insurers per practitioner and a malpractice system more concerned with punishing a few offenders than improving the overall quality of care. Fraud, waste and abuse contribute to these high costs. Macroeconomic concerns include a period of increased inflation and economic instability, reduced competitiveness of American manufacturing products because of additional healthcare costs for each good produced, a widening gap between the rich and the poor, and the fact that many Americans are either not covered with health insurance or under-covered and susceptible to medical bankruptcy.

Canada has found that converting to a single payer system has reduced administrative costs in health care to from 15-20% down to 2% of premiums.3 The estimated savings from this switch would be more than $200 billion per year in the US. With their current single payer system, Canadians consistently outpace us in quality outcomes in end stage renal disease, type 1 and 2 diabetes, maternal and infant mortality and cystic fibrosis to name a few. Though many initially claimed that delays in the system would make it impractical, at this time complaints about access and quality are no different than those in the US.3

The ACP also includes “public choice” as an alternative which would continue to allow competition among insurers but have significantly less administrative savings compared to a single payer system. Currently in Medicare Advantage and Affordable Care Act (ACA) private insurer run plans “cherry pick” or choose those with lowest predicted expenses. They also pursue a strategy of “lemon dropping” or letting those poli-

cies with the highest medical expenses lapse, dropping plans offered previously, or confusing members through their telephonic customer service and confusing websites. In a similar fashion, the ACA private insurer run plans implement these strategies to remove a de facto “highrisk pool” of patients with greater severity of illness, pre-existing conditions and higher costs for medical care per year. Despite government attempts to thwart the insurers strategies, costs continue to rise as does administrative overhead charged by insurers. An advantage of “public choice” would be avoidance of confrontation with powerful health plans and their lobbies, and the option to allow individuals to retain their current insurance coverage.

How do the options, single payer versus public choice compare? In a single payer system, if all providers, doctors and hospitals were in one network, it would end self-selecting out of networks which now results in small networks of willing providers and longer wait times or unavailability in some areas for poor or high-risk patients. The overhead of each office would be reduced as fewer staff would be needed for collections and insurance follow-up. It would not exclude the inevitable “Blue Stockings” trade which is always available to those able and willing to pay for care outside of the system. Public choice would require a much more robust regulatory arm to assure fair application of Federal and State resources and would not assure great cost savings as single payer would.

According to a Congressional Budget Office report in December of 2020, single payer would raise worker wages since employers would no longer provide health coverage. It would eliminate a household’s health insurance premiums and most out of pocket expenses thus boosting disposable income, reduce administrative waste and free up resources for other sectors of the economy. Workers’ health outcomes and longevity would be improved, and single payer would create a longterm care program which would compensate unpaid caregivers and increase wages among care workers.4,5

Other necessary changes suggested by the ACP would include changing the way doctors are paid. Much of the work of primary care is therapeutic, preventative and cognitive. Rewards would require redistribution to recognize the cost savings to the system of the work done in a primary care medical home. For example, by assuring primary prevention measures are recommended and discussed, significant savings would accrue from earlier diagnosis, preventive care measures, and therapeutic recommendations tailored to the individual and their current regimens.

The ACP recommends universal coverage to avoid safety-net gaps, join other economic partners who assume that such care is the responsibility of industrialized and technologically advanced nations, and avoid the current cost sharing seen when under- and un-insured patients enter the health care system often through the emergency room door.

The ACP champions caring for vulnerable people so that no person is left behind.6 Over the past two years, significant health disparities have been evident in our nation. Those with lower incomes were unable to stay home, get large government payments, afford childcare and use the internet to “zoom” to work. They went into their jobs at their own peril as cleaners, cooks, grocery workers, firefighters, construction workers, nurses and aides, doctors, teachers, police and other critical personnel. As a result, deaths in these groups were higher than in protected groups particularly before vaccines were available and widely distributed.

Has the time come for us to switch to a single payer system? Will such a system fix all the problems in our current healthcare dilemma? Clearly these changes will not fix all our problems and will contribute to a massive bureaucracy larger than that many of us have seen in the Veteran’s Administration, the Military and in Medicare. Although the ACP recommended these changes two years ago, we are in for a prolonged period of debate and discussion. We present this now for our members to begin to formulate their own best solutions and practices to the problems that confront us in delivering the best care to our patients and all members of our community.

References 1. San Antonio Express News. Special Feature. A broken system got worse: How COVID ravaged San Antonio’s South Side by Laura

Garcia 4/20/22 2. Envisioning a better US healthcare system for all: a call to action by the American College of Physicians. Doherty, R, Cooney, TG, Miro,

RD et al. AIM vol 172 no.2 (supplement). 1/21/2020. Pp. s3-s6.

Doi:10.7326/M19-2411 3. The ACP endorsement of single-payer reform: a sea change for the medical profession. Woolhandler, S and Himmelstein, DU. AIM vol 172 no.2 (supplement). 1/21/2020. Pp. s60-62. Doi: 10.7326/M193375 4. https://www.cbo.gov/system/files/2019-05/55150-singlepayer.pdf

Key Design Components and Considerations for Establishing a Single-Payer Health Care System CBO 5/2019 5. https://www.peoplespolicyproject.org/2020/12/11/cbo-medicarefor-all-reduces-health-spending/

CBO: Medicare for All Reduces Health Spending 12/11/2020 by

Matt Breunig 6. A comprehensive policy framework to understand and address disparities and discrimination health and health care: a policy paper from the ACP. Serchen, J, Doherty R, Atiq, O, and Hilden H. AIM vol.174 no.4. 4/2021. Pp. S29-31 doi:10.7326/M20-7219

John J. Seidenfeld, MD is the Chair of the BCMS Publications Committee and a Fellow of the American College of Physicians.