What About Single-Payer?

The Supreme Court may have divined the solution to America's health care woes that Congress refused to consider

President Barack Obama's vision for health-care reform could have resulted in a much better law had it not been for congressional decrees at the start that a single-payer system was "off the table." But guess what has appeared back on the table during the thoughtful pondering of the problem by the Supreme Court?

Justice Anthony Kennedy said on March 27: "Let's assume that it could use the tax power to raise revenue and to just have a national health service, single payer. How does that factor into our analysis? In one sense, it can be argued that this is what the government is doing. It ought to be honest about the power that it's using and use the correct power."

As a doctor viewing the Supreme Court drama unfolding over the Affordable Care Act, I have high hopes that patients will emerge with much more access to the wonders that modern medicine can provide. Being able to treat and perhaps cure patients is essential to the freedoms and entitlements protected by the Constitution and its Bill of Rights. But the constitutional question has been framed as one of interstate commerce -- not rights.

Commercial interests dominated during the formulation of the Affordable Care Act. An average of eight lobbyists were at work for each member of Congress, and the insurance companies were delighted when they saw the initial draft.

Patients may get sick and need care without adequate insurance. Doctors have always known this, but the conundrum is now occupying our country's best legal minds. That and other failures of our insurance-based system of coverage for health care have been highlighted. And the logic is overwhelming: We need to just get on with providing affordable, quality health care coverage for everyone, like every other developed country.

It is easy for the naysayers to prey on fears that a national system must cost too much, must allow people to get too much health care at others' expense, and must subject patients and doctors to rationing and government interference. But none of this is necessarily so.

If patients understand that their doctors are practicing high-quality medicine when they employ just the right care for a health problem -- not less but also not more -- we are on the way to solving the problem. Excess care is harmful as well as expensive. The insurance companies profit because they force patients to make unhealthy decisions based on finances, not medical need.

Fear of higher taxes comes from extrapolation of present spending patterns. But the things that would make universal coverage cost too much are bad for patients. In overcoming them, we can save $500 billion by avoiding unnecessary care, more than $150 billion in administrative costs, and billions more in avoidable, excess costs for the uninsured.

Doctors are faced with decreasing incomes and at the same time are beset by a huge proliferation in Medicare billing codes due to fee-for-service payments, and by increasing administrative quality requirements and insurance restrictions. Given the necessary legal responsibility and authority, doctors (not insurers) can define necessary care, which will cut excessive spending and end the fear of unfair, unrestrained use of health care. Doctors tend to resist this proposed responsibility, viewing it as the government again telling them what to do -- but many are ready for change. And this would be different: It could work according to rules that would be set by doctors for doctors, doing what federal and insurance company administrators cannot do.

In short: We doctors, along with our patients, need to take over the decision-making and control harmful and unnecessarily expensive practices. Dr. Toby Cosgrove, president of the Cleveland Clinic, recently noted that "health-care overhaul is happening, regardless of what the Supreme Court decides," with improvements that doctors are already achieving.

The savings from having everyone automatically covered will support better professional incomes. Patients will be safer and healthier, and the deficit will no longer be held hostage to increasing health care costs.

Good sense about what the Constitution means may carry the legal day. But even if the Affordable Care Act is struck down, we must move forward with the intent of the law: to make the purpose of medical coverage to create good health.

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