Internist society sees single-payer as option

Washington -- The American College of Physicians has endorsed the concept of a single-payer health care system for the first time.

In a new position paper, the organization, which represents 124,000 physicians in internal medicine and related subspecialties, identified a system in which the federal government is the sole third-party payer as one of two reform vehicles to achieve universal coverage. The other is a public-private system that includes a legal guarantee that everyone has access to coverage and that offers health care subsidies to low-income residents.

The ACP likely was influenced by the general deterioration of the U.S. health system, with its 47 million uninsured and decreasing affordability of health care, said David Dale, MD, the organization's president.

The 31-page paper, published Dec. 4 on the Annals of Internal Medicine Web site and in the Jan. 1, 2008, print issue, compares the U.S. health care system to systems in 12 other industrialized countries and offers eight major health reform recommendations based on that review. One proposal calls for adoption of a single-payer or pluralistic system, while the others tackle everything from electronic health records to physician training.

The paper is part of the college's ongoing effort to effect changes to the U.S. health care system that would support patient-centered medical homes, in which a primary care physician coordinates care. The ACP endorsed guidelines for establishing medical homes in March.

"I think there's a consensus that our system is not working very well, and when we compare it with others, that brings it into the spotlight," Dr. Dale said. The paper highlights how the U.S. system, compared with others, underemphasizes primary care, in part, by not covering everyone.

Dr. Dale said the heart of the reform proposal is making sure that everyone has access to primary and preventive care.

ACP leadership reviewed the paper for about six months. "What we have is a consensus document," he said. Dr. Dale said he received only a few e-mails -- all positive -- about the paper in the first few days after it was published online. He had anticipated receiving some negative comments from members questioning why the ACP didn't ask for their opinion, but Dr. Dale said he senses that support for single-payer is growing among younger physicians.

That consensus does not extend to the American Medical Association or the American Academy of Family Physicians. The AMA opposes a single-payer health system, and the AAFP has not taken a position on the issue.

But a co-founder of Physicians for a National Health Program welcomed the ACP position. "It says that the mainstream is ready for [single payer]," said David Himmelstein, MD. "It doesn't go as far as we'd like to see, but it's a big step forward."

Dr. Dale said the U.S. already has more than 40 years' experience with single-payer health care -- in the Medicare program. "So single-payer hasn't failed in America. It's actually succeeded."

But AMA President Ron Davis, MD, takes a different lesson from Medicare. Both Medicare and Medicaid sometimes pay physicians less than it costs doctors to provide care. Inadequate payment leads physicians to limit the number of elderly, disabled and poor patients they see.

"While other nations' experiences with single-payer health care provide important information, we need look no further than our own experiment with government-run health care to see the flaws with this approach," Dr. Davis said.

AAFP President Jim King, MD, said many of his members wouldn't support the organization endorsing a single-payer system. AAFP membership is divided on the issue much in the way America is split between urban and rural, and Democratic- and Republican-leaning areas, he said.

Instead, the AMA and AAFP have proposals that would expand health care access and call for patient protections, choice and responsibility.

The 26-page AMA plan, promoted in its Voice for the Uninsured campaign, recommends increasing individual access to health insurance by offering refundable tax credits or vouchers, with larger subsidies for low-income people, who could get their credits in advance. The Association also calls for increasing individual choice by standardizing health insurance regulations to help broaden insurance markets.

"Our pluralistic approach to covering the uninsured focuses on tax credits to individuals and families, individual ownership and choice of health insurance, and market reforms," Dr. Davis said.

The seven-page AAFP plan, "Health Care Coverage for All," recommends creating patient-centered medical homes and offering incentives for patients to seek care through those entities.

It also would safeguard patients against excessive medical costs by capping out-of-pocket spending at a fixed amount per household, possibly $5,000, and offering a free, basic set of mostly primary and preventive health care services.

The AAFP proposal doesn't delve into how the U.S. should pay for health care. Dr King said it's more important for the organization to focus on the kind of health care delivery system the country should have.

The financial structure can be worked out later, he said. "The problem at this particular stage is when you start mentioning a specific plan and how it's going to be paid for, it closes so many doors," he added.

Could be influential later

The ACP position paper won't cause the 2008 presidential candidates to change their health plans, which already have been issued, but it could influence health reform after the election, said Robert Blendon, ScD, professor of health policy and political analysis at Harvard School of Public Health.

A large physician organization like the ACP hasn't endorsed single-payer before. Once the election is over, the paper could gain political traction.

"[The paper is] important for sort of setting an agenda for the future," Dr. Blendon said.

That assumes, however, that Congress tackles health system reform. "The country is concerned about things now other than redoing the health care system," he said.