Single payer health care is enjoying a boomlet in public opinion.

A Pew Research Center poll released in June 2017 found that, “Overall, 33 percent of the public now favors such a ‘single payer’ approach to health insurance, up 5 percentage points since January and 12 points since 2014.”  58 percent of those surveyed by Pew said that the government has a responsibility to ensure health for all, with a third saying it should be through a single national government program and 25 percent through a mix of government and private programs.  Another 33 percent said the government is not responsible to ensure health care for all but agreed that Medicare and Medicaid should be continued, while 5 percent said the government should not be involved at all. The poll also showed that a majority of Democrats now favor single payer; support was also stronger among younger persons than older ones.  However, most Republicans and older voters oppose single payer.

The Kaiser Family Foundation’s June 2017 tracking poll found even higher levels of support for single payer, with 53 percent in favor and 43 percent opposed.  However, it also described support for single payer as being “malleable” and subject to change when presented with arguments for or against: “While a slim majority favors the idea of a national health plan at the outset, a prolonged national debate over making such a dramatic change to the U.S. health care system would likely result in the public being exposed to multiple messages for and against such a plan. The poll finds the public’s attitudes on single-payer are quite malleable, and some people could be convinced to change their position after hearing typical pro and con arguments that might come up in a national debate.”

A Harvard-Harris poll conducted in September 2017 found even higher levels of support for single payer, with a narrow majority (52 percent) supporting it while 48 percent opposed.

Doctors also appear to be warming to single payer, according to some recent polls.  And, as I have traveled around the country in recent months to visit ACP chapter meetings, I’ve found more and more ACP members are advocating that the College come out strongly in favor of single-payer health care, and not just in so-called liberal-leaning “blue” states.  I’ve explained that a 2007 ACP paper, which I co-authored on behalf of our Health and Public Policy Committee, examinedwhat the United States could learn from other countries’ health systems.  We recommended “that the federal and state governments consider adopting one or the other of the following pathways to achieving universal coverage:

1. Single-payer financing models, in which one government entity is the sole third-party payer of health care costs, can achieve universal access to health care without barriers based on ability to pay. Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access. They may require a higher tax burden to support and maintain such systems, particularly as demographic changes reduce the number of younger workers paying into the system. Such systems typically rely on global budgets and price negotiation to help restrain health care expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals’ freedom to make their own health care choices.

2. Pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs (Australia and New Zealand). Pluralistic financing models must provide 1) a legal guarantee that all individuals have access to coverage and 2) sufficient government subsidies and funded coverage for those who cannot afford to purchase coverage through the private sector.”

(Note that this paper was written a year before the Affordable Care Act (ACA) became law; the ACA is an example of the second option, although it has fallen short of assuring universal access.)

Recognizing the growing interest in single payer, and in other models that may still involve multiple payers but with the government having a much large role in financing and ensuring coverage (most European countries are not truly single payer, because they still allow some role for private insurance), ACP’s Health and Public Policy Committee will over the next several months begin examining different alternatives to advance universal coverage.   As it does, I think there are several important questions that will need to be asked, particularly of single payer:

1. Will all Americans be required to get their coverage through a single, government-financed system (compulsory coverage), meaning that they would have to give up their employer-based or individual coverage?  (If not, it really isn’t single payer; if so, will Americans react favorably to being compelled to get their coverage from the new program.)

2. Related, will Americans conclude that the coverage under the new program is better or worse than what they have now?  Will deductibles and co-payments be higher or lower?  Many single-payer advocates assume that deductibles will be lower under single payer than most Americans typically now pay, but that is in no way a given; one could imagine a single payer plan based on the ACA’s silver plans, for instance.  Will the covered benefits be more or less generous?  Will premiums — or if funded solely through taxes, the taxes they pay — cost them more or less compared to what they and their employers now contribute?  Will taxes be progressive, meaning the wealthier pay more, or regressive, as is the case with Social Security taxes?  Will they have limited networks of physicians and hospitals, like Medicare Advantage plans, or complete choice of physician and hospital, like traditional Medicare?  Will they and their physicians be able to have access to any FDA-approved prescription drugs, or will there be a limited formulary to choose from?

3. Will the government contract with insurance companies to run the new system, like is the case today with Medicaid managed care, Medicare Advantage, and even Medicare Part B (administered by private insurance carriers) and Part D (pharmacy benefit managers)?  It would be so typically American to create a single payer system, and then pay insurers to administer it.

4. How will costs be controlled?  With global budgets, price controls, limits on capacity, and/or limiting access to care based on determinations of quality-adjusted life years like in other countries? How will physicians, hospitals, drug companies, and medical device manufacturers be paid?

This may seem like I am arguing against single payer; I’m not.  The same questions might be asked of other approaches.  And models that continue to rely on multiple payers, as is the case with the ACA, may never be as effective and efficient as a single payer system in ensuring that everyone has affordable coverage. Single payer almost certainly would have lower administrative costs and be more egalitarian.

Rather, what I am suggesting is that as ACP, and the country, considers different approaches to achieve universal coverage and access (not the same things), the questions that will need to be considered are far more complex than the snapshot (do you favor or oppose Medicare for All) questions asked in polls.  How those questions are answered will likely determine if the public, and physicians, are truly ready to embrace single-payer health care.

Bob Doherty is senior vice-president, governmental affairs and public policy, American College of Physicians and blogs at the ACP Advocate Blog.

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