Sliding Toward Single Payer?

Now that the budget and debt ceiling battles are safely kicked down the road for a few months, the news is filled with stories of glitches and snafus in the rollout of the Obamacare exchanges. From dysfunctional websites to finger pointing over who is at fault, the rollout has been embarrassing. What other surprises lie in store, especially if this is only the first chapter in a long novel?

For the insurance exchanges to work, the young and healthy must enroll and pay premiums, to provide funds to cover care for the elderly and sick. Twenty-somethings are used to making purchases in seconds through their smart phones, from iTunes or Amazon. Do they have the interest and patience to struggle through the morass or will they give up and pay the small penalty for not having insurance? The diabetic with a bad heart and failing kidneys will understandably do whatever it takes, for how ever long it takes, to get insurance through the exchanges. This is called adverse selection, meaning that there won't be enough healthy individuals, paying insurance premiums, but not making claims, to support the unhealthy who will account for most of the claims. And what if the individual mandate is not enforced or is delayed. A further blow to the insurance companies. This is unsustainable and will drown the insurance companies.

Meanwhile those who give up on the exchanges and don't have insurance may still need health care. As will the millions who have lost their coverage through their work or who have had their individual policies cancelled due to not meeting the Obamacare mandates. When these folks get sick, they can still go to any emergency room and receive care. But what if they are among the 90 million Americans who could be working but are not, and cannot afford to pay their hospital bill? How sustainable is this for the hospitals, providing more and more uncompensated care?

And the physicians, too. Declining reimbursement and increasing costs of practice, due to numerous mandates, are making private medical practice unsustainable. Many physicians are already feeling this pinch, and in response, are retiring, becoming hospital employees, or opening non-insurance concierge practices.

Eventually this perfect storm reaches a point where patients cannot get the medical care they need. Owning insurance doesn't guarantee anyone medical care, especially if they can't find a doctor or hospital to care for them. The chaos and confusion, fanned by the nonstop news cycle, may create a panic and outcry for relief. 

Enter the "Expanded and Improved Medicare for All Act" (H.R. 676). This bill, originally introduced to Congress by Rep John Conyers in 2003, and reintroduced each year since, has not seen the light of day in terms of potential passage. But what if it magically reappears when America is crying out for relief from the chaos and confusion of Obamacare? What a perfect solution. After all, the problem is the evil and greedy insurance companies, right? Medicare for all eliminates and outlaws private insurance, so what could be simpler and fairer?

The President, in 2003 declared, "I happen to be a proponent of a single payer universal health care program. But as all of you know, we may not get there immediately." Senate Majority Leader Harry Reid was asked this year whether his goal was to move Obamacare to a single-payer system. His answer? "Yes, yes. Absolutely, yes." Such a plan had little hope of passage through Congress in years past. But as circumstances change, it may actually look appealing. Foods you would never normally eat suddenly become quite palatable when you are starving. 

So when is a glitch not a glitch, but part of a grand plan? Perhaps the rocky rollout of Obamacare is just setting the stage for a single-payer plan. After all, the administration has had three years to plan and implement the roll out. Why would the administration not be certain that its signature legislative accomplishment was tested and ready to work on day one? Keep an eye on Rep Conyers and his bill. After ten years of rehearsals, Medicare for All may be ready for the big stage.

Brian C Joondeph, MD, MPS, a Denver based retina surgeon, is an advocate of smaller, more efficient government. Twitter @retinaldoctor.

If you experience technical problems, please write to