A ‘reality check’ on single payer health care

With Sen. Bernie Sanders saying the middle class will pay a little more in taxes in the Democratic debate this week, it is time for a reality check.

Single payer health care will not cost more. That canard has surfaced only as a last gasp in the drowning struggle of corporate medicine trying to retain its profits. How can anyone believe, in view of the overgrown commercial colossus of American medicine, that a simplified sensible system for doctors caring for their patients cannot save money?


Since medical care is not amenable to market forces (if you are seriously ill, the cure is priceless), the charges for medical care are not corralled by the usual constraints. If the costs go up, insurance companies benefit over time since they take their percentage of the costs off the top. In the Journal of the American Medical Association this week, a series of articles describe the waste in U.S. health care as due to failure of care delivery, failure of care coordination, over-treatment, pricing failure, fraud and administrative complexity.

Marginally unnecessary care is not curtailed now. Patients want “everything to be done” of course. But they will be better served by a system that avoids potential harm from tests and treatment that are known to be inappropriate for their situation but are done because the insurance company will pay and the patient does not get thoughtful guidance. Studied carefully at Dartmouth, it was found that 30% of care was not indicated. Getting rid of that completely could save $1 trillion for the U.S. health care system. As a doctor, I doubt we could achieve that, but I would settle for a realistic 20%.


As a patient, you or someone in your family may have encountered the need for “prior authorization.” Doctors often encounter this administrative move by insurance companies, which adds to their office work load and impairs efficient operation of the system. It asks that another opinion be obtained before proceeding with an exam, test or treatment. One doctor observed that it is like the bank teller being required, before cashing any check, to go in to the back office and get permission. This is a classic example of the administrative complexity that plagues doctors as well as patients and adds unnecessary expense to the system. Others include co-pays that do not work), restrictions on referral to anyone other than pre-approved doctors, and balance billing for necessary medical care not available within the system to name a few.

Partly to maintain these medically-harmful strategies, insurance overhead is tenfold that of Medicare. The attempts to benefit from information technology to make providing care easier for doctors and more effective for patients have failed due to competition between multiple systems, each trying to maximize both profits and financial returns from billing for the business-motivated hospitals buying the systems. Medical records at present are not helping patient care quality or cost.

The savings possible from a single national system that can avoid all of these expensive problems are the answer to the establishment claim that it will cost more. The problem is that people figure from present day costs that providing the additional coverage for those Americans with inadequate or no insurance will cost that much more. It won’t, not in a single payer Health Care for All system. We will save so much that costs with the additional coverage needed may well add up to less than we are spending now.

I excuse Bernie on the basis that he is trying to be as fair as possible — who would believe that it will cost less to cover more? And, of course, he is not in the day-to-day medical situation that doctors are in, crushed by unnecessary complexity and demands.

By making our health care system better for ourselves and patients we can help to save money. The key for doctors will be to use common sense and help shape the right federal approach. This will allow us to have appropriate incomes and realize the potential for modern medicine to be available to help every American.

Dr. James Burdick ( is a professor of surgery with Johns Hopkins Medicine and author of “Talking About Single Payer.”