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Once Its Greatest Foes, Some Doctors Now Embrace Single-Payer

Aug 10, 2018

California Healthline
Shefali Luthra

When the American Medical Association met in Chicago this June, its medical student caucus seized an opportunity for change.

Though the medical students had tried for years to advance a resolution calling on the physicians’ lobby group to drop its decades-long opposition to single-payer health care, this was the first time they got a full hearing. The debate grew heated — older doctors warned their pay would decrease and said the younger advocates were naïve about the consequences of a single-payer system. But by the meeting’s end, the group — including its older members — had agreed to at least study the possibility of changing the stance of the organization, which is one of the nation’s most powerful health care groups.

“We believe health care is a human right, maybe more so than past generations,” said Dr. Brad Zehr, a 29-year-old pathology resident at Ohio State University, who was part of the debate. “There’s a generational shift happening, where we see universal health care as a requirement.”

California doctors — young and old — advocated on behalf of the single-payer advocates during the debate, said Dr. Anna Yap, 26, an emergency medicine resident at UCLA, who served as a medical student delegate to the AMA until June.

“They said, ‘At the end of the day, we should support our younger physicians, who will be practicing in this environment,’” she said.

Despite the role that some of them played in the discussion, Golden State doctors as a whole remain opposed to single-payer in their own backyard — even as the topic has become a flashpoint in the state’s gubernatorial election.

Last October, when some California Medical Association members called for a vote to support the most recent single-payer measure, “it was resoundingly defeated,” said Dr. Ted Mazer, a head and neck surgeon in San Diego who is president of the association. The measure ultimately stalled in the legislature, partly because of its exorbitant cost.

The policymaking deliberations of these doctor groups may sound like inside baseball. But this year’s youth uprising at the nexus of the medical establishment speaks to a cultural shift in the profession, one with big political implications.

Amid Republican attacks on the Affordable Care Act, an increasing number of Democrats — ranging from candidates to established members of Congress — are putting forth proposals that would vastly increase the government’s role in the health system. These include single-payer, Medicare-for-all and an option for anyone to buy in to the Medicare program. At least 70 House Democrats have signed on to the new “Medicare-for-all” caucus.

Organized medicine, and previous generations of doctors, have for the most part staunchly opposed any such plan. The AMA has thwarted public health insurance since the 1930s and has long been considered one of its most powerful opponents.

The California Medical Association has fought every statewide single-payer proposal that has come before lawmakers. “There just hasn’t been a single-payer model that’s viable,” Mazer said.

But the battle lines are shifting as younger doctors flip their views, a change that will likely assume greater significance as the next generation of physicians takes on leadership roles.

Many younger physicians are “accepting of single-payer,” said Dr. Christian Pean, 30, a third-year orthopedic surgery resident at New York University.

And Mazer acknowledged that the growing support for a single-payer system within the California doctors’ association is “dominant in the younger physicians.”

In prior generations, “intelligent, motivated, quantitative” students pursued medicine, both for the income and because of the workplace independence, running practices with minimal government interference, said Dr. Steven Schroeder, 79, a longtime medical professor at the University of California-San Francisco.

In his 50 years of teaching, students’ attitudes have changed: “The ‘Oh, keep government out of my work’ feeling is not as strong as it was with maybe older cohorts,” Schroeder said. “Students come in saying, ‘We want to make a difference through social justice. That’s why we’re here.’”

Though “single-payer” health care was long dismissed as a left-wing pipe dream, polling suggests a slim majority of Americans now support the idea — though it is not clear whether people know what the term means, or that it could significantly boost their taxes.

A full single-payer system means everyone gets coverage from the same insurance plan, usually sponsored by the government. Medicare-for-all, a phrase that gained currency with the presidential campaign of Sen. Bernie Sanders (I-Vt.), means everyone gets Medicare, but, depending on the proposal, it may or may not allow private insurers to offer Medicare as well. (Sanders’ plan, which eliminates deductibles and expands benefits, would get rid of private insurers.)

In California, single-payer has emerged as a key issue in the gubernatorial campaign. Democratic candidate Gavin Newsom supports it in principle, but he has not spelled out what that system would look like. His opponent, Republican John Cox, adamantly opposes it and government involvement in health care more broadly.

Meanwhile, many countries have achieved universal health care in which everyone is covered, though the methods vary. In France, for example, citizens are required to sign up with the national health system, which is funded mostly through taxes and administered by a series of quasi-public insurance funds. In Germany, most people get insurance from a government-run “public option,” while others purchase private plans. In England, health care is provided through the tax-funded National Health System.

American skeptics often use the phrase “socialized medicine” pejoratively to describe all of these models.

“Few really understand what you mean when you say single-payer,” said Dr. Frank Opelka, the medical director of quality and health policy for the American College of Surgeons, which opposes such a policy. “What they mean is, ‘I don’t think the current system is working.’”

But the willingness to explore previously unthinkable ideas is evident in young doctors’ ranks.

Recent surveys through LinkedIn, recruiting firm Merritt Hawkins and the trade publication NEJM Catalyst indicate growing support. In the March NEJM survey, 61 percent of 607 doctors who responded said single-payer would make it easier to deliver cost-effective, quality health care.

Delving further, that survey data shows support is stronger among younger physicians, said Dr. Namita Mohta, a hospitalist at Brigham and Women’s Hospital and clinical editor at NEJM Catalyst.

But it’s unclear whether these findings reflect young doctors’ feelings about single-payer or are mostly tapping in to broader frustrations with the American health system.

Much like the general public, doctors often use terms like single-payer, Medicare-for-all and universal health care interchangeably.

“Our younger generation is less afraid to come out and say we want universal health care,” but it’s not always clear what they mean by that, said Yap, the emergency medicine resident at UCLA.

In interviews, younger doctors also pointed to growing concern about how best to keep patients healthy. They cited research that broadly suggests having health insurance tracks with better health outcomes.

“Medical students, I would say, are very interested in public health and improving social determinants of health — one of them being access to health insurance,” said Dr. Jerome Jeevarajan, 26, a neurology resident at the University of Texas-Houston. He was referring to non-medical factors that improve health, such as food or housing.

Some of the shift in opinion has to do with the changing realities of medical practice. Doctors now are more likely to end up working for large health systems or hospitals, rather than starting individual practices. Combined with the increasing complexity of billing private insurance, many physicians said, that means contracting with the government may feel like less of an intrusion.

At this point, the debate is still theoretical. Republicans — who control all branches of the federal government — sharply oppose single-payer. And single-state efforts in California, Colorado and New York have fallen flat.

Moreover, doctors represent only one part of the sprawling health care industrial complex. Other health care interests — including private insurance, the drug industry and hospital trade groups — are less amenable to catchphrases like single-payer or universal health care, which would likely mean a drop in income.

Increasingly, though, physicians seem to be switching sides in the debate, and young physicians want to be part of the discussion.

“There’s tremendous potential,” Pean said, “to be at the table if single-payer becomes a significant part of the political discourse and create a system that is more equitable.”

California Healthline reporter Pauline Bartolone contributed to this report.