What do you want to see, a publicly funded national health insurance
system—the "single-payer" solution—or insurance reform
and tax credits to empower individuals to buy their own insurance?
One promises universal coverage, a unified market that puts an end to cost
shifting and adverse risk selection, and freedom from corporate oversight of
medicine. The other promises greater individual buying power and choice of
These choices were discussed at APA's Institute on Psychiatric Services in
Chicago—a month prior to the presidential election—when past APA
President Steven Sharfstein, M.D., and John Kay, J.D., a member of the AMA's
Board of Trustees, argued the merits of the competing proposals to reform the
American health care system (see also Stotland Vows to Educate Members About
Health Reform Choices).
Past APA President Steven Sharfstein, M.D., says APA should support a
single-payer plan for health system reform, because it is the best one for
Credit: Ellen Dallager
Sharfstein, a long-time supporter of the single-payer solution and a member
of the Physicians for a National Health Plan and the AMA, urged APA to
advocate for the proposal and said psychiatrists had special reasons to be
drawn to a single-payer system.
He is president and chief executive officer of Sheppard Pratt Health System
"I believe that for the average psychiatrist in private practice, in
community practice, in hospital practice, and in academic medicine, single
payer is the best option," Sharfstein said. "If you talk to
colleagues in Canada, which is a model for single payer, they can't believe
what we deal with in this country. Ask them how much time they spend
billing—10 minutes a week. Patients have choice [of physicians], and
psychiatrists make on average $200,000. It seems to be a no-brainer for
The AMA, in turn, offers a proposal of insurance reform and tax credits to
allow individuals to buy their own insurance. Kay, arguing the case, said the
AMA plan was politically feasible and a more practical solution to an issue
that has plagued American policymakers for 30 years.
"The AMA has worked very hard to come up with a plan that we believe
will work for everyone," Kay said. "We think income-related tax
credits are the best way to modify behavior and address problems. And it works
best for those who need it most—low-income people. It puts money in the
hands of people to obtain their own insurance.
"Politically this is an idea whose time has come," Kay said,
adding that the AMA's proposal has already received bipartisan support in
AMA Board member John Kay, J.D., speaks on behalf of the AMA's proposal
for health insurance reform and tax credits to give individuals resources to
buy their own health care.
Credit: Ellen Dallager
Kay said a single-payer system would be costly, require increased
government regulation, and restrict choice of physicians and cause patients to
wait excessive amounts of time for essential services. "I say treatment
delay is no treatment at all," he said. "The single-payer system
Arguing for a total overhaul of current policies in favor of a single-payer
system, Sharfstein employed cartoons depicting the sometimes absurd
contortions of the American health care system—like the drawing of a
doctor consoling a woman in a waiting room about the death of her loved one
with the words: "We did all we could, but the paperwork was too
Sharfstein outlined the key features of a single-payer system: universal,
comprehensive coverage; no out-of-pocket payment; a single insurance plan for
each region of the country administered by a public or quasi-public agency;
and global operating budgets for hospitals and other health care systems and
providers with separate allocation of capital funds.
A publicly funded national health insurance program would also feature
public accountability, as opposed to accountability to corporate dictates, and
a ban on for-profit health care providers, he said.
"One of the big issues around single payer is that people don't want
government telling us what to do," Sharfstein said. "Well, today
what we have is a lot of unaccountable private corporations telling us what we
can do and where we can go."
He emphasized that the familiarity of psychiatrists with insurance
discrimination and administrative hassles should make the single-payer option
especially appealing to APA members. And Sharfstein was especially critical of
the enormous amount of administrative waste in a fragmented, privatized
"We have a huge overhead," he said. "In my hospital [at
Sheppard Pratt Health Care System, in Baltimore], we have 70 staff just to
collect bills. A similar hospital in Canada with the same number of beds has
one or two people."
Sharfstein noted that a study in the April Annals of Internal
Medicine found that psychiatrists support the establishment of national
health insurance more than any other medical specialists do; 83 percent of
psychiatrists say they favor a single-payer system, compared with 59 percent
for all other medical specialists.
Finally, he argued that a national health insurance program serves public
health needs by covering everyone and spreading the insurance risk across the
entire population. Also, the current patchwork quilt of hospital, outpatient,
and emergency services encourages cost shifting from one sector of the system
to another, raising costs and creating inefficiencies and inequalities.
"Only single payer would eliminate administrative waste and other
inefficiencies, freeing funds to cover the uninsured," Sharfstein
"APA should endorse single payer as the best option for
America," he concluded, adding with a nod to presidential candidate
Barack Obama "for change we can believe in."
Kay, in turn, outlined the basics of the AMA proposal for tax credits and
insurance reform. "After you figure your tax liability, [the federal
government] would subtract an additional amount so that you will get money
back," he said. "And you can use it as an advance. If you don't
use the credit to buy health care, you can't take advantage of it.
"In addition to providing greater choice for patients, it offers
greater savings overall," Kay said. "The cost of individual
coverage is 60 to 65 percent less than what it costs in premiums to have the
same person insured by [his or her] employer."
Kay stressed also the need for streamlined regulation of insurance to
eliminate the multitude of state mandates "Right now we have to pay for
every idiosyncratic change that is made in 50 states and the District of
Columbia," he said. "We need one set of rules for all
But much of Kay's argument was more about what he described as the perils
of a single-payer system. He especially emphasized the waiting lists for some
specialty services in Canada and noted that on at least two occasions Canadian
citizens sued the government for delay of services and lack of access to
private insurance that might have provided access to more timely service.
Sharfstein countered that there were more than enough horror stories on the
U.S. side of the border. "There are plenty of people literally dying in
emergency rooms for lack of insurance," he said. Moreover, according to
basic public health indices, he said, the United States is falling far short
of other countries.
"We are just slightly ahead of Portugal for what we get in terms of
health for what we are paying," he said.
More information about the AMA's proposal is posted at<www.voicefortheuninsured.org>.▪