Sunday Dialogue: Curing the
appeared August 27, 2011 in the New York Times' on-line
Author: Samuel Metz
To the Editor:
In “Will Health Care Reform Survive the Courts?” (State of
Play, Sunday Review, Aug. 21), Philip M. Boffey states
that “reforms would work far less well without an
individual mandate” that requires citizens to buy health
insurance or pay a penalty.
I disagree. Health care reform could provide better care
at less cost by replacing individual mandates with a
single-payer national health care plan financed by taxes.
Congress’s power to mandate purchase of private products
sold at a profit is disputable, but Congress’s power to
tax is not.
Other industrialized countries have national health plans
providing care to more citizens at less cost with better
outcomes than our system. And they don’t use mandates that
allow insurers to charge different prices for different
These health care systems have three common properties:
public subsidies ensure that everyone has access to care
regardless of health, wealth or employment; primary care
is encouraged; and publicly accountable, transparent,
not-for-profit agencies transfer funds from patient to
There is no need to experiment with mandates. Convert our
current health care system into a national health plan.
SAMUEL METZ Portland, Ore., Aug. 21, 2011
The writer, an anesthesiologist, is a founding member of
Mad as Hell Doctors, which advocates a single-payer
Dr. Metz is spot on with his advocacy of a single-payer
plan instead of the individual mandate.
Sadly, despite the success of Medicare — a single-payer
system that politicians tamper with at their peril — the
“just say no” climate in Washington, fostered by
Republicans who place ideology over country, took that
option off the table and left us with an alternative that
not only raises legal questions but also fails to address
the real threat: the escalating costs of health care.
That said, the health care plan that the politicians have
given us, which extends protection to millions of
uninsured, is better than no plan at all.
After decades of talking about reform, we finally have a
plan in place. With luck, a day will come when the
political will for a single-payer system exists.
Until then, let’s do our best to make the plan we have
JAY N. FELDMAN Port Washington, N.Y., Aug. 24, 2011
Dr. Metz is right that a single-payer system would be
better than an individual mandate. But he does not mention
that Medicare, although it is a single-payer,
tax-supported system, still cannot control costs and will
soon be bankrupt. A national health plan that controls
costs needs to reform the way doctors are paid and are
organized in practice.
This is how doctors, if they are really “mad as hell,”
could help. They should join salaried multispecialty,
not-for-profit group practices that can accept capitated
prepayment for comprehensive care instead of fee for
service, and can provide good, cost-effective care that
supports primary-care doctors working in close
collaboration with specialists.
ARNOLD S. RELMAN Cambridge, Mass., Aug. 24, 2011
The writer, a physician, is professor emeritus of
medicine and of social medicine at Harvard Medical School
and a former editor in chief of The New England Journal of
Dr. Metz’s call for single-payer national health care
imposes costs on taxpayers rather than directly on those
being served. Patients are not charged more for services
they value the most or are more costly to provide. Tax
bills simply rise in sync with something else like income,
property or sales.
It takes no leap of faith to understand how this will
affect demand for health care. Anyone who has dined at a
fixed-cost food buffet knows the outcome of not directing
price with food portions.
It is tempting to believe that government will fairly and
efficiently make these choices for us, but experience
suggests otherwise. Dr. Metz appears to anticipate this
problem given his suggestion that Congress’s power to tax
is indisputable and so government will predictably raise
taxes to pay for growing demand for health care.
MICHAEL L. MARLOW San Luis Obispo, Calif., Aug. 25, 2011
The writer is a professor of economics at California
Polytechnic State University, San Luis Obispo.
Here are my suggestions:
First, impose a three-year moratorium on increases in
health care costs.
Second, dissolve Medicare and Medicaid and use that money
to provide for universal coverage for the less fortunate.
Third, require every person to participate.
Fourth, every participant would be required to have a
yearly physical, major medical catastrophic insurance and
a health care savings account to provide for a large
The yearly physical would start the process of creating a
universal electronic patient record. Furthermore, the
physical would be an attractive revenue stream for doctors
in primary-care practices. The yearly physical and
universal coverage would make medicine more
EDWARD L. BYRD Atlanta, Aug. 24, 2011
We need Dr. Metz to keep the flame of national health
insurance alive until this country is ready to embrace it
as the most cost-effective way to provide coverage. But as
Winston Churchill said, “You can always count on Americans
to do the right thing — after they’ve tried everything
The battle to pass the Affordable Care Act and the
challenge to sustain it should make clear that national
health insurance will not be given serious consideration
by politicians for some time.
Our approach to health reform has desirable features, like
elimination of pre-existing condition exclusions. An
individual mandate is required to make health reform work.
Dr. Metz simply prefers another way to require all
Americans to have coverage. More power to him. In the
meantime, let’s try the next best thing.
BRUCE KELLEY Minneapolis, Aug. 24, 2011
I am a young professional who is just starting out on my
I have already been juggled among health care systems
because of different schools and different jobs, and the
experience was not fun. Recently, I was lucky enough to
find employment that offers health insurance, but if I
should lose my job, I would lose my health insurance. This
doesn’t make me feel secure. The individual mandate
doesn’t make me feel secure either. Health insurance does
not equal health care.
I don’t want to start paying into health insurance that I
may lose because of powers beyond my control. With a
single-payer system, you simply get enrolled into a public
health insurance system. Through my taxes, I would be
making an investment in my health future that would be
there whether I lost my job or not. Now that would make me
MOLLY TAVELLA Rancho Cucamonga, Calif., Aug. 24, 2011
The writer is the education and outreach coordinator
for Physicians for a National Health Program California.
Of course Dr. Metz is correct that a single-payer system —
comparable to that used in a number of other countries —
would be both beneficial and less expensive than the
privately skewed, hodgepodge system we have now.
Unfortunately, the lack of political maturity in this
country means that arguing that other societies have
better ideas than we do is counterproductive, since the
myth of American exceptionalism is more important than
actually providing better health care while saving money
in the process.
ALAN POSNER East Lansing, Mich., Aug. 24, 2011
Dr. Metz presents a compelling argument in support of a
single-payer plan. He cites the experience of other
countries to show that such a system provides better
health outcomes at lower cost. Our own experience shows
that Medicare requires only about 3 percent for
administrative costs, as opposed to 29 percent for private
Alas, these arguments are fated to fall on deaf ears.
Between 2006 and 2009, the health sector spent $1.7
billion lobbying Congress and federal agencies. No wonder
our government can’t hear the rest of us!
SHERMAN C. STEIN Philadelphia, Aug. 24, 2011
The writer is a clinical professor of neurosurgery at
the Hospital of the University of Pennsylvania.
Let me add some data to support Dr. Metz’s proposal. The
evidence is overwhelming. The cost of health care per
person in other industrialized countries is on average
less than half of that in the United States. If we spent
as much per person as the other countries do, we would
save $1.3 trillion every year.
One characteristic of those countries’ health care is that
there is a single entity that runs the system. This
ensures uniform and minimal overhead and compliance costs,
and provides guidance and regulation for the medical
effectiveness of the various procedures.
We can learn much from other countries. The question is
whether we are mature enough to do so.
LEONARD S. CHARLAP Princeton, N.J., Aug. 24, 2011
The Writer Responds
I thank these readers for their thoughtful comments.
Dr. Stein notes that private insurance overhead is many
times higher than Medicare’s. Most economists agree.
Including the cost to providers to collect from insurance
companies nearly doubles the difference.
This administrative excess is more than sufficient to
finance comprehensive health care for every American.
Nearly 25 state and national studies of single-payer plans
Although single payer enables universal care without
additional cost, Dr. Relman notes that it will not slow
cost increases. He proposes a salaried physician model to
replace fee for service. There is much evidence in
The salaried physicians in the Department of Veterans
Affairs medical system care for America’s sickest patients
at the lowest cost with the best outcomes and highest
patient satisfaction of any system in the country.
Clearly, when financial pressures are removed, physicians
provide superb care.
Mr. Marlow is only partly correct. In countries with
national health plans, patients see their physicians more
frequently than we do and spend more days per year in the
hospital. Despite this increased access to care, these
nations spend half as much as we do, and their populations
are healthier. Presumably, unlimited access to inexpensive
primary care reduces consumption of more expensive, more
complex intensive care.
Ms. Tavella makes two important points. First, an
insurance policy is no guarantee of health care. Most
personal bankruptcies in America are precipitated by
medical crises in families with health insurance when the
Second, when the young, healthy and employed make health
care payments in excess of what they consume, this is not
a loss. It is an investment in future care when they are
old, sick and retired.
Messrs. Feldman, Kelley, Posner and Charlap mourn our
inability to achieve single-payer health care despite its
obvious financial advantages. But our obstacle is not
political, but moral. Many Americans believe that it is
immoral to pay for other people’s care, even if doing so
reduces their own costs. Others believe that it is immoral
to pay taxes for health care, even if doing so protects
their family from illness and financial catastrophe. We
cannot argue morality, but we can present the health and
financial consequences of allowing these morals to drive
health care policy.
American single-payer systems include the Department of
Veterans Affairs system; the Indian Health Service;
Tri-Care, the military health plan; Taft-Hartley
multiemployer plans; and Medicaid and Medicare. Any of
these systems could be improved and expanded to cover all
Single-payer health care is America’s health care solution
to America’s health problem.
SAMUEL METZ Portland, Ore., Aug. 25, 2011