Can You Keep Your Doctor Under Single Payer?

Senator Bernie Sanders says that under his single-payer health plan, everyone will be able to keep their doctor. In his recent speech touting Medicare for All,  Sanders said: “I have met many people who do love their doctors and their nurses who have very good experiences in their hospitals. And what we do is to say you can go to those doctors, you can go to those hospitals...”¹

There’s one problem with that: single payer doesn’t guarantee that you can keep your doctor.

Specifically, under single payer, physicians are not required to participate in the expanded Medicare program that would cover everyone. There’s a reason for that: it’s unconstitutional. A federal requirement would significantly limit the license to practice medicine granted by a state and violate the constitutional right to due process when the government deprives a citizen of life, liberty, or property.² In keeping with that principle, Section 303 of Sanders’ single-payer bill (S. 1129 - Medicare for All Act of 2019) specifically allows individuals to privately pay doctors for treatments that Medicare for All covers. That means a person could directly pay for a doctor visit, more time with doctors, or shorter wait times outside the government system. Because of that, some doctors will refuse to join the government program and instead serve only or mainly wealthy patients, locking in today’s two-tier system.

Beyond the immovable legal barrier, there are a number of market conditions in the health care sector that would also make it less likely that every doctor would participate:

1. Many doctors do not accept Medicare patients now. Medicare might be a universal benefit for seniors and disabled Americans, but it is not universally accepted by doctors. One study found that 9% of office-based doctors don’t accept new Medicare patients.³ A more recent study of large and mid-sized metropolitan areas found that one-in-five doctors in five major specialties don’t accept new Medicare patients; rates varied from 54% to 0% by region.⁴ Yet another study found that 28% of primary care physicians do not accept new Medicare patients.⁵

2. Medicare shortchanges providers. Medicare typically pays much lower reimbursement rates than those paid by private health insurance.⁶ For example, in 2012, private insurance paid hospitals approximately 75% more than Medicare did for similar inpatient services.⁷ Although private insurance often overpays, Medicare often underpays. According to a 2010 study, primary care doctors could expect to lose 11% of their compensation if all their reimbursement were at Medicare levels.⁸ That low reimbursement rate significantly impacts providers’ willingness to participate, and it could also drive them out of business altogether. Any attempts to increase payments beyond current Medicare rates would require even more taxes on taxpayers, who are the primary source of financing for a single-payer system.

3. Concierge medical practices are already on the rise. In recent years, there has been a move toward concierge medicine, or direct primary care, where patients pay a premium for VIP-level service outside of typical insurance coverage. It is estimated this subscription-based industry is growing by 3% to 6% annually.⁹ For consumers, this growing model gives anyone who can afford it unlimited access to their doctor and avoids the typical delay to see a new doctor.¹⁰

4. Long wait times are only going to get worse. Under single payer, consumer demand for medical services would swell since everyone would suddenly be able to see a doctor for free any time they wanted. While it is essential to ensure everyone has access to affordable care when they need it, the reality is that single payer would create massive new demand on the existing supply of already busy providers. It already takes about a month for new patients to see their physician, and this delay can be even more significant depending on your location.¹¹ A new patient in Boston, for example, can expect to wait 109 days to see a family medicine doctor.¹²

5. Doctors opt out of government health insurance throughout the world. Doctors regularly operate outside of the public health care systems in many countries, including Australia, Switzerland, UK, and Sweden. With low payment rates from government plans, physicians often operate outside of the system to supplement their income or increase access to services with long wait times or services that the government doesn’t cover. This creates a two-tiered system where some can afford to pay for private care, while the rest of the population remains on the government plan.

How policymakers propose to insure everyone and lower their health care costs will have profound effects on individuals and families. For many people, one of the most basic questions is whether they will be able to keep their doctor. Unfortunately, that’s not a promise single payer can keep.