From the President...

Health Care Quality: Would It Survive a
Single-Payer System?

Robert J. Cihak, MD, and Merrill Matthews, Jr., PhD

In recent years some have been promoting a government-managed, single-payer health care system at state and national levels. What would a state-run system mean to the quality of the U.S. medical services? But first, what does "quality" in medical care really means? Is it an issue of access? Or is it related to "outcomes?" Does it mean the best care available? Or do convenience and cost play a role?

In a normal market, people make quality tradeoffs, sometimes substituting less quality for lower costs or greater convenience. However, when people are insulated from the cost of health care because the government is paying the bill, the role of value declines. Patients want quality at any price --- because someone else is paying that price. Ironically, when someone else is paying the bill, the insistence upon quality declines because patients --- indeed, any type of consumer --- are willing to tolerate bad outcomes and poorer service when they are free.

Some quality factors are objective, while others are subjective; some can be measured, some cannot. We identify some factors below and explain why they should be part of any evaluation of health care quality under a single-payer system.


One of the most touted benefits of a single-payer system is that it would be more efficient than the current system. People would have a family physician who they can see regularly, rather than postponing needed care until they are forced to go to the more expensive emergency room.

However, getting to see a family physician under a single-payer system may not be as easy as proponents suggest. A recent flu epidemic in Toronto expanded the waiting times to see a family physician to five to six weeks --- so far in the future that most patients either would have recovered from their illness and no longer need to see a doctor or would have become critically ill and gone to an emergency room.


Proponents of a single-payer system contend that when the government controls the cost of health care, the profit motive is removed, which means the same money can be spread over more people, which saves even more money as well as lives.

When most people enter the single-payer system, they believe someone else - personified as "the government" --- is picking up the bill. As a result, people feel insulated from the cost of care and therefore tend to overconsume --- driving health care spending much higher than it would be if patients insisted on value for money. The irony here is that the process that makes health care affordable for the vast majority of people --- a third party paying the bill --- is the primary factor behind making the health care system unaffordable. In their effort to contain the cost escalation, single-payer systems control health care utilization from the top down with spending limits and price controls.

Scarce Funding and Rationing

As a result, there is never enough money to fund any program as much as proponents and patients would like. Moreover, the decision on which programs get funded and by how much is often determined more by which group has the most political power rather than a program's true needs and merits.

In a single-payer system, the government makes the larger decisions about funding levels, leaving bottom feeders such as the doctors, hospitals and other health care providers to make the tougher individual decisions about whose care to ration. The targets of rationing are usually the marginal cases, the very young, the very old and the very sick. The patient is often simply told, "There's nothing more we can do for you," a true statement within the confines of the limited budget.

In England, some kidney patients died while dialysis machines remained idle because hospitals said they did not have the resources to keep the machines running full time.

In Canada, 121 patients waiting for heart bypass surgery were removed from the waiting list because their condition had worsened to the point that they could no longer survive the surgery.

New Technologies

In a single-payer system health care budgets always end up tight after the politicians discover that they can't raise taxes to meet the demand for services. Middle level feeders, such as the administrators and bureaucrats, often limit adoption of new medical technology because it's too costly. They usually provide only enough funds to purchase a limited amount of the newest technology - if any at all. Decisions on what to buy and when to buy it are often arbitrary and guided more by expedient politics than good medicine.

Stories abound of Canadians going to extreme measures in order to gain access to medical technology. For example, several years ago an enterprising hospital in Guelph, Ontario, decided to allow animals needing CT scans to enter the hospital in the middle of the night --- charging pet owners C$300 apiece. There is nothing necessarily wrong with that except that thousands of people in Ontario were waiting up to three months for an appointment on the same machine.

For physicians, single-payer means single employer. Yet some proponents for a single-payer monopoly gripe about working for corporate HMOs. Yet any single-payer system will surely resemble a huge HMO, without any competing services. This would look like a U.S. Postal Service without competition from UPS, FedEx, e-mail or fax machines.

Finally, in light of the recent attacks on the American homeland, we believe that the federal government has been grievously distracted from its primary duties, such as national defense, as spelled out in the U.S. Constitution. The resources of the federal government would be best redirected to such primary duties and away from meddling with the alluring mirages, such as the single-payer medical care vision.

The best way to expand citizens' control over their own care is to adopt free-market options that allow more choices and options. If policymakers move toward a single-payer system that tries to impose universal coverage, they will find that citizens will be left with neither care nor quality.

Dr. Cihak is the President of the Association of American Physicians and Surgeons. He is a retired radiologist in Aberdeen, Washington, and a nationally-distributed columnist. This column was adapted from their Washington Policy Center study. The complete study (# 01-13) is available at

Originally published in the Medical Sentinel 2001;6(4);113-114. Copyright©2001 Association of American Physicians and Surgeons (AAPS)