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Another Perspective
A Rebuttle to "An Introduction to Single Payer for Pharmacists and Pharmacy Technicians"

by By Mark E. Greg, PharmD, RPh; Director, Ambulatory Pharmacy Services; Northwestern Medicine Physician Network

“Opinions expressed by authors of Op-Ed articles in the KeePosted are their own and are not necessarily shared by ICHP or its members.  ICHP will publish these articles from time to time to direct you to topics that may be of interest to you and to stimulate discussion on potentially controversial issues of the day.”

Thank you to Drs. Rotolo and Knoebel for their article providing an introduction to single payer health care.1 The intent of this rebuttal is to provide additional information so that the reader may make a fully informed decision regarding single-payer vs. the current free market health care system. 

The introductory article indicates the current single-payer House and Senate bills, “endeavor to provide robust health care coverage – medical, pharmacy, dental, vision for everyone living in the U.S.” and to eliminate private health insurance.1 The purpose of a business is to produce a product or deliver a service at a profit. No profit, no business. Health care is a business. If a hospital, community pharmacy, mail service pharmacy, consultant pharmacy, etc. does not make a profit, it would go out of business and the services provided would not be available to the patients or communities served. We all want to deliver the highest quality of health care… and I would add – in a financially-responsible manner. 

A single payer plan that includes medical, pharmacy, dental, and vision care with no deductibles, copays, or coinsurance sounds great! Keep in mind, “Nothing in life is free. Someone has to pay.” The United States (U.S.) spent $3.6 trillion dollars on healthcare in 2018– a year/year increase of 4.6%.2 That’s 17.7% of the U.S. Gross Domestic Product (GDP) – almost one-fifth of the total U.S. economy. It’s also $11,172 for every U.S man, woman, and child. Medicare and Medicaid spend was $750.2 billion and $597.4 billion, respectively – a total of $1.3 trillion dollars or 37.4% of total health care spend. Ginsburg points out that if the Senator Bernie Sanders’ Medicare-for-All plan was implemented today; annual federal spending would not be the $1.3 trillion (2018 spend) – but closer to $4.1 trillion.3 This cost will increase as the population ages and as programs expand to include additional lives. Medicare and Medicaid populations represent 58.7 million and 72.8 million lives – a total of 131,500,000 covered or 39.8% of the population. The number of Americans receiving Social Security and Medicare will continue to increase yearly. It’s estimated that by 2050, 22% of the population will be aged 65 and older - up from 16.9% in 2020.4 

Australia, Canada, Sweden, and the United Kingdom are frequently highlighted as successful examples of single payer systems or socialized medicine. How many of us would turn down care available in the U.S. for care provided in Australia, Canada, Sweden, or the United Kingdom? Would any of us choose care offered in Italy, China, or the UK given these nations’ responses to the COVID-19 pandemic?
Rotolo and Knoebel1 mention the advantage of lower overhead if healthcare was run by a single payer (the government). One must keep in mind that healthcare providers must comply with governmental rules, regulations, and laws. In many cases, “compliance” is a condition for compensation for the service provided. Overhead also includes personnel costs - salaries and benefits. Thousands of people work for Aetna, Blue Cross Blue Shield, Cigna, UnitedHealthcare and others. What will those individuals do for employment if the U.S. adopts single-payer healthcare and private health insurers are eliminated?  
U.S. drug spend in 2018 was $335 billion – approximately 9% of overall healthcare spend.2  Profitable markets for pharmaceuticals have traditionally been the U.S., Germany, and Japan. If a business is not profitable, the organization will not remain in business, employ people, produce a product, conduct research, and develop new treatments. That’s why in the COVID-19 pandemic pharmaceutical and vaccine manufacturers were able to ramp up vaccine development and production of various life-saving medications.    

Medicare Part D plans were introduced in 2006. A key component was the government “getting the best price” via discounts and rebates from pharmaceutical manufacturers. To offset the loss in profit, the cost to other purchasers [commercial insurers, Pharmacy Benefit Managers, and cash paying customers (those without a prescription drug benefit)] increased. The net result was higher Average Wholesale Prices (AWPs). 

Tax dollars fund national, state, county, and in some cases, city health departments. Individuals may not want to pay higher taxes. Let’s use the State of Illinois as an example. According to a Chicago Tribune article from December 29, 2019, “Illinois’ population decreased in 2019 by an estimated 51,250 people, or 0.4%, marking the sixth consecutive year the state has lost residents, according to new data from the U.S. Census Bureau. Since the turn of the decade, Illinois has lost more residents than any other state, with a drop of about 159,700 people, or 1.2% of its population.”5 Perhaps this is due in part to the state’s income tax rate, county property tax rates, consumption taxes (gas tax) and other sales taxes. Are individuals in favor of paying more in state taxes?  

The Physicians for a National Health Program (PNHP) website, landing page states, “The answer to our health care crisis is clear. We propose a publicly financed, non-profit single-payer national health program that would fully cover medical care for all Americans.”6  As for physician support for a single-payer, Rotolo and Knoebel1 cite PNHP claiming to have 23,000 and 1,200 medical students on its roster. According to Statista, there were 870,900 active medical doctors in the US in 2015.7 It appears PNHP represents 2.6% of physicians (23,000/870,900). Does PNHP represent the majority of physicians? Similarly, the Association of American Medical Colleges website indicates there were 29,746 students enrolled in medical schools.8 It appears PNHP represents 4% of medical students (1,200/29,746). Does PNHP represent the majority of medical students?

I encourage pharmacists and pharmacy technicians to critically think though the pros and cons of single-payer health care. For more information I refer the reader to articles by Blumberg and Holahan9, Ginsburg3,or Neeman.10 

  1. Rotolo SM and Knoebel RW. An introduction to single payer for pharmacists and pharmacy technicians. KeePosted. 2020 46(2):20-21.
  2. Hartmann, MA, Martin AB, Benson J et al. National Health Care Spending in 2018: Growth Driven By Accelerations in Medicare and Private Insurance Spending. Health Affairs. 2020;39:1.
  3. Ginsburg PB. Commentary on “Health Spending Under Single-Payer Approaches.” J Ambulatory Care Manage. 2020. 43(3):199-204. 
  4. Statista. Share of old age population (65 years and older) in the total U.S. population from 1950 to 2050. (accessed 2020 May 28)
  5. Reyes C. Illinois loses population for 6th straight year — and it lost more residents than any state this decade. Chicago Tribune. December 30, 2019. (accessed 2020 May 28)
  6. Physicians for a National Health Program. (accessed 2020 May 28)
  7. Statista. U.S. Physicians - Statistics & Facts (accessed 2020 May 28)
  8. The Association of American Medical Colleges. U.S. Medical School Enrollment Surpasses Expansion Goal. (accessed 2020 May 28)
  9. Blumberg L and Holahan J. The Pros and Cons of Single-Payer Health Plans. (accessed 2020 May 28)
  10. Neeman E. The Pros And Cons Of A Single-Payer Health Care System. published September 12, 2018. (accessed 2020 May 28) 



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