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Editorial & Opinion

Dr Anita Kestin: Choice, Freedom, and Single Payer

Rationing care has also been described as un-American but the current system rations care by economic status, by geography, and indirectly by the red tape involved (accurately described as “rationing by inconvenience.”

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One of the arguments consistently used against Single Payer is that it would limit people’s choices and freedoms and thus is un-American. That is exactly backwards. Here’s why.

Under our current system, we do have the following freedoms and choices:

  1. The freedom to go without health insurance altogether (even if we can afford it).
  2. The freedom to choose among a bewildering array of insurance plans with varying deductibles, co-pays, networks, and hidden costs for drugs and services.

These choices and freedoms are pretty thin benefits of our current system, if they are choices and freedoms at all. The first item actually shifts the burden of paying for care for catastrophic illness or injury onto all of us and impairs the stability of the hospitals and clinical practices we need, especially those in underserved or rural areas. The second item lets us choose among an array of plans that are confusing, don’t provide comprehensive services, and are often unaffordable.  Rationing care has also been described as un-American but the current system rations care by economic status, by geography, and indirectly by the red tape involved (accurately described as “rationing by inconvenience.”

Let’s compare the choices and freedoms listed above (which I would characterize as “the illusion of choice”) to those that would accompany Single Payer.

  • Everyone would be covered (regardless of employment) so everyone would have the freedom to receive care.
  • All doctors and hospitals and pharmacies would be in network so people would have real choice when seeking care. 
  • A Single Payer system would have the leverage to negotiate fair prices for drugs and other services so treatments and tests with a scientific evidence base would be covered.
  • There would be the freedom for those who are ill (or worry about becoming ill) to focus on care rather than fears of bankruptcy as a consequence of illness.
  • Covered care would be comprehensive and would include care for mental health, among other essential services.

Those are the basics but from those real choices and real freedoms flow numerous other freedoms and choices.

  • Doctors and patients could focus on clinical care rather than on mountains of paperwork. 
  • Office staff could focus on ensuring the health of the patients in the practice rather than on insurance forms.
  • People would not be tied to a job due to health insurance coverage considerations because health insurance would no longer be linked to employment.
  • Hospitals would not be placed at great risk of insolvency (due to insurance considerations) and be forced to close.
  • People would no longer be deterred form starting new enterprises and small businesses due to concerns about their own health insurance coverage or about the challenges or cost of providing coverage to employees.
  • Racial and economic inequities would be addressed in a far more effective manner than small programs aimed at pieces of the problem.
  • Individuals could leave abusive or toxic work environments or relationships without fearing loss of health coverage.
  • Unions could focus on advocating for issues apart from health insurance.
  • People who are ill or have ill family members or could develop illnesses (that’s all of us) would not be burdened about coverage concerns.
  • Overall costs of health care would go down due to the leverage and negotiating capabilities of Single Payer. There would be more money available for other priorities (many of which relate to health care) such as housing and food insecurity.
  • Use of preventive care would be enhanced and such care can avert a decline in clinical condition and save money.  This is particularly important with mental health as people with untreated or poorly treated mental illness presently are at risk of incarceration- an unmistakable barrier to freedom and one that disproportionately affects the poor and fuels racial inequities.

This very week, over 100 Rhode islanders signed up to testify in the RI Senate Health and Human Services committee dealing with health.  The overwhelming majority testified in favor of Single Payer, many relating accounts of the human toll of our current system of paying for health care.

Single Payer is also the moral, ethical, equitable thing to do.

Sounds great- you may be thinking. But what about cost?  The simple truth is that we are already paying for Single Payer but not getting the benefits.  Let’s get our money’s worth!


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Single Payer is the answer we need RIGHT NOW.  Please use  this form to ask all your state and federal elected officials to support legislation seeking universal, affordable, comprehensive healthcare that only a single payer program can achieve. 

About the Author

Dr. Anita Kestin is a member of PNHP-RI with an M.D. degree and an M.P.H. degree from Brown University.