The idea of a single-payer healthcare system has come back into prominence lately with the release of a single-payer healthcare proposal by Sen. Bernie Sanders (I-Vt.), a candidate for the Democratic presidential nomination. But what would it mean for doctors?

Proponents argue that a single-payer system -- in which healthcare is financed entirely by the government through higher taxes on Americans -- would have several advantages for providers. "If we look at what happened in Canada," which went to a single-payer system in 1966, "Canadian doctors are doing quite well," Steffie Woolhandler, MD, MPH, a co-founder of Physicians for a National Health Program, a lobbying group for single-payer, said in a phone interview.

"Their incomes on average are a little less than [doctors] in the U.S., but just a little less. They don't have to pay their own healthcare costs, and the amount of time spent on [administrative tasks] is a fraction of what American doctors have to spend on administration."

In addition, if the U.S. moved to single-payer, "doctors and hospitals will all be paid according to same payment rules -- and I think this is a very important step because one of the problems we have now is multiple tiers of payment, and that creates incentives for doctors and hospitals to prefer one type of patient over another based on their insurance," said Gerald Kominski, PhD, director of the Center for Health Policy Research at the University of California in Los Angeles, in a phone interview. "That's been true for years and it has gotten worse over the last few decades.

"Now that we have the Affordable Care Act, it adds another tier. I don't have good research evidence yet, but I can tell you anecdotally that ACA insurance is paying closer to Medicare [rates] or below, as opposed to rates more like private insurance."

Payment Guaranteed

The guaranteed payment would also relieve some worries, said Harold Pollack, PhD, Helen Ross Professor at the School of Social Service Administration at the University of Chicago, in a phone interview. "Most physicians want to know they're getting paid and that patients can get the healthcare they need without suffering terrible financial consequences."

But it wouldn't be all roses. "My colleagues and I think this is nothing more than a government monopoly and it would have economic consequences as any government monopoly would," Robert Moffit, PhD, senior fellow at the Center for Health Policy Studies at the Heritage Foundation, a right-leaning think tank in Washington, said in a phone interview.

"Monopolies are bad because they are basically vast concentrations of economic power in very few hands," he continued. "We are talking about the government controlling virtually everything because it will be the single provider of a particular set of services, and that means ... every decision dealing with the system is not simply an economic decision or a medical decision, ultimately it's a political decision."

"You have to make political calculations, like how much you are going to spend, and when you get down to doctors and hospitals, what the reimbursement will be and will not be."

Turning Away from Value Instead of Volume

In addition, a single-payer system probably would mostly use fee-for-service and might derail current efforts to pay for value rather than volume, according to A. Mark Fendrick, MD, director of the Center for Value-Based Insurance Design at the University of Michigan in Ann Arbor.

"There's a very good reason for saying [patients] should have higher cost-sharing for a drug that treats toenail fungus versus one that treats cancer," but the single-payer plan proposed by Sanders would make all covered services free of copayments or deductibles, "which is the farthest thing from value-based insurance design," he said in a phone interview. "Single-payer says 'You're in or you're out' and that's very problematic to me."

Having just one entity making the rules about which services get paid for has its pluses and minuses, said Katharine London, MS, a principal at the Center for Health Law and Economics at the University of Massachusetts Medical School in Charlestown. "If there were one plan and everybody had one set of rules, the good part of that is that doctors could focus all their efforts on ensuring that those rules make sense; on the other hand, if there's a rule they don't like, that affects all patients and they can't go around it."

London was involved in developing a proposal for a single-payer plan for the state of Vermont -- in the end, Vermont governor Peter Shumlin (D) ended up dropping the idea. "It was frustrating because we did come up with an option that was affordable," she said in a phone interview. "But they had to bury it because of politics. The public financing is a heavy lift -- the idea that you're going to pay for your healthcare through your taxes."

A Gradual Approach

The best way to get to single-payer -- if the country decided that was what it wanted to do -- would be a gradual approach, according to Pollack. That might mean, for example, having a "public option" that allows people to buy into the Medicare program voluntarily, and then eventually moving everyone into it. "People are saying that if you believe in single-payer, you should support the public option because it gets us from here to there and it's cheaper than [private coverage] in a lot of ways," he said.

The idea of a public option was floated when the ACA was passed, but it was eventually dropped from the bill because it was too controversial, Pollack noted. "Unfortunately, we ended up with these co-ops, which are a very weak substitute. I'd like to see us return to the public option idea because it has some real value."

Like anything, when it comes to implementing a single-payer system, the devil will be in the details, London said. "It depends on the details of how it's implemented; I don't think how the plan is financed affects the practice of medicine necessarily. if you could change the system so doctors could practice medicine and spend time with their patients, I think that's really what doctors want."