Why Do So Many Doctors Oppose Single-Payer Health Care?

Legislation that would help create a single-payer health care system in California, the first of its kind in the nation, faces a crucial test in the next week. The bill — AB 1400 — must pass the full Assembly by Jan. 31, or it’s dead.

The California Nurses Association, the state’s nurses union, is leading the effort to pass AB 1400. But the state's largest association of doctors, the California Medical Association, opposes the bill.

“It will disrupt people's health care at the worst possible time,” said Ned Wigglesworth, a spokesperson for Protect California Health Care, a coalition formed to oppose AB 1400. The coalition includes the California Medical Association as a member.

“It will force all 40 million Californians into a new untested state government program and will prohibit them from being able to choose private coverage even if they want it,” he said.

In nearly all previous attempts to create a single-payer health system in the United States, the fiercest objections have come from doctors, said Dr. Micah Johnson, co-author of the book "Medicare for All: A Citizen’s Guide" and a practicing internal medicine physician in Boston.

Doctor opposition to single-payer may seem counterintuitive — but Johnson said doctors cannot help but view health reform through the lens of what's best for them as well as what's best for their patients. To the extent they're most concerned with changes to their own pay and autonomy, Johnson called doctors "double agents in the health reform debate for the last century."

Johnson spoke with KQED's April Dembosky about the history of physician opposition to single-payer.

The following interview has been edited for length and clarity.

April Dembosky: In your book, you call doctors the "perennial opponents of health reform." What events led you to draw that conclusion?

Dr. Micah Johnson: Doctors have had a century-long history in the health reform debate, usually as the opponents. That started back in the 1910s during the progressive era of reforms. This is after Germany, in 1883, had passed health insurance. In 1911, Great Britain had passed health insurance. It seemed clear that the U.S. would be following suit. And initially, it looked like doctors and the American Medical Association were going to be supporters of the bill. But as the discussions unfolded, doctors turned.

What were their concerns?

The top one is really their own pay. And the second one is their autonomy in the practice of medicine. Going back to the 1910s and also in the 1940s, there's this fear that if there is a universal public insurance plan, doctors are going to get paid less.

The most striking example is Harry Truman's health care proposal in the 1940s. This is the first and really only time a sitting U.S. president gave a full-throated endorsement of a single-payer-style, truly universal national health insurance plan.

The American Medical Association were the top opponents of the plan. They hired a PR firm called Campaigns Inc. that rose to fame in California, helping to defeat a statewide universal health insurance plan. The American Medical Association put an incredible amount of money behind this at the time: $3.5 million. In today's dollars, that's about $40 million. It was the largest lobbying campaign the nation had ever seen — and it worked.

So at the beginning, the public was in support of this national health insurance plan. But then support dwindled over the years — and the vast majority of people had heard of the AMA's opposition to the plan.

When I talk to doctors who are opposed to the single-payer proposals right now, they say their top concerns are their patients.

I think doctors have been double agents in the health reform debate for the last century.

We wear two hats in these conversations. We wear the hat of medical experts, people who know a lot about what's best for patients, and we also wear a hat that's just our own personal financial interest. I think these things can often get confused and, you know, can be leveraged against each other.

In the early '60s, there was an early attempt to create a Medicare program for seniors, and back then, doctors hired actor Ronald Reagan to speak out against the idea. He said, “One of the traditional methods of imposing state-ism or socialism on a people, has been by way of medicine. It’s very easy to disguise a medical program as a humanitarian project.”

Definitely a remarkable moment in the history of health reform, and even though Medicare passed, Ronald Reagan was also elected in a landslide in 1980 and ended up presiding over the Medicare program. So we have all these ironies in health reform.

How has doctors' thinking evolved from the early 20th century to the Medicare days, to now?

I think we're really seeing an evolution.

First, in seeing doctors support the Affordable Care Act in 2008, 2009. And then over the last 10 years, we've seen a lot of very interesting developments.

For one, a majority of doctors in most polls now support single-payer health care. Secondly, we've seen at the American Medical Association that there's some internal debate about what the stance is going to be. In recent years, at one of the AMA's big meetings, it was actually the medical student chapter that brought up a resolution to try to remove the AMA's opposition to single-payer health care — and it very narrowly failed.

It got 47% support. So the AMA still opposes single-payer, but we can see signs that things are changing.