Universal healthcare pros & cons: a physician’s perspective

Universal healthcare is sometimes a contentious issue, with physicians presenting solid arguments on both sides. Proponents point to improved healthcare equity, improved public health, fewer ethical issues caused by insurance companies, and lower costs to society. Opponents, on the other hand, cite increased bureaucracy, longer wait times for some procedures, and, potentially, reduced physician pay. A GP on Sermo put it simply “We must always be at the forefront of offering help to others.” 

Overall, 71% of physicians surveyed on Sermo support universal healthcare and a further 15% are not sure which way to jump. Most physicians think the U.S. system needs some reform, but there are arguments as to whether a single payer system is the best way to go. 

These are all valid arguments. One GP in Argentina says “Universal healthcare offers significant benefits, such as increased access to medical services for all citizens and improved public health outcomes.”  

It’s also worth addressing a misconception up front. Universal healthcare does not necessarily mean “free” healthcare. Universal healthcare simply means that everyone is guaranteed coverage, which can also be handled using a private health insurance system or a combination system. The Affordable Care Act (ACA), for example, was designed to improve coverage within a private insurance system. A system in which the government pays all claims using tax money is “single payer.” In the U.S., this can become complicated. Medicaid, for example, is a dual-payer system because funding comes from both the federal government and the state. Even single-payer systems are not “free healthcare” as they almost always involve some kind of special tax and patients are still charged a copay in most cases. 

Countries with universal healthcare 

The two countries we most often think of as having universal healthcare in the west are Canada and the United Kingdom. However, at least 20 countries have single payer healthcare and more have some form of universal coverage. 42% of physicians on Sermo practice in a country with universal healthcare and feel it works well, while 23% disagree; and 22% of doctors in a country without universal coverage would prefer to work in such a system. 

Below are 10 countries that offer universal healthcare and some notes on how they implement it: 

1. The United Kingdom 
   The UK has a single payer system through the National Health Service. Private insurance is used by higher income individuals to supplement coverage. The NHS has a reputation for poor dental coverage. 

2. Canada
   Canada has universal coverage (Medicare) that is funded by each province or territory, but which has national guidelines. 

3. Germany  
   Germany was the first country to introduce a social health care system, in 1883. At the start, it covered blue-collar workers, who were at high risk of occupational illness. Modern-day Germany uses a multi-payer system that combines statutory and private insurance. 

4. Taiwan
   Taiwan is considered to have the best healthcare system in the world. It has a single-payer national health insurance plan similar to the United Kingdom but is considered particularly efficient. 

5. Australia.  
   Australia uses a public-private model. They have a national single-payer funding model with public health facilities that give care, while other care, such as GP clinics, are run privately. 

6. South Korea
   South Korea also uses a compulsory social insurance plan for single payer, with a social welfare program covering the unemployed and others unable to pay. 

7. India
   In theory, India has universal healthcare on a multi-payer system similar to Germany’s. Tax-funded public hospitals charge only small co-payments for most services. However, these hospitals are underfunded and provide only basic care, and wealthier individuals still carry private insurance. 

8. Argentina
   Argentina also has a public-private system. Care can be received free of charge at public medical facilities. Interestingly, many union workers are obliged to purchase insurance through their union, and private health insurance coverage remains common. 

9. Brazil
   Healthcare in Brazil is a constitutional right and is free for everyone including foreigners. Some facilities are run by the government at the local level. 

10. Egypt
    Egypt has a similar system to India. Public hospitals and clinics provide care to citizens free of charge, but wealthier individuals pay for private care. 

Universal healthcare can be handled in a wide variety of ways, but how well it works is determined more often by how well it is administered, and the impact of politics. 

Pros of universal healthcare for physicians 

For physicians and their patients, universal healthcare can provide a variety of benefits. These include: 

More consistent patient access to care 

There is reduced risk of a patient stopping care because they or a family member are facing financial difficulties. Patients are more likely to come in for routine appointments, and the increase in preventive care can result in better health outcomes for individuals and their communities. 

Doctors can intervene in a developing chronic condition before the patient experiences severe symptoms, resulting in a better outcome and less suffering for patients and families.  

Potential for more predictable income 

Because patients have more consistent access, they will come in more regularly. This can make clinic income more predictable and reduce cash flow issues. Standardized reimbursements help physicians plan by allowing them to predict what they will be reimbursed for any given procedure. Patient copays, if any, will also be standard and can be charged immediately. 

Reduced administrative burden 

When a patient comes in with private insurance, practitioners have to establish whether the procedure is covered, file the claim, get reimbursed, then bill the patient. Single payer systems tend to have standard reimbursements that are sent automatically. Single payer also typically means one set of rules for every patient, with no need to look up specific details, and that physicians can refer a patient to any specialist without needing to check with the patient’s health insurance. This can also improve interprofessional communication. 

Increased public health improvements 

Universal coverage means that more people seek care, resulting in an overall healthier population and government spending on increased preventative measures. Healthcare systems can shift their overall focus to preventive care as national health policies are easier to manage and promote, and everyone is recommended the same, high-quality preventive care. 

Guaranteed access to essential healthcare services 

59% of physicians believe improved access to healthcare is a primary benefit of universal healthcare coverage. A key part of this is improved healthcare equity. Lower income people get access to primary care, without having to resort to using the emergency room for non-emergency situations, shortening wait times for everyone. This also reduces healthcare inequity overall, allowing minority populations and others that are less likely to seek care to do so. 

Reduced financial barriers to treatment 

Not being able to give a patient the best treatment because they are unable to pay is one of the worst things a doctor can face. Financial barriers also mean that: 

• Practices can seldom afford to subsidize patients. 

• Patients suffer more financial hardship and are less likely to complete courses of treatment. 

• Uninsured patients are often afraid to seek treatment. 

In a universal healthcare system, practices will spend less time on billing issues such as following up with patients who do not make payment. The physician can focus on patient care and outcomes, rather than the cost of treatment. 

Less stress about medical bills and insurance coverage 

High levels of stress slow healing and reduce outcomes. 51% of physicians on Sermo say they have patients who are concerned about costs, and this is not limited to patients with lower incomes. In a system that reduces healthcare costs, the patient spends less energy stressing about medical bills and coverage, and can better focus on their recovery. 

Cons of universal healthcare for physicians 

Not all physicians are enthused about universal healthcare. They have some legitimate concerns, which include: 

Potential for lower reimbursement rates for physicians 

Physicians in the U.S. commonly point to low reimbursement rates from Medicare/Medicaid as a concern. Using Canada as an example, income rose at the start as people sought delayed care, and incomes have stayed steady since, but are typically lower than remuneration rates in the U.S. 

Additionally, lower reimbursement rates could tighten practice budgets, limiting resources and slowing the acquisition of new technology and staff. 

Increased patient loads and longer working hours 

An increase in people seeking healthcare without a matching increase in availability of clinicians can result in increased loads, longer hours, and longer waits for patients. This can contribute to physician burnout if the practice does not have sufficient resources.  

Overtreatment is another issue. “Overtreatment – where unnecessary or excessive treatments are provided – can lead to increased healthcare costs, potential harm to patients” per an ophthalmologist on Sermo. 

Risk of lower quality care in overstressed systems 

If systems become overstressed, the quality of care can suffer, impacting a doctor’s ability to do their job as well as their mental health. Single payer systems are particularly vulnerable, especially when the economy is poor. 

Less autonomy in treatment decisions  

A key concern for many physicians is reduced autonomy in treatment decisions. Government regulations may impact care through prior authorizations and national guidelines. It is not easy to determine, however, how this compares to the impact of, for example, prior authorizations from private insurers. A U.S. based internist on Sermo shares their thoughts, “From what I have observed in similar programs in the U.K. and Canada, I think this would result in gross inefficiency of all aspects of medical care because they become governmental controlled and physicians increasingly will have less input to treat their patients according to their best professional judgment that they have been taught”. 

More bureaucracy and administrative oversight 

Medicare/Medicaid have regulations impacting facilities that take their patients. Many physicians are concerned about this expanding under a universal system and having to spend more time complying with regulations, although this is obviously offset by less time dealing with health insurance. In a multi-payer system, though, admin burdens might increase. 

Longer wait times for appointments and procedures 

We often think of this as a concern for patients, but it also affects physicians. Doctors face clinical, emotional, and professional challenges if delays in treatment affect outcomes, and it can strain the doctor-patient relationship. Doctors often take the blame for treatment delays even when they simply do not have the resources to help. 

Universal health coverage systems must also prioritize essential care, and this can result in delays in accessing more advanced treatments and elective or “cosmetic” treatments. The latter may sometimes not be covered. 

Economic strain could lead to higher taxes 

Taxes are likely to go up under a universal system, although this is offset by reduced or absent insurance premiums and reduced costs for businesses who no longer have to provide employer sponsored care. However, in times of downturn, benefits could have to be reduced and/or taxes raised further. Care may become less available during these periods of financial instability.  

Physicans’ compensation under universal healthcare 

Many physicians in the U.S. and other countries without universal healthcare worry about reduced compensation. This is a particular concern in the U.S., where many practitioners are paying off large student loans.  

Overall, compensation is likely to rise from increased utilization even if individual fees for service decline, and physician compensation may also be increased as practices spend less money on billing, which would be greatly simplified, and more on patient care. While some practices may see net gains, others—especially smaller or rural practices—may face tighter margins.  

However, while compensation may go up, hours worked may also increase due to falling reimbursement and increased use of care. Some doctors may be concerned that they will not be able to opt out…at the same time, allowing providers to opt out will result in a two-tier health system that loses most of the benefits of universal coverage and forces more people to purchase private health insurance, which may not be available for low income patients. 

What would universal healthcare mean for your practice? 

The impact of universal healthcare depends in part on your practice type. However, the likely changes would be an increase in the overall number of patients, improved consistency in compliance with care, and greatly streamlined billing. Your strategic challenges  are also likely to change. 

Doctors will gain broader access to patients and specialists, as well as less time spent dealing with billing and insurance, and will no longer have to deal with issues such as payment plans for uninsured patients. However, they could experience lower reimbursements and thus less pay for time spent with patients, and may lose some autonomy to national bureaucracy and guidelines. 

Universal healthcare: an ongoing discussion 

There are legitimate arguments on both sides of the healthcare debate. In the U.S., public sentiment has been shifting slightly towards universal healthcare. Most surveyed physicians on Sermo support some form of universal healthcare, as it can improve patient access and outcomes, reduces healthcare costs, and saves clinics a lot of time on administration.  

However, it can also reduce physician pay and result in a loss of autonomy to bureaucracy. A GP in Brazil explains some of the challenges: “Unfortunately, political corruption and millionaire embezzlement have brought many negative consequences” and from a cardiologist in Italy, “loads of inappropriate prescriptions and useless diagnostic examination… impact on the increasing costs of healthcare system.” 

Even physicians who are in favor see challenges, but most think it is better than the alternative and their opinions clarify a key fact: Universal healthcare has to be done right to work well, and it has to be adapted to a country’s challenges and needs.