Only a small fraction of U.S. physicians surveyed supported leaving the U.S. health care financing system as it is. Overall, a plurality supported modifying the current employer-based, private insurance system by the addition of either tax credits or tax penalties to expand coverage. A substantial minority reported prefering an entirely different health care financing system–a taxpayer-financed single-payer NHI program. Such reform was supported by a majority of Northeastern physicians, older physicians, and psychiatrists, and was also endorsed by a plurality of primary care physicians, hospital-based physicians, and medical subspecialists. We also found that the overwhelming majority of physicians believe that all Americans should have access to needed care regardless of ability to pay. Yet, the majority also believes that the uninsured lack such access and one fifth believed that even those with insurance lack adequate access.
To our knowledge, no recent published studies assess physician opinion on single-payer NHI or other financing reform in a nationally representative sample. A physician survey conducted 5 years ago showed that while nearly 50% of physicians “in principal” supported legislation to establish NHI, only 26% supported NHI with a single government payer that covers everyone (given only “yes” and “no” as response options)24
. A recent update showed that support for NHI, not otherwise specified, has grown to 59% but opinions about single-payer financing of NHI were not assessed23
. The 46% of physicians that support single payer NHI in our study is a significantly greater proportion than in the study of Ackerman et al.24
conducted 5 years earlier and may suggest that such support has grown. Because of the different wording of the questions used in these two surveys, however, definitive conclusions about changes in the level of such support are difficult to draw.
A plurality of respondents preferred the current system with the “addition of tax credits for buying, or tax penalties for failing to buy health insurance”. It is worth noting two points in interpreting this result. First, because of the complexity, and variability of each of these two reform approaches, we did not specify details of reform features that are often advocated as part of the tax credit approach (such as health savings accounts and deregulation of insurance markets) and the tax penalty approach (such as subsidies for the poor, expansion of existing public insurance programs, tighter regulation of insurance markets and sometimes, employer mandates) in this response option. This level of generality prevents us from drawing firm conclusions about potential differences in support for these specific reform features.
Second, while there are substantial differences between tax credit and tax penalty approaches, they are similar to the extent that they employ financial incentives to expand coverage within the existing employer-based, private insurance health care financing system. Because these were combined in a single response option, we interpret support for this option as support for either of these incremental approaches to reform compared with the more fundamental changes entailed in single-payer proposals or with no change (i.e., maintenance of the current system).
There are several potential reasons why a greater percentage of physicians indicated support for the use of financial incentives (tax credits or penalties) than for single-payer NHI. More physicians may simply believe in the greater effectiveness of incentive-based reform proposals to achieve increased coverage, decreased cost, improved quality and protect practice autonomy and compensation 8,29,30
. Alternatively, physicians support for incentive-based reform options may be driven by the perception that they are more politically feasible and therefore more likely to result in the implementation of at least some health reform option, even if it may not be their first choice12
. Our data do not allow us to determine the relative importance of these factors in determining physicians support for different reform options. As the level of physician support for single-payer NHI approaches that of its principal alternatives, it may be seen as a politically viable option as well.
Our finding that the belief that all Americans should receive needed medical care regardless of ability to pay was strongly associated with support for single-payer NHI is not surprising. Even among its detractors, single-payer NHI is widely believed to be more likely to achieve universal coverage than its principal alternatives. The majority in our sample do not believe that the uninsured have access to needed care and, again, it is not surprising that this belief was also associated with support for single payer NHI for the same reason. Hence, efforts to educate physicians about the limitations on access to care that are associated with being uninsured, such as those amply documented in the Institute of Medicine’s “Insuring Health” series31,32
, might increase physician support for this option.
Physician support for single-payer NHI is somewhat lower than in public opinion polls which have consistently demonstrated majority support for NHI33,34
and, recently, single payer NHI in particular25
. Although the majority of physicians in our survey believed that the uninsured lack access to needed care, one third did not. It is possible that physicians are more likely than the general public to believe that the uninsured can ultimately receive needed care for serious conditions though emergency departments and to equate this with access to needed care. Alternatively, physicians may simply be less willing to accept whatever trade-offs they may perceive (accurately or not) in implementing universal coverage (higher taxes, lower professional autonomy, etc.).
Our study has several limitations. First, our 50.8% response rate was modest, though typical for physician surveys. Although the non-respondents in this survey were very similar to our respondents, it is possible that physicians with a strong interest in health policy issues or strong views about reform options may have been more likely to respond. These physicians’ views may not be representative of all physicians.
Second, as with all surveys, question wording and response option content could have led to misinterpretation of question meaning or bias. In our question about support for health care financing reform (taken from a prior Kaiser / ABC News / CNN survey), the description of the current health care system in the “status quo” and “tax credit/penalty” response options was “in which most people get their insurance from private employers, but some have no insurance”. While few would disagree with the accuracy of this description, it is possible that the phrase “but some have no insurance” could overemphasize this negative attribute of the current system relative to the single-payer NHI response option which contained the phrase “in which everyone is covered”. However, the lack of access to health insurance in the current health care system has become a top issue on the minds of Americans nationally3
and is the key problem most reform proposals are designed to address. It seems unlikely, therefore, that the use of the phase “some have no insurance” to describe the current system would cause physicians who would otherwise support the status quo or incremental reform to change their response to support for single payer NHI, a fundamentally different approach.
Our survey showed that although a plurality of physicians favored incremental health care reform proposals based on the use of tax credits and penalties, a substantial proportion of physicians preferred an entirely different health care financing system–a government-run, taxpayer-financed single-payer NHI program. Physicians play a central role in the health care system and these views could be influential in reforming the financing of the American health care system.