The Affordable Care Act: Objectives and Likely Results in an Imperfect World

To the editor:

We read the recent editorial by Dr. Silvers [1] with great interest. We share his fear that the Affordable Care Act (ACA) "may be doomed to far less impact than planned". Dr. Silvers lays out how increased "agency costs" are a serious impediment to the effectiveness to the ACA. The examples he gives are only a few of the many inherent inefficiencies built into the current private-insurance system, and are part of the reason that this model has administrative costs that dwarf those of a publicly-funded program such as Medicare. We also wholeheartedly agree with his assessment of the problem of differential information, which makes it extremely difficult to have a functioning free-market system around healthcare.

After reading about these serious flaws in the ACA, we were surprised that the conclusion of his editorial, which was under the subheading of "What does it mean for the future and what can be done", did not propose a solution or any alternative to the ACA. Given that the problems he laid out are serious and real, we would like to propose at least one such solution: a single-payer system, also known as "Medicare for all". Such a plan would lead to true universal coverage, eliminate much of the excess spending on administrative costs [2], and enormously simplify what is currently an overly complex patchwork of systems. There is increasing support for a single-payer system among physicians, with over 59% [3] indicating preference for such a program. The popularity of Medicare, even among ardent opponents of the ACA, suggests that a "Medicare for all" approach may be spared the numerous attempts at repeal or defunding of the legislation. Given the need to move towards a more functional, just, and affordable system of medical care in the United States, we believe that it is important to both highlight weaknesses in the ACA, and to provide a better alternative. In our opinion, the data suggests that a single-payer system is such an alternative.

1. Silvers, J.B., The affordable care act: objectives and likely results in an imperfect world. Ann Fam Med, 2013. 11(5): p. 402-5.
2. Woolhandler, S., T. Campbell, and D.U. Himmelstein, Costs of health care administration in the United States and Canada. N Engl J Med, 2003. 349(8): p. 768-75.
3. Carroll, A.E. and R.T. Ackerman, Support for National Health Insurance among U.S. Physicians: 5 years later. Ann Intern Med, 2008. 148(7): p. 566-7.

Competing interests: The authors belong to the Minnesota chapter of Physicians for a National Health Plan