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Primary Care Physicians, Health Promotion and Health Care Reform

This commentary is submitted for the Journal of Healthcare Communications special issue on Primary Care and Health Promotion. It argues that the renewed national debate over health care reform in the United States has resulted in a surge of support for single payer, improved Medicare for All reform. Primary care physicians, as well as patients, have a major stake in single payer reform. One way that primary care physicians can improve health promotion is involvement in single payer reform.


Introduction
Since the presidential election of 2016, there has been a renewed debate over health care reform. In response to the Republican threat to repeal the Affordable Care Act, much of the attention has been focused on defending the ACA, President Barack Obama's signature health reform. However, there has also been a surge of support for single payer, improved and expanded Medicare for All. Popular support for single payer has been demonstrated in recent polls that have found up to 53% of the public favor single payer, 64% of self-identified as Democrats, 55% of Independents, and even 28% of Republicans [1]. Congressman John Conyers has gained 115 co-sponsors in the House of Representatives for his single payer bill HR676, almost double the number of co-sponsors obtained last year. Primary care physicians have frequently been in the leadership of these efforts for single payer. Over the last two decades, almost all of the presidents of Physicians for a National Health Program (PNHP), the principal single payer physician advocacy organization have been primary care physicians.
More than ever before, I have found patients in my primary care practice raise the question: "Doctor, what kind of health care reform do you favor? Do you want to repeal the ACA, improve it, or expand Medicare to the whole population?" This is a new level of patient awareness and opens a conversation that I have seldom had on a patient encounter. In this context, my response is time constrained: "I'm for improved Medicare for all. Learn more at www.PNHP.org." The ACA did expand health insurance coverage and access to care for over 20 million people, but it left about 28 million uninsured.
Many patients are burdened with high copays and deductibles and limited choice of physician and hospitals because of narrow networks. These issues also affect the primary care physician, who worries about the increasing number of patients who cannot afford the lab tests and prescription drugs because they are under-insured and cannot keep referral appointments because of the narrow networks of specialists created by private health insurance companies.

Statement for Primary Care Physicians
Primary care physicians find that they have less and less face time with patients. In a study published in the Annals of Internal Medicine [2], physicians in ambulatory care practice, devoted only 27% of their time in face-to-face contact with their patients and 49% on desk work and filling out the electronic medical record, in order to maximize revenue from the insurance company. Meanwhile, the health care system continues to waste enormous amounts of money on billing and insurance-related bureaucracy. We could eliminate marketing, insurance underwriting, cost shifting in order to maximize profits, by converting to a single payer financing system. It is estimated that private insurer's overhead averages 12.4%, compared with traditional Medicare's overhead of 2.2%. Reducing overhead to Medicare's level would save about $220 billion [3].
In addition, single payer could also sharply reduce billing, prior approval, and other paperwork costs for primary care doctors,

ARCHIVOS DE MEDICINA ISSN 1698-9465
Journal of Healthcare Communications ISSN 2472-1654 hospitals, specialists and other providers. In Scotland and Canada hospital administrative costs amount to 12% of their revenues because their single payer system pays them in a simple lump sum rather than billing on a per-patient basis. In the United States, hospitals have a 25.3% administrative cost. The simplified billing procedures under single payer could save doctors time and money spent on billing-related documentation [4].
Single payer financial reform would not solve all the problems facing the primary care physician, but it would open the space for dialogue about delivery system reform that could benefit both patient and physician. The national debate about health care reform has certainly raised awareness of the single payer option [5].

Conclusion
In this special issue devoted to primary care [6,7] and health promotion [8][9][10], single payer should be considered one of the fundamental steps toward promoting better health. As this Journal has stated: "Health promotion is based on several values: equity and social justice (it) empowers people and builds individual and collective capacity, seeks to enhance people's social participation and involves intersectional collaboration [11]." Single payer health care reform embraces all these values. It will take grassroots organizations of patients and providers united around the theme of health care is a human right, not just a commodity to be bought and sold, to get single payer in the United States. Primary care physicians need to be involved in this movement.