The notion of a single-payer health system has been central to the 2020 presidential election, dominating much of the news cycle in recent months. According to an editorial published Nov. 4, that could be a good thing for physicians.
Clinicians, administrators, payors and patients all know the U.S. is suffering from a fragmented healthcare system, Blake Thomson, MPhil, and colleagues at the University of Oxford in the U.K., said in Circulation. But, on the brink of a major election year, that fragmented system is gaining traction as a platform for change; Democrats in particular have been staunch supporters of the idea of “Medicare for All.”
“If support for an expanded or exclusively single-payer system continues to grow, it is worth considering the effect of this potential transformation of the U.S. healthcare system on clinical care and medical research,” Thomson et al. wrote. “While the implications for cost, patient satisfaction and outcomes and equity are worth serious consideration, so, too, are the implications for medical research.”
Thomson and his co-authors said the U.K.’s single-payer system, the National Health Service (NHS), has actually improved medical research over the years. The NHS partnered with clinicians to build the UK Biobank, a prospective cohort study of half a million adults, and established NHS Digital, which produces a database of all admissions, emergency visits and outpatient appointments at NHS hospitals in England.
The NHS helps consolidate health information in the U.K., Thomson et al. said, enabling it to provide large-scale databases like the UK Biobank with detailed information about patients’ ongoing health events via electronic health records. The Biobank is a popular resource for clinicians across the globe, and the authors said that wouldn’t be possible without linkage to national cancer registries, death registries, hospital data and—you guessed it—the NHS.
These are three ways the U.K. has benefited from a single-payer system:
1. A more centralized healthcare system allows for longer-term follow-up in observational studies.
The U.S.’s counterpart to the UK Biobank, known as the All of Us Research Program, is a prospective study that’s aiming to enroll 1 million American adults and track their health status over time. Exposure information “promises to be exceptional” in this case, Thomson and colleagues said, but follow-up will suffer from a lack of standardized health data.
“In the United States...healthcare information is currently spread across numerous healthcare providers, making systematic follow-up difficult,” the authors wrote. “This may be one of the biggest limitations of large prospective studies being conducted in the United States.”
If follow-up in the All of Us program is going to work, they said, it will require “substantial ingenuity and effort.” Researchers will need to devise novel methods to access and standardize the health records of all 1 million patients.
2. Single-payer systems can cut the costs of clinical trials.
A trial like ASCEND (Aspirin for Coronary Events in Diabetes)—a randomized controlled trial that leveraged the NHS to both expand the size and reduce the cost of the study—would typically cost hundreds of millions of dollars, Thomson et al. said. But researchers were able to streamline the recruitment process for ASCEND, a trial that explored the efficacy of aspirin and omega-3 fatty acids in preventing CVD in people with diabetes mellitus, by identifying adults with diabetes from consolidated registries within the NHS.
The ASCEND team targeted those patients and invited them via mail to participate in the study. The rest of the study was also conducted through snail mail; participants were sent new treatments through the mail and were followed-up with via mail and central registries. Ultimately, the trial followed more than 15,000 patients for an average of seven years and cost just $13 million.
3. A centralized system might help solve recruitment issues.
As shown in the ASCEND trial, streamlined recruitment with help from the NHS enabled researchers to conduct their trial at a lower cost and in an ideal set of patients. Identifying patients on a day-to-day basis as they present with disease is a slow process, Thomson and colleagues said, so the idea of a single system streamlining that process is attractive.
The authors said the consolidated nature of the NHS allows researchers to easily link their data to routine health records, reducing and in some cases even eliminating the need for costly, active follow-up.
“With careful planning and execution, the NHS’s health information system is being harnessed to conduct trials at a larger scale, more rapidly, at lower cost and with potentially longer follow-up than would otherwise be possible,” Thomson et al. wrote. “If the movement toward a single-payer healthcare system in the United States gains traction, its possible consequences are worth serious consideration. If lessons from the United Kingdom are any indication, the possibilities for medical research, at least, are promising.”