Despite all the hand wringing and arguments over single payer healthcare in American social debates past and present, what most observers seem to miss (but patients and doctors know very well) is that we already have a long established single payer system of healthcare financing in the US—our healthcare is already paid for by the ubiquitous “them.”

• A physician sees a patient and recommends a battery of tests, expecting it will be paid for by “them.”
• A patient receives an unexpectedly high bill for services their insurance did not cover, and requests dismissal of the charges or recoding of the bill, because “I shouldn’t have to pay for it, ‘they’ should cover it.”
• Preventive guidelines recommend routine vaccines (and physicians are held accountable for ensuring patients receive those vaccines), but not all are covered by insurance—because we expect “they” will cover the immunizations.

Of course, we don’t really have a “single payer” system. We have a patchwork of commercial payers, government programs, and private out-of-pocket payment, yet physicians and patients alike often operate as though they assume that whatever is recommended (or done) will be paid for—and paid by someone else.

If I were a student of behavioral economics, I could explore the theoretical underpinnings of such behavior, expound on the adverse effects on our larger economy, and perhaps (best of all) propose some economically based behavioral solutions. Alas, an economist I am not—to paraphrase the good Dr McCoy, “I’m just a country doctor.”

However, I am also a customer and I know how most of the rest of the economy works for us ordinary folks. Costs are posted, payment is given for services rendered, estimates are given for expensive services, and the customer is responsible for the bill. (When I take my car to the shop there is no assumption, by myself or the mechanic, that some third party will cover any and every charge that happens to accrue!)

Medicine is certainly a profession that carries with it altruistic ideals, yet healthcare is also a business. For many and varied reasons, our efforts to be altruistic and our attempts to enshrine healthcare as a “right” (all of which I applaud) have unhooked the behavior of patients and physicians from the economic realities of the healthcare marketplace.

One of the fundamental challenges of parenting is to teach responsibility. As physicians, we are happy to see patients being “responsible” for their health—we need to work just as hard to train ourselves and our patients in financial responsibility when it comes to the economic realities of medicine and healthcare.

Despite the many and wide ranging opinions on a single payer policy for American healthcare, the current behavioral reality is that most parties to the healthcare marketplace function as though there is already a single payer system with infinitely deep pockets. If we are to have any hope of economic sustainability for healthcare (whether in the US, or any other part of the “developed” world for that matter), we need to work just as hard on responsible health economic behavior as we do on responsible health habit behavior.

Who knows? More disciplined, responsible stewardship of healthcare funds might allow us all a bit more margin for funding our altruistic ideals as well.

William E Cayley Jr practices at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare (and I am certainly not a trained economist!).