Single payer and other models for health care financing

Pros and cons of a single-payer system

a/​k/​a Issues with both current health insurance system and single-payer system
Medicare-for-All Isn’t the Solution for Universal Health Care (Joshua Holland, The Nation, 8-2-17) The health-care debate is moving to the left. But if progressives don’t start sweating the details, we’re going to fail yet again. Holland talks about steps needed for significant change.
The detail that could make Medicare for All generous — and expensive (Drew Altman, Axios and Kaiser Family Foundation, 1-9-18) There will be plenty of other arguments, for and against a Medicare for All-style plan. But the burden of rising out-of-pocket costs is one reason the plan could have appeal for many Americans — even if it's not possible to get rid of them completely. If and when the debate gets to that point, it seems likely that there would end up being a modest level of cost sharing to deter unnecessary use of medical care and keep the overall costs of the plan down.
Want National Health Insurance? Dump the Term ‘Single Payer’—and ‘Medicare for All’ Too (Trudy Lieberman, Kaiser Health News, 7-13-17) “Medicare for all” is better than “single payer,” but better yet is “guaranteed lifetime coverage for all.” The latest polls show that a majority of Americans now support getting insurance from a single government plan. “Single-payer” is a shop-worn phrase from previous battles that hardly describes all national health systems. We should fight for a system that provides for all citizens, regardless of the financing or billing details. "Changing the narrative won’t be easy. Americans don’t want their money used to pay for someone else’s insurance, although that kind of cross-subsidization is central to Medicare, a point that has never been made clear to beneficiaries or the general public."
• ****As renewed debate over health care reform begins to simmer in Washington, can journalists give the topic the attention it needs? (Trudy Lieberman, Health News Review, 12-21-18) "The drive for a more inclusive health care system will continue–regardless of continued efforts by opponents to strike down the ACA....Whether journalists are up to the challenge of chronicling a new and vicious debate remains to be seen....What kind of reporting is needed? Berwick et al outline some key policy questions: “knotty issues such as determining the covered benefits of the plan, exploring alternative revenue sources and cost controls, deciding how providers would be paid and at what prices, how to pave a practical transition pathway from current health plans, how to craft a soft landing for the employees of the current insurance industry, and more.”

Politicians Hop Aboard ‘Medicare-For-All’ Train, Destination Unknown (Elisabeth Rosenthal and Shefali Luthra, Kaiser Health News, 10-22-18)
‘Don’t Get Too Excited’ About Medicare for All (Elisabeth Rosenthal and Shefali Luthra, NY Times, 10-19-18) More and more politicians are calling for single-payer health care. Is it just talk? The broader goal — affordable, universal health care — could be achieved by a range of strategies. Rosenthal and Luthra compare the systems of Britain, Canada, France, and Germany; discuss the pros and cons of a "Medicare for All" approach, and various changes such an approach might require.
Establishment looks to crush liberals on Medicare for All (Adam Cancryn, Politico, 12-10-18) The coalition that fought Obamacare repeal has fragmented as the Democratic party tries to follow through on campaign promises. Deep-pocketed hospital, insurance and other lobbies are plotting to crush progressives’ hopes of expanding the government's role in health care once they take control of the House. The private-sector interests, backed in some cases by key Obama administration and Hillary Clinton campaign alumni, are now focused on beating back another prospective health care overhaul, including plans that would allow people under 65 to buy into Medicare. This sets up a potentially brutal battle between establishment Democrats who want to preserve Obamacare and a new wave of progressive House Democrats who ran on single-payer health care.
What Exactly Does ‘Medicare for All’ Mean? (Letters to Opinion page about "Don't Get Too Excited" piece, NY Times, 11-1-18) Readers discuss how a single-payer system might work, and the pros and cons.
Internist Samuel L. Rosenthal: "The most common systems involve taxpayer-funded, nonprofit insurance, provided by private companies that are regulated by the government. The insurance companies earn operating costs and salaries for their employees but not large profits. There is no benefit to denying coverage for pre-existing medical conditions or conditions that require frequent or extensive medical care. Prices for medical care, medical devices and drugs are usually determined by negotiation and are uniform throughout a country. By contrast, we have unregulated for-profit medical insurance with a middleman whose “product” we must buy, a product that adds nothing to medical care except unnecessary hassle and enormously increased cost. Medicare for all addresses this problem by eliminating the middleman."
Edward Volpintesta, general practitioner: 'Unless the public does get excited, stirred up, agitated, energized, provoked or stimulated by Medicare for all, it will never become a reality. Health care will remain divided between federal, state and private insurers, each with different plans, physician panels, co-pays, deductibles, coverage and premiums, which makes for a fragmented, depersonalized and dysfunctional health care system."
Hugo Dante, economics student: "With Medicare for all, Americans have a choice between universal health care or quality health care. We can’t have both."
Allan D. Bogutz, past pres. of National Academy of Elder Law Attorneys: Medicare for All "would mean the end of Medicaid. Since everyone would be covered under Medicare, we would no longer need a separate health care program for the poor. Ending Medicaid means huge savings for the states that administer and partly fund the program and huge savings from ending duplicated systems between the programs. All state governments should be aggressively supporting this change."
Quick: What’s The Difference Between Medicare-For-All and Single-Payer? (Samantha Young, Kaiser Health News, 11-5-18) As politicians across the country toss about such health care catchphrases, sometimes interchangeably, many voters say they’re “just confused.”
Once Its Greatest Foes, Some Doctors Are Now Embracing Single-Payer (Shefali Luthra, KHN, 8-7=18) Young physicians are pushing the medical establishment to rethink its long-held opposition. The political fallout could be substantial. “We believe health care is a human right, maybe more so than past generations,” said Dr. Brad Zehr, a 29-year-old pathology resident at Ohio State University, who was part of the debate. “There’s a generational shift happening, where we see universal health care as a requirement.” At least 70 House Democrats have signed on to the new “Medicare-for-all” caucus. The AMA has thwarted public health insurance proposals since the 1930s and long been considered one of the policy’s most powerful opponents. But the battle lines are shifting as younger doctors flip their views, a change that will likely assume greater significance as the next generation of physicians takes on leadership roles.
Medicare For All? CMS Chief Warns Program Has Enough Problems Already (Phil Galewitz, KHN, 10-16-18) Seema Verma, who heads the Centers for Medicare & Medicaid Services, tells private insurance officials that a push by some Democrats to expand Medicare would only increase troubles the program already faces.
70% of Americans now support Medicare-for-all—here's how single-payer could affect you (Yoni Blumberg, CNBC, 8-28-18) "The vast majority of Americans, 70 percent, now support Medicare-for-all, otherwise known as single-payer health care, according to a new Reuters survey. That includes 85 percent of Democrats and 52 percent of Republicans. Only 20 percent of Americans say they outright oppose the idea....Health care in the U.S. is criticized primarily for its inefficiency, inaccessibility and ever-rising costs........The bill has little chance of passing with a Republican majority in Congress, as Bernie Sanders has conceded....Health care in the U.S. is criticized primarily for its inefficiency, inaccessibility and ever-rising costs. The average annual deductible for employer-sponsored health care plans, which make up most of the plans in the U.S., was $1,505 in 2017, compared to $303 in 2006, according to the KFF....Although the quality of care tends to be high, care doesn't reach everyone. Americans forego treatment because of the cost more often than residents in 11 other high-income countries, according to a report published in the Journal of the American Medical Association. Passing on treatment when an issue arises is bad enough. But affordability is important because simply going to the doctor for a physical on a regular basis can save your life. That's according to MacArthur Foundation "genius" Atul Gawande, who was recently selected to lead the joint health care venture formed by Amazon, J.P. Morgan and Berkshire Hathaway to tackle rising health-care costs."Incremental care — regular, ongoing care as opposed to heroic, emergency care," he writes in The New Yorker, "is the greatest source of value in modern medicine."Reuters defines Medicare-for-all as "a publicly financed, privately delivered system with all Americans enrolled and all medically necessary services covered." In theory, it would solve some of the main issues of America's current system.
Once Its Greatest Foes, Some Doctors Are Now Embracing Single-Payer (Shefali Luthra, KHN, 8-7-18) Image: protestor holding a sign: "Healthcare is a human right! Single payer now!" This year’s youth uprising at the American Medical Association's annual meeting speaks to a cultural shift in the medical profession, and one with big political implications. “We believe health care is a human right, maybe more so than past generations,” said Dr. Brad Zehr, a 29-year-old pathology resident at Ohio State University, who was part of the debate. 'Though “single-payer” health care was long dismissed as a left-wing pipe dream, polling suggests a slim majority of Americans now support the idea — though it is not clear people know what the term means. Much like the general public, doctors often use terms like single-payer, Medicare-for-all and universal health care interchangeably. Other health care interests — including private insurance, the drug industry and hospital trade groups — have been slower to warm to catchphrases like single-payer or universal health care, all of which would likely mean a drop in income.'
The Best Health Care System in the World: Which One Would You Pick? (Aaron E. Carroll and Austin Frakt, NY Times, 9-18-17) "To better understand one of the most heated U.S. policy debates, we created a tournament to judge which of these nations has the best health system: Canada, Britain, Singapore, Germany, Switzerland, France, Australia and the U.S." Universal coverage is a c0mmon ideal, but wealthy nations have taken varying approaches to it, some relying heavily on the government (as with single-payer); some relying more on private insurers; others in between. In this tournament, the authors discuss: Canada vs. Britain: Single-Payer Showdown; U.S. vs. Singapore: A Mix of Ideas; France vs. Australia: Everyone Covered; Switzerland vs. Germany: Neighborly Rivalry; Switzerland vs. Britain: Meaning of a Market; France vs. U.S.: Access vs. Innovation; France vs. Switzerland: Top of the Mountain (Alps Edition). An interesting way to frame the discussion we should be having.
What American Healthcare Can Learn From Germany (Olga Khazan, The Atlantic, 4-8-14) Under Obamacare, the U.S. healthcare system is starting to look more like Germany's. Here's what Germans do right—and how Americans could do even better. Under the German system of "sickness funds," which cover nearly everyone, a small segment (13 percent) of the population, generally the very wealthy, can opt-out and instead go with the private Krankenversicherung, which follows rules more similar the pre-Obamacare U.S. individual insurance market. But those differences aside, it’s fair to say the U.S. is moving in the direction of systems like Germany’s—multi-payer, compulsory, employer-based, highly regulated, and fee-for-service."
Looking North: Can a Single-Payer Health System Work in the U.S.? (Shefali Luthra, KHN, 12-18-17) "To many American advocates, Canada’s health system sounds like the answer to the United States’ challenges. But in Toronto, experts and doctors say the United States first must address a more fundamental difference. In Canada, health care is a right. Do American lawmakers agree? 'The U.S. needs to get on with the rest of the world and get an answer on that issue before it answers others,' said Dr. Robert Reid, a health quality researcher at the University of Toronto, who has practiced medicine in Seattle." And there are tradeoffs with the Canadian system, which most Canadians are willing to accept.
Single-Payer Health Care in California: Here’s What It Would Take ( Patricia Cohen and Reed Abelson, NY Times, 5-25-18) With a single-payer system, "Even a state as big, wealthy and liberal as California — with the world’s fifth-largest economy and nearly 40 million people — would find itself hamstrung by money, a legal and regulatory thicket, and highly motivated opposition....'The savings you’re going to get are going to come out of someone’s pockets.' 'Medi-Cal — the state’s version of Medicaid, the health insurance program for low-income Americans — covers about a third of the population. Here, the state has lots of leeway to experiment, and the federal government has tended to let that happen. But almost everyone else gets coverage through an employer, Medicare or the individual marketplace. And in these arenas, the state has less authority. To redirect Medicare funds, California would require a federal waiver — something unlikely to be granted by any administration....A bigger stumbling block comes from employer plans, which cover roughly 43 percent of Californians.' Plus health care costs would rise because more people would be using the system.
Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care The Commonwealth Fund, 2017)
What single-payer healthcare would mean to doctors (Liz Seegert, Medical Economics, Modern Medicine Network, 5-25-16) "Health insurance is again in the political spotlight as Democratic presidential candidate Bernie Sanders promotes his version of single-payer that he calls 'Medicare for all.' He says it will improve care, reduce administrative burdens and allow physicians to focus just on practicing medicine. Dissenters say it’s a pipe dream that will only lead to rationed care, lower reimbursement rates and long waiting lists. A nationwide Physicians Foundation Survey of 20,000 doctors revealed common physician complaints of increased paperwork and overhead, too many different rules and rates from too many different payers and too much time spent arguing about coverage instead of delivering care....The U. S. spends more on healthcare per capita than all other Western countries, except for Norway and the Netherlands, according to a 2014 Commonwealth Fund report. Although many Americans gained coverage under the Affordable Care Act, the U.S. is the only industrialized nation without a true “universal” system. Despite the high level of spending, most health performance measures are only average, and many are worse than those of other industrialized nations...."
"Single payer is not the same as 'socialized medicine' or 'universal healthcare.' Single payer refers to system financing under which both the collection of payments from patients and reimbursements to providers is carried out solely by the government. However, physicians can still be in private practice and work for public or private facilities, and hospitals can be public or private." (Read the whole article, in which Liz Seegert explains the difference between systems in the U.K., Canada, Taiwan, Germany, explores the advantages and the downsides to doctors of a single-payer system, and talks to experts on whether a single-payer system is feasible in the United States.)
The Leap to Single-Payer: What Taiwan Can Teach (Aaron E. Carroll and Austin Frakt, The New Health Care, NY Times, 12-26-17) Taiwan is proof that a country can make a swift and huge change to its health care system, even in the modern day. The United States, in part because of political stalemate, in part because it has been hemmed in by its history, has been unable to be as bold....Less than 25 years ago, Taiwan had a patchwork system...In the end, Taiwan chose to adopt a single-payer system like that found in Medicare or in Canada, not a government-run system like Britain’s....Relative to the United States and some other countries, Taiwan devotes less of its economy to health care."

Sanders Releases Single-Payer Proposal: ‘Health Care In America Must Be A Right, Not A Privilege’ (Kaiser Health News, 9-14-17) Summaries of health policy coverage from major news organizations--about and in reaction to Bernie Sanders kicking off "Medicare for all" proposal.

How U.S. Health Care Became Big Business (Terry Gross, Fresh Air, NPR, 4-10-17) Terry Gross interviews Elisabeth Rosenthal, author of An American Sickness: How Healthcare Became Big Business and How You Can Take It Back by Elisabeth Rosenthal. ("An authoritative account of the distorted financial incentives that drive medical care in the United States . . . Every lawmaker and administration official should pick up a copy of An American Sickness. Then, at last, the serious debate could begin.” -The Washington Post) She "explains how health care became big business and how the pricing and billing of medical services, devices and prescription drugs became so complicated even a lot of doctors don't understand it." Among points made: "More competition doesn't mean better prices. In fact, it can drive prices up" "...if you look at drug prices, for example, there was a miraculous drug called Gleevec which really changed cancer patient's lives when it came out maybe 10, 15 years ago. Now there are many, many kind of copycat versions of Gleevec. We call them in the profession sons of Gleevec. And they're all four or five times more expensive than Gleevec was when it came out....So if you were looking at a world where an economic market worked, you would think, wow, there are 10 of these now so the price should have come down - it hasn't...because the standard in health care has been usual and customary...the ultimate lesson of much of American health care is that prices rise to whatever the market will bear. And another concept that I think is unique to medicine is what economists call sticky pricing...and you see this over and over again in the drug sphere and also in the hospital chargemaster sphere - once one drug maker, one hospital, one doctor says hey, we could charge 10,000 for that procedure or that medicine. Maybe it was 5,000 two months ago, but once everyone sees that someone's getting away with charging 10,000, the prices all go up to that sticky ceiling....What you see often now is when generic drugs come out, so there's lots of competition, the price doesn't go down to 20 percent of the branded price, it maybe goes down to 90 percent of the branded price. So we're not getting what we should get from a really competitive market where we, the consumers, are making those choices." But to comparison shop you need to know the prices available. "No one's going to tell me the price. They're all going to say it depends on your insurance or we don't know."

Another rule: "A lifetime of treatment is preferable to a cure." You've got to look at every medical problem from two sides - what's right for health care and what's good for business. Which is more likely: that a drug manufacturer would invent a pill that would cure diabetes, would make the disease go away overnight, or that it would keep going with the current multi-billion dollar business market. They want a treatment that would go on for life. Then there's hospital consolidation: "what we see in research over and over again is that the cities that have the most hospital consolidation tend to have the highest prices for health care without any benefit for patient results." A lot of procedures that used to be done in hospitals began being done outpatient (in a clinic in a shopping mall, for example). "So the hospitals as a whole don't like it. But in the latest twist of this ongoing consolidation of financial power, many of the hospitals have decided to end this trade war with the outpatient surgery centers and are just buying them up."
"...if Americans really want something that's more market-based, other countries have used market-based solutions or more market-based solutions and have gotten really good health care, too. If you look at Switzerland, they have a largely market-based system. But - and this is a really important but - all the countries that have working marketplace-based systems have some form of control over pricing. It's not kind of the Wild West open market. They'll say this is the ceiling you can charge for that procedure. They'll say this is a bandwidth in which you can charge. And you can compete all you want below that ceiling or within that band. But you can't just drive up prices to whatever the market will bear because - I think one of the legitimate analogies is if water or electricity was a totally free market, imagine what prices would be like." [Emphasis added.]
Advocating “single payer” as an immediate goal is demagoguery, not progressive; AND it is really stupid politics (Mike Shatzkin, Medium, 10-29-17) One hundred fifty-seven MILLION Americans get their health insurance through their jobs. The minute you say “we are switching to Medicare-for-all” you have 157 million people saying, “but what does that mean for ME?” And the honest answer, under the best of circumstances, is “that’s complicated”. And “not the same for everybody.” What we should be advocating are the two obvious next steps: lowering the Medicare eligibility age to 55 and offering a public option health plan. Both of these are comprehensible and achievable.
Medicare for All or State Control: Health Care Plans Go to Extremes (Robert Pear, NY Times, 9-13-17) Pear reports that Bernie Sanders and sixteen Democrats are proposing “a Medicare-for-all, single-payer health care system,” and Republicans are proposing block grants ("to send each state a lump sum of federal money, along with sweeping new discretion over how to use it"). "Neither is likely to be enacted any time soon."
Universal health care much loved among Canadians, monarchy less important: poll (Bruce Cheadle, Globe and Mail, 11-25-12) Canada has had universal health care coverage for hospital care since 1957 and for physician services since 1966. A new national poll examined the pride Canadians place in a list of more than a dozen symbols, achievements and attributes.The online survey of 2,207 respondents by Leger Marketing found universal health care was almost universally loved, with 94 per cent calling it an important source of collective pride – including 74 per cent who called it "very important." For a look back at attitudes toward the concept of universal health care, see Physician Resistance and the Forging of Public Healthcare: A Comparative Analysis of the Doctors’ Strikes in Canada and Belgium in the 1960s (Gregory P. Marchildon and Klaartje Schrijvers, Medical History, April 2011) (H/​T Michael Corcoran).
Medicaid Block Grants and Federalism: Lessons from Canada (Benjamin D. Summers and C. David Naylor, JAMA Network, 4-25-17) "Block granting of social programs is not inherently good or bad. Rather, it is a policy associated with specific economic and political tradeoffs. Increased local control and predictability for the federal budget come at the risk of increased cost-shifting to states or provinces. That, indeed, is the Canadian experience. Once block funding was initiated in 1977, health care funding became a line item in the federal budget that could be arbitrarily cut or capped for fiscal or political reasons, as opposed to a level of funding pegged to the needs and health care use of the population. Importantly, these cuts occurred under both conservative and liberal federal governments. The federal share of provincial spending today remains substantially lower than in the 1970s. "
Restructuring Medicaid as Block Grants — Unconstitutional Coercion? (Sara Rosenbaum, J.D., and Timothy Westmoreland, J.D., New England Journal of Medicine, 5-7-15) "Perhaps Congress could give states the option of a block grant as an alternative to open-ended funding. Some states might take such an option — but they'd be foolish to do so, since children and families are the least costly beneficiaries, and Medicaid funding for long-term care is politically popular. States would forgo billions of dollars in federal funding while inflicting terrible pain and generating virtually no savings. They could attempt to replace lost funding with state tax funds, but state tax hikes are even less popular than federal taxes. Congress could repeal Medicaid altogether and replace it with a new program. Such a strategy might avert the constitutional problems associated with fundamentally altering Medicaid. But in our view that would be a terrible idea. Furthermore, achieving any sensible alternative program would be impossible in such a politically riven atmosphere. Before 2012, Congress's power to redesign Medicaid seemed a legal given. After NFIB, that's no longer the case. Legislation that would radically transform the federal–state Medicaid bargain without states' consent may no longer pass the Tenth Amendment test."
Moving Forward From the Affordable Care Act to a Single-Payer System (Adam Gaffney, Steffie Woolhandler, Marcia Angell, and David U. Himmelstein, American Journal of Public Health, June 2016) "For almost a century, efforts to achieve universal health care in the United States raised hopes, fears, and prodigious lobbying, but yielded little beyond Medicare and Medicaid. In 2010, the Affordable Care Act (ACA; Pub L No. 111–148) ushered in a new era of reform. Last year, the Supreme Court upheld the legality of the ACA subsidies, rejecting the last serious legal challenge to President Obama’s signature health care legislation....[The authors summarize their updated proposal for a National Health Plan.] Despite the ACA, many serious problems remain in American health care. Uninsurance and underinsurance endure, bureaucracy is growing, costs are likely to rise, and caring relationships take second place to the financial prerogatives of health insurers and providers. A single-payer NHP offers a salutary alternative, one that would at long last take the right to health care from the realm of political rhetoric to that of reality."
Dispelling the Myths About Single-Payer Health Care (PDF, Marcia Angell, MD, Physicians for a National Health Program)
Statement of Dr. Marcia Angell introducing the U.S. National Health Insurance Act (Physicians for a National Health Program, 2-4-03)
Single-Payer Reform: The Only Way to Fulfill the President's Pledge of More Coverage, Better Benefits, and Lower Costs (Steffie Woolhandler and David U. Himmelstein, Annals of Internal Medicine, 4-18-17) This extract is longer than it should be, but it pretty much summarizes good arguments for a single-payer system. Longtime health policy experts Woolhandler and Himmelstein warn that the proposals by Speaker Paul Ryan, R-Wis., and Secretary of HHS Tom Price "would shrink the coverage of poor and low-income persons in the United States while maintaining (or expanding) outlays for some higher-income groups. That approach might save federal dollars by shifting costs onto patients and state budgets. But containing overall health care costs requires denting the revenues (and profits) of corporate giants that increasingly dominate care—an unlikely outcome of policies that expand the role of private insurers and weaken public oversight.
"Although Republicans' proposals seem unlikely to achieve President Trump's triple aim (more coverage, better benefits, and lower costs), single-payer reform could. Such reform would replace the current welter of insurance plans with a single, public plan covering everyone for all medically necessary care—in essence, an expanded and upgraded version of the traditional Medicare program (that is, not Medicare Advantage).
"The economic case for single-payer reform is compelling. Private insurers' overhead currently averages 12.4% versus 2.2% in traditional Medicare. [Tables illustrate points.] Reducing overhead to Medicare's level would save approximately $220 billion this year. Single-payer reform could also sharply reduce billing and paperwork costs for physicians, hospitals, and other providers. For example, by paying hospitals lump-sum operating budgets rather than forcing them to bill per patient, Scotland and Canada have held hospital administrative costs to approximately 12% of their revenue versus 25.3% in the United States. Simplified, uniform billing procedures could reduce the money and time that physicians spend on billing-related documentation." "Additional savings could come from adopting the negotiating strategies that most nations with national health insurance use, which pay approximately one half what we do for prescription drugs."
"Microlevel experiments indicate that when a few persons in a community gain full coverage, their use surges. But when many persons gain coverage, the fixed supply of physicians and hospitals constrains community-wide increases in use. For example, when Canada rolled out its single-payer program, the total number of physician visits changed little; increased visits for poorer, sicker patients were offset by small declines in visits for healthier, more affluent persons. Despite dire predictions of patient pileups, Medicare and Medicaid's start-up in 1966 similarly shifted care toward the poor but caused no net increase in use.
"Despite some uncertainties, analysts from government agencies and prominent consulting firms have concluded that administrative and drug savings would fully offset increased use, allowing universal, comprehensive coverage within the current health care budgetary envelope. International experience with single-payer reform provides further reassurance. It has been thoroughly vetted in Canada and other nations where access is better, costs are lower, and quality is similar to that in the United States.
"The potential health benefits from single-payer reform are more important than the economic ones. Being uninsured has mortal consequences. Covering the 26 million persons in the United States who are currently uninsured would probably save tens of thousands of lives annually. And underinsurance now endangers many more by, for example, delaying persons from seeking care for myocardial infarction or causing patients to skimp on cardiac or asthma medications. Single-payer reform would also free patients from the confines of narrow provider networks and lift the financial threat of illness, a frequent contributor to bankruptcy and the most common cause of serious credit problems.
"The ACA has helped millions. However, our health care system remains deeply flawed. Nine percent of persons in the United States are uninsured, deductibles are rising and networks narrowing, costs are again on the upswing, the pursuit of profit too often displaces medical goals, and physicians are increasingly demoralized. Reforms that move forward from the ACA are urgently needed and widely supported. Even two fifths of Republicans (and 53% of those favoring repeal of the ACA) would opt for single-payer reform. Yet, the current Washington regime seems intent on moving backward, threatening to replace the ACA with something far worse." (This is a way too long excerpt, but there is more. Read the whole article!)
What Is Single Payer? Why Now? And More Questions About Sanders’ New Bill Answered (Kaiser Health News summaries of health policy coverage from various sources)
History of attempts to reform US health insurance coverage (Graphic, Boston Globe, 6-28-12)
A Brief History: Universal Health Care Efforts in the US (transcribed from a talk Karen S. Palmer gave in spring 1999 to Physicians for a National Health Program)
Health Care Reform and Social Movements in the United States (Beatrix Hoffman, American Journal of Public Health, Jan. 2003, on PubMed Central)
A Tale of Two Healthcare Systems (Matt Straus, Medium, Healthcare in America, 6-7-17) How WWII caused America and England’s healthcare systems to diverge. During World War II, when industrial production needed more workers and there was a labor shortage, companies offered medical benefits to attract new recruits (there was a salary freeze). In 1945 the federal government exempted employer-paid health benefits from income taxation, which gave employer-sponsored insurance an advantage over individually paid insurance. "However, America’s new insurance model did not account for the unemployed or the elderly. Realizing these issues, President Harry Truman called for a national universal health insurance program in 1945. But opponents, especially the American Medical Association, used America’s Communist paranoia to rally against this idea. They warned that Truman’s “socialized medicine” plan could lead to socialism throughout American life. They even called his administration 'followers of the Moscow party line.'" "England’s universal health care model was a direct result of WWII, which spurred egalitarianism in that country. Whereas America’s healthcare system was created from a more peripheral effect of the War, and a healthy dose of capitalism. In short, if we look closely at the history of American healthcare, we begin to realize that the sad state of our current system is largely due to historical events and (bad) luck....And now that America’s political system has become exceedingly polarized, and special interest groups are so deeply entrenched, it’s hard to imagine that things will ever change. But, let’s not lose hope yet… have you seen what California is doing?"
A Superior System: Single Payer Legislation vs. Affordable Care Act (PDF, Physicians for a National Health Program) A chart that provides clarity on the issues.
What is Single-Payer? (Physicians for a National Health Program). See answers to FAQs about single payer.
An Open Letter To Trump: The GOP Health Plan Won’t Work, Replace ACA With Single Payer (Steffie Woolhandler and David Himmelstein, co-founders, Physicians for a National Health Program, 3-9-17)
How Sanders Shaped the National Discourse on Class: A Media Analysis (Michael Corcoran, Truthout, 8-23-16) Sanders supporters should not be disillusioned; the "primary goal of the Sanders' campaign was not the presidency, but a 'political revolution.'...Sanders' campaign planted important seeds that make his larger goals more plausible....Sanders lost the election, but he has expanded the debate and helped raise class consciousness....Sanders repeatedly lamented the 'billionaire class,' and the 'massive gap between the very rich and working class Americans.'...In the 1970s we saw the 'advent of 'neoliberal' capitalism,' as Dollars & Sense described it -- the 'triumph of an economic policy agenda hostile to government economic intervention, social welfare programs, and labor organization,' which was part of a broader shift to the right. But while working class anxiety and financial insecurity both rose during this period, for decades, organized mobilization from the working class did not rise up to resist it.
"Consider, for instance, Sanders' position that the United States should have a national, single-payer health care system that covers the entire population. Having a public, universal system is the norm in the industrialized world, and the US public has long supported one. Despite this, mainstream politicians and pundits have (sometimes literally) portrayed it as a deceptive push toward Soviet-style Bolshevism. But after years of this policy solution being dismissed, Sanders helped to bring it to the mainstream." During three months in the Sanders' campaign (Jan.-March 2016), 41 New York Times articles mentioned the term "single-payer," compared with 39 Times references in the preceding five years. During the presidential campaign, "the Times had an increase of articles mentioning the following issues, all major parts of Sanders' platform: inequality, campaign finance, Medicare for All, socialism, tuition-free college and establishment politics." "The fact that Sanders has been able to penetrate the mainstream debate should not be interpreted as confirmation that the media has changed in its structural, institutional biases. However, that these issues were raised at all -- even if they were attacked -- reflects progress from previous years when they were largely ignored."
The Single-Payer Solution (John Buntin, Governing, 5-24-11) In 1988, the government of Taiwan asked economist William Hsiao, a Harvard School of Public Health professor, "to lead an effort to overhaul the country's health-care system. The success of the single-payer system Hsiao designed attracted the notice of health reformers in Vermont, who persuaded then-Senate President Pro Tempore Peter Shumlin to make a similar system a centerpiece of his gubernatorial campaign. When Shumlin won, he asked Hsiao to develop a variant for the Green Mountain State." The legislation signed into law in 2011 "set Vermont on a course to become the first state in the country to adopt a single-payer system." This Q&A addresses the issues involved in switching to such a system. See State-Based Single-Payer Health Care — A Solution for the United States? (William C. Hsiao, New England Journal of Medicine, 3-31-11)
The fix for American health care can be found in Europe (The Economist)
A Better Deal for American Workers (Chuck Schumer, OpEd, WashPost, 7-24-17) Today’s working Americans and the young justifiably have greater doubts about the future than any generation since the Depression. Americans believe they’re getting a raw deal from both our economic and political systems. The wealthiest special interests can spend an unlimited, undisclosed amount of money to influence elections and protect their special deals in Washington. As a result, our system favors short-term gains for shareholders instead of long-term benefits for workers. Democrats must show that "we're the party on the side of the working people — and that we stand for three simple things: First, we’re going to increase people’s pay. Second, we’re going to reduce their everyday expenses. And third, we’re going to provide workers with the tools they need for the 21st-century economy....We’re going to fight for rules to stop prescription drug price gouging and demand that drug companies justify price increases to the public. And we’re going to push for empowering Medicare to negotiate lower drug prices for older Americans. Right now our antitrust laws are designed to allow huge corporations to merge, padding the pockets of investors but sending costs skyrocketing for everything from cable bills and airline tickets to food and health care. We are going to fight to allow regulators to break up big companies if they’re hurting consumers and to make it harder for companies to merge if it reduces competition."
Poll: Most Americans want to replace Obamacare with single-payer — including many Republicans (Philip Bump, Washington Post, 5-16-16) Gallup poll: Three-way tie between Single-payer, Repeal Affordable Care Act, Keep Affordable Care Act. "Well over half of Americans want to replace Obamacare with a single-payer system. That figure, amazingly, includes 41 percent of Republicans and Republican-leaning independents — even though the wording of the question specifies that the program would be "federally funded." (Mind you, more than half of Republicans oppose the idea.)...Democrats are happy with the ACA but would love single-payer. Republicans hate the ACA and a majority still oppose a federally funded program."
Why Is Obamacare Complicated? (Paul Krugman, Op Ed, NY Times 10-28-13) "Obamacare isn’t complicated because government social insurance programs have to be complicated: neither Social Security nor Medicare are complex in structure. It’s complicated because political constraints made a straightforward single-payer system unachievable....Konczal is right to say that the implementation problems aren’t revealing problems with the idea of social insurance; they’re revealing the price we pay for insisting on keeping insurance companies in the mix, when they serve little useful purpose."
Behind the Challenges to Universal Health Coverage (Drew Altman, Wall Street Journal, 2-11-16) "Sen. Bernie Sanders has acknowledged that single-payer health care is not politically feasible in the foreseeable future and has said that it is unlikely without, among other things, campaign finance reform first....The makeup of the uninsured population and political realities suggest that the most likely path to universal coverage is a series of incremental steps–implemented in combination or sequentially–that build on the progress made by the ACA and chip away at the remaining uninsured in the U.S. group by group."
Bernie Sanders’ Health-Care Plan Would Provide ‘Medicare for All’ (Ally Boguhn, RH Reality Check, 1-19-16) "Sanders’ “Medicare-for-all” proposal detailed the candidate’s long-awaited plan to do away with the ACA and replace it with a universal single-payer system—a plan once supported by Hillary Clinton. The plan promises to eliminate all co-pays and deductibles, claiming that the average family of four would pay $466 per year for the program." Hillary Clinton has "faced scrutiny over her change-of-heart on universal health care by those who note that the former secretary of state, who previously backed a single-payer system, has accepted millions in speaking fees from the health industry in recent years."
Getting There from Here: How should Obama reform health care? (Atul Gawande, New Yorker, 1-26-09) Gawande doesn't favor single-payer health care--he believes we can build new systems on what we already have.. Such systems should have three attributes: it should leave "no one uncovered—medical debt must disappear as a cause of personal bankruptcy in America"; it should no longer be an economic catastrophe for employers"; and "it should hold doctors, nurses, hospitals, drug and device companies, and insurers collectively responsible for making care better, safer, and less costly."
A pro-single payer doctor’s concerns about Obamacare (Adam Gaffney, MD,4-11-14 on Salon, posted by Physicians for a National Health Program)
Did the SCOTUS Obamacare Ruling Open the Door for a Single-Payer System? (Crystal Shepeard, Care2, Truthout, 8-4-15) " a bit of karmic retribution, opponents' efforts to stop Obamacare has led to further consolidation with the federal government and may have just opened the door to their worst nightmare – a single payer healthcare system."
Himmelstein responds to Gawande on single payer (Don McCanne, MD, Physicians for a National Health Program, 2-12-09, writes about what's wrong with Gawande's argument)
What is Single Payer? (Physicians for a National Health Program, PNHP) See also Articles of Interest.
Surprise Medical Bills: ER Is In Network, But Doctor Isn't (Carrie Feibel, All Things Considered, NPR, 11-11-14) It would be like going into a restaurant, and ordering a meal and then getting a bill from the waiter, and from the restaurant separately, and the cook separately and the busboy separately.
Why markets can’t cure healthcare by Paul Krugman (The Conscience of a Liberal, NY Times, 7-25-09). "Consumer choice is nonsense when it comes to health care. And you can’t just trust insurance companies either — they’re not in business for their health, or yours.... insurers try to deny as many claims as possible, and that they try to avoid covering people who are actually likely to need care....HMOs have been highly limited in their ability to achieve cost-effectiveness because people don’t trust them — they’re profit-making institutions, and your treatment is their cost."
Surprise Medical Bills Take Advantage of Texans (Center for Public Policy Priorities, Texas) Little known practice of "balance billing" creates a "second emergency" for ER patients. “Balance billing” occurs when a consumer receives out-of-network health care services and is directly billed by the provider for the balance of what the insurer didn’t pay--in other words, the difference between the provider’s billed charge and the amount the insurer pays.
Assaulted by "Health Care" (Sandra Shea, Pulse, 1-23-15) "All told, I've had eleven surgeries and fourteen colonoscopies. Paperwork is practically my middle name. But the last twenty-four hours have been ridiculous. In that time, I've had three different encounters with healthcare billing--each absurd in its own way, and each more challenging than the last."
That CT scan costs how much? (Consumer Reports, July 2012) Health-care prices are all over the map, even within your plan’s network
Surprise Medical Bills (Consumer Reports). One way in which out-of-control health care costs manifests itself is surprise out-of-network bills. New York State took this issue head on, passing strong legislation that aims to protect consumers from these surprise bills. Links to many resources, articles on topic.
Guaranteed Health Care (National Nurses United). We don't need insurance. We need Medicaid for all. See article When health insurers play games, patients lose (David Lazarus, 4-18-14). A doctor jumps through numerous hoops to get UnitedHealthcare to pay for a patient's breast reduction — only to finally be told the surgery wasn't covered by her policy.
Woman taken to 'wrong' hospital faces bankruptcy (Adam Schrager,, 11-10-14)
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Gradual and modified approaches to single payer system

California Dreamin’? With Newsom’s Win, Single-Payer Unlikely To Follow Anytime Soon (Samantha Young, KHN, 11-7-18) As Gov.-elect Gavin Newsom and the Democratic-controlled legislature take steps to provide more people with health insurance, they’ll likely approach it piecemeal over several years. Newsom himself is already tempering expectations about California’s move to a single-payer system, saying it will take more than the will of one person to realize.Like many Democrats, Newsom has described health care as a right and vowed to defend the Affordable Care Act as governor. He also criticized the legislature last year when it held up a single-payer bill that would have created one government-run public insurance program for all Californians. Now Newsom’s attitude is cautious — many say realistic — even in a state that aims to set national trends and relishes its role at the forefront of the resistance to the Trump administration. Undaunted, the California Nurses Association said it intends to bring another single-payer bill before the legislature next year and has launched a national campaign to pass single-payer in other states and convince Congress of its merits.
Designing a Medicare Buy-In and a Public Plan Marketplace Option: Policy Options and Considerations (health policy analysts Linda J. Blumberg and John Holahan, Urban Institute, Sept. 2016)
Medicare buy-in for the age 55-to-64 set: Would it make sense? (Stephen Koff,, 8-7-17) What if, these Democrats ask, you could buy into the program starting at age 55? This could solve a number of problems for that age group, and even ease some of the financial pressures in the private market that push up premiums for younger people, they say. How would this work?
The Case Against the Public Option (Adam Gaffney, Jacobin, July 2017) We have the capacity to wage a transformative health care fight in the days ahead. Medicare for All or bust.
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Retainer or concierge medicine and other new models for paying doctors

At Forest Direct Primary Care, the doctor is in; insurance is out (Amy Trent, News Advance, 11-1-14) "Unlike concierge medicine, which caters to the wealthy with pricey membership fees, this is direct primary care, a small but growing field where patient loads are small — about a fourth of the number the average family physician cares for, according to national statistics — and fees are affordable, $75 to $150 a month." And the doctor does make house calls.
Ethical Concierge Medicine? (William Martinez and Thomas H. Gallagher, Virtual Mentor, AMA) "Frustrated by excessive paperwork, large patient loads, short visits, and diminished income, some primary care physicians have limited their involvement with traditional health insurance plans and embraced a less conventional model of medical practice known as “concierge medicine” or “retainer medicine.” These medical practices generally limit their physicians to somewhere between 300 to 800 patients, rather than the 2,000-plus panel sizes typical of traditional primary care physicians, and charge participating patients an upfront annual fee varying from less than $1,000 to more than $5,000." Discusses the practical and ethical implications of changing to such a practice. Not everyone can afford it, for example.
Concierge Medicine and Your HSA (American Health Value) "However, HSA funds can only be used for qualified expenses that have already happened. They cannot be used in anticipation of future expenses. For this reason, a concierge fee cannot be paid from an HSA....If your physician provides an invoice showing the actual cost of qualified medical expenses received under your concierge agreement, you can reimburse yourself for that $1,000 from your HSA."
Pros and Cons of Concierge Medicine (Jen Wieczner, WSJ, 11-10-13) 'Because concierge doctors aren't at the mercy of insurance companies, they say they take on fewer patients and spend more time with each, often guaranteeing appointments within 24 hours. They also don't need patients to come into the office to get paid, so they can provide care via video, email and phone. One of the great conveniences that private physicians offer is virtual conversations, as in "text me a photo of your tick bite." ...But the lower-cost concierge practices keep their rates low by focusing on simple services—you won't find advanced medical technology, and you'll have to go elsewhere (and pay extra) for screenings like MRIs."
Retainer medicine: an ethically legitimate form of practice that can improve primary care. (Ann Intern Med. 2011 Nov 1;155(9):633-5. doi: 10.7326/​0003-4819-155-9-201111010-00013.)
Why concierge medicine will get bigger (Elizabeth O'Brien, Retire Well, MarketWatch,1-17-13) If you’ve joined a concierge medical practice, recent trends in the worlds of health care and insurance may have you feeling good about your decision. If you haven’t signed up with one of these practices—also called “boutique,” “personalized” or “private-physician” practices—some of those same trends may lead you to consider it down the road.
Are Retainer-Based Medical Expenses Tax Deductible? (Zacks) http:/​/​​retainerbased-medical-expenses-tax-deductible-9307.html
The Future of Healthcare Could Be in Concierge Medicine (Nina Lincoff, Healthline, 6-30-15) Concierge medicine allows doctors to charge a flat monthly fee for services. It’s an idea that finally might be catching on.
Physicians Abandon Insurance for 'Blue Collar' Concierge Model Once the bastion of high-end specialists, more and more primary-care and family physicians are launching concierge practices for middle- and lower-income patients.
Don't blame doctors for going concierge (, 2-23-14) Nothing cuts the cord between the doctor and her patient like the mention of money. Yet, doctors all over the country are rushing to become “concierge physicians.” The more you pay, the closer you can get to the doctor. For $1000 a year, you can be part of the club. Pay $2000 annually and you can have the doctor’s email. Pay $3000 and you can text or call her cell.
My Doctor, the Concierge (Merrill Markoe, Time, 2-6-14) orget the Hippocratic oath--welcome to a world of Gold and Platinum patients
Enhanced Medical Care for an Annual Fee (Ginia Bellafante, NY Times, 12-6-13) "The health care market in New York is sufficiently unusual that members of the affluent classes routinely question the merits of doctors who do take insurance. How could the doctor satisfied to receive a $20 co-pay also be the doctor skilled enough to know that your palm’s itch is really the early sign of something rare and disfiguring? This psychology, along with the cost-cutting strategies pursued by insurance companies over the years, have driven the field of concierge medicine — typically, boutique general practices that charge premiums for enhanced attention." "The risk of course is that these sort of practices multiply and become a new norm for the very rich, aggravating not only the development of a two- (or really three-) tiered medical system but also creating a science-fiction metropolis in which only the best-off remain, living the longest and healthiest lives, never looking a day older than Mary-Kate Olsen, and moving into luxury condominiums built with CT scanners."
Concierge Medicine will get massive boost from Obamacare (Dike Drummond, Happy MD)
6 Things to Know About
Concierge Medicine
(Lisa Gerstner, Kiplinger, Sept. 2012) You can avoid packed waiting rooms—if you're willing to pay extra.
Concierge Medicine Journal
Concierge Medicine Today (another trade journal)
http:/​/​​Bethesda-Magazine/​January-February-2013/​Theres-a-Doctor-in-the-House/​ (Rita Rubin, Bethesda Magazine, Jan-Feb 2013) It’s a new-old idea: Physicians who don’t make you come to them—they come to you. An increasing number of concierge medicine practices are offering house calls to patients in wealthier parts of the country.
A new kind of doctor's office that doesn't take insurance and charges a monthly fee is 'popping up everywhere' — and that could change how we think about healthcare (Lydia Ramsey, Business Insider, 5-17-18) It could be a model for big employers like Amazon and JPMorgan. Pay to read.
Everyone Should Have A Concierge Doctor If doctors could be completely freed from the shackles of third party payment, they could take full advantage of phone, email and telemedicine (time spent on which they are not currently reimbursed).
The Case for Concierge Medicine (Richard Gunderman, The Atlantic, 7-16-14) Critics see such models as promoting a two-tiered system of healthcare, in which those with more money get better care.In the trade-off between more patients and more personalized care, growing numbers of physicians are choosing the latter
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Dealing with physician (and other healthcare professional) shortages

Physician Shortages in the Specialties Taking a Toll (Bonnie Darves, New England Journal of Medicine, March 2011) In the persisting, sometimes heated national conversation about physician shortages, the focus and headline-grabbing reports have largely centered on the dearth of primary care physicians and attendant access problems. "In its June 2010 report on non-primary care specialty shortages, AAMC’s Center for Workforce Studies ventured a dire prediction for the decade ahead: a current deficit of 33 percent in surgical specialties, and an undersupply of 33,100 surgeons and other specialists by 2015, increasing to 46,100 by 2020. The AAMC expects the primary care physician shortage to top 45,000 by 2020. The forecast from the Health Resources and Services Administration (HRSA) is even more unsettling. The government agency calls for a shortage of 62,400 in the non-primary care specialties by 2020. In addition, one third of U.S. practicing physicians are expected to retire over the next decade."
The government was trying to fix the transplant system. But it got complicated. (Michelle Andrews, WaPo, 6-12-16) A well-intended policy has unintentionally created perverse incentives. To get or keep a good performance rating from the federal government, transplant centers have been labeling some patients “too sick to transplant” and dropping from the waitlist some who may have been viable candidates, a decade-long study found. The researchers also determined that, despite the centers’ actions, one-year survival rates for transplant recipients didn’t improve.
Doctor Shortage Likely to Worsen With Health Law (Annie Lowrey and Robert Pear, NY Times, 7-28-12) Quotes many on how to deal with the problem.
How Congress causes (and could fix) the doctor shortage (Sarah Kliff, Wonkblog, Wash Post, 8-29-12) The residency program to train doctors has, for decades, largely been financed by Medicare. Back in 1997, when Medicare costs were skyrocketing, Congress passed the Balanced Budget Amendment. Among its many provisions to control Medicare cost growth, it included a hard cap on how many residencies it would fund. That residency cap remains in place right now. It is a lot of the explanation for why we have too few doctors."
What Should Be Done to Fix the Predicted U.S. Doctor Shortage? (The Experts, Wall Street Journal, 6-20-13). Kathleen Potempa : Let nurses provide primary care. George Halvorson : Relieve doctors of their student-loan debts. Murali Doraiswamy: Don't focus on supply. Focus on demand. Train more psychiatrists. Harlan Krumholz : Our assumptions could be impairing us. Fred Hassan : Make it easier to become a primary-care doctor in the U.S. Bob Wachter: There really isn't a doctor shortage in the U.S.; there is a doctor maldistribution, both geographically and by specialty. J.D. Kleinke : Increase the number of 'non-doctor' doctors. Gurpreet Dhaliwal : Lack of access to care is the greater problem. Leah Binder : An M.D. isn't always necessary for care. Atul Grover : Increase federal funding for residency training. John Sotos : Let doctors be doctors. Carol Cassella : If we want more doctors, we have to pay for more training. Peter Pronovost : Make being a doctor more rewarding. Susan DeVore : Leverage under-used care providers. David Blumenthal : Allow nurse practitioners to provide more care. Drew Harris : Market forces will help, to a degree. Pamela Barnes : Think about teams, not just doctors. Charles Denham : Stop stifling medical assistants. Helen Darling : Encourage a team effort.
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