Michael Lighty explains the waiver process proposed for a California single payer system

Posted by on Friday, Jul 7, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Policy Rant: CA SB 562 and Federal Waivers

By Michael Lighty
Medium, July 6, 2017

Skeptics of SB 562, the California single-payer bill, latch onto the question of obtaining federal waivers to help fund the new Healthy California Trust Fund, an independent public authority created by SB562 that will guarantee healthcare to all Californians thru single-payer financing. But these skeptics fail to recognize the political, statutory and legal paths available to ensure the new system receives all the federal funds for which Californians are eligible.

Through on-going consultations with advocates, administrators, legal authorities and health policy analysts, the sponsor of SB 562 is preparing for how the new system can build upon the existing Medicaid 1115 waiver for California, utilize newly granted state flexibility under the current Administration, apply for a 1332 waiver under the ACA, and establish Healthy California as a Part B provider for Medicare as well as subsidize Part D premiums, approaches consistent with current law and regulation.

Professor William Hsiao in his July, 2011, analysis of constraints to state single-payer, cites existing provisions of the Social Security Act that give states the opportunity to administer Medicare, an element useful to creating the “single channel” entity that reimburses all providers, the model for Healthy California.

He also discusses the usefulness to state single payer of Section 1332 of the ACA, which Congress intended to facilitate state universal healthcare systems, including single-payer financing. Converting federal tax subsidies under the ACA to monies into the new Healthy California Trust Fund, and getting federal tax credits for any employer and individual tax payments to fund the new Trust Fund, are the primary changes, the granting of which are contemplated by the legislative debate and the ACA statute. The waiver must certify the state program is budget neutral to the federal government and expands coverage. Hawaii obtained a 1332 waiver in January to provide federal tax credits for employer paid state taxes, replacing tax credits for employer paid insurance or coverage, a precedent relevant to SB 562.

Much uncertainty surrounds the future of Medicaid, but greater state “flexibility” is expected, along with reduced funding. Such flexibility does make it more likely that California can obtain those federal Medicaid dollars, however we organize our healthcare financing, provided we spend those dollars per the eligibility rules.

In other words, Californians will receive every federal healthcare dollar for which we are eligible, the question is in what form — can we use those dollars as part of the “single channel” created by the Healthy California Trust Fund to pay providers? And if we don’t get those monies, or the Federal government denies waivers to California while granting great flexibility to other states, we can litigate. These decisions are subject to judicial review.

In a political environment of gridlock and worse at the federal level, and increasing focus for change at the state level, with Democrats in control of California government holding 2/3 legislative majorities and the governorship, the politics strongly favor organizing to win in the golden state. With the resources of a nation, California can and should lead the country to achieve healthcare as a human right.

Michael Lighty is Director of Public Policy at California Nurses Association/National Nurses United.


What legislative process on the state level is there that would allow a state to use Medicare, Medicaid, ACA subsidies and other federal funds for a state-based single payer system? That question is apropos to SB 562, the California single payer bill. Michael Lighty, the policy director for the California Nurses Association – the major driving force behind the current efforts to enact a single payer system in California, explains that process to us.

I will make no effort to paraphrase his comments.

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Single payer support growing but malleable

Posted by on Thursday, Jul 6, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Data Note: Modestly Strong but Malleable Support for Single-Payer Health Care

By Liz Hamel, Bryan Wu, and Mollyann Brodie
Kaiser Family Foundation, July 5, 2017

As Congress continues to negotiate a repeal and replacement of the Affordable Care Act (ACA), some observers have suggested that if Republicans are unable to pass a replacement plan, it will create momentum for Democrats to push the country towards a single-payer health care system. This section of the latest Kaiser Health Tracking poll finds that while there has been a modest increase in the public’s level of support for single-payer in recent years, a substantial share of the public remains opposed to such a plan, and opinions are quite malleable when presented with the types of arguments that would be likely to arise during a national debate.

Trending support for single-payer

The June Kaiser Health Tracking poll finds that a slim majority of the public (53 percent) now favors a single-payer health plan in which all Americans would get their insurance from a single government plan, while just over four in ten (43 percent) are opposed. This is somewhat higher than the level of support found in a variety of Kaiser polls with slight variations in question wording dating back to 1998. From 1998 through 2004,  roughly four in ten supported a national health plan, while about half were opposed. In polling from 2008-2009, the period leading up to passage of the ACA, the public was more evenly divided, with about half in favor of a single-payer plan and half opposed.

Independents may be diving slight shift in overall attitudes

Not surprisingly, there are partisan divisions in how the public feels about single-payer health care, with a majority of Democrats (64 percent) and just over half independents (55 percent) in favor and a majority of Republicans (67 percent) opposed. However, the recent increase in support for single-payer has largely been driven by an increase among independents. Among this group, on average in 2008-2009, 42 percent said they would favor a single-payer plan, a share that has increased to a majority (55 percent) in the most recent tracking poll.

“Medicare-for-all” vs. “Single-payer”

Language often matters in framing questions about health policy. For example, the February 2016 Kaiser Health Tracking Poll found that when terms were tested on their own, outside the definition of a national health plan that would cover all Americans, the public was more likely to react favorably to the term “Medicare-for-all” (64 percent favorable) than “single-payer health insurance system” (44 percent favorable). However, the current poll finds that when the plan is defined as one in which all Americans would get their insurance from a single government plan, support is similar when the plan was referred to as “Medicare-for-all” (57 percent in favor) as when it was referred to as “single payer” (53 percent).

Support for single-payer is malleable when given opposing arguments

While a slim majority favors the idea of a national health plan at the outset, a prolonged national debate over making such a dramatic change to the U.S. health care system would likely result in the public being exposed to multiple messages for and against such a plan. The poll finds the public’s attitudes on single-payer are quite malleable, and some people could be convinced to change their position after hearing typical pro and con arguments that might come up in a national debate. For example, when those who initially say they favor a single-payer or Medicare-for-all plan are asked how they would feel if they heard that such a plan would give the government too much control over health care, about four in ten (21 percent of the public overall) say they would change their mind and would now oppose the plan, pushing total opposition up to 62 percent. Similarly, when this group is told such a plan would require many Americans to pay more in taxes or that it would eliminate or replace the Affordable Care Act, total opposition increases to 60 percent and 53 percent, respectively.

On the other side, when those who initially oppose a single-payer or Medicare-for-all plan are asked how they would feel if they heard such a plan would reduce health insurance administrative costs, four in ten (17 percent of the public overall) change their position and say they would now favor the plan, bringing total support to 72 percent. Similarly, when this group is told such a plan would ensure that all Americans have health insurance as a basic right or that it would reduce the role of private health insurance companies in health care, total support increases to 71 percent and 65 percent, respectively.


Topline: Precise questions and trends in responses


This highly credible Kaiser Foundation poll confirms the results of other recent polls showing that there has been a modest increase in support of single payer reform. A few specific points in this poll are worth noting.

Partisan polarization persists with 64 percent of Democrats supporting single payer and 67 percent of Republicans opposed. Amongst independents support has increased – now a majority at 55 percent, indicating that the single payer message is gaining traction amongst those not locked into a partisan camp. There is still a divide within each of the two dominant parties in that a significant minority of Democrats oppose single payer and a significant minority of Republicans favor it. For these reasons, single payer advocates should not narrowly target their educational efforts to a single party.

Last year a Kaiser poll showed that the term “Medicare-for-all” was preferred to “single payer” by 64 percent to 44 percent. With the recent increased interest in single payer, partly attributable to the presidential campaign of Bernie Sanders, the preference for Medicare-for-all over single payer has narrowed – now 57 percent to 53 percent. This is further evidence of the increased traction of single payer.

We have known that support for single payer is malleable. Previous surveys have shown that when supporters are asked about features of single payer that might be perceived as negative (too much government control, requiring more taxes, or now eliminating the Affordable Care Act) then support declines. This survey shows that the reverse is also true. When opponents are asked about single payer features that might be perceived as favorable (health insurance as a basic right, reduction in administrative costs, or reducing the role of private insurance) then support increases. In practice, the malleability has been used to defeat state ballot measures through the use of a few soundbites late in the campaigns. California’s measure lost 3 to 1 and measures in Oregon and Colorado lost 4 to 1. Positive soundbites do not seem to offset the uncertainty and fear created by negative soundbites.

Although this poll shows that there has been a modest increase in support of single payer – now 53 percent, up from the 40s over the past two decades – that support is malleable and 43 percent remain opposed. We still have a lot of work to do – education, coalition activities, and enlisting more grassroots support. Almost everyone would prefer single payer; it’s just that too many do not yet realize it.

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CMS halts release of Medicare Advantage data

Posted by on Wednesday, Jul 5, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Medicare Halts Release of Much-Anticipated Data

By Charles Ornstein
ProPublica, June 29, 2017

In the past few years, many seniors and disabled people have eschewed traditional Medicare coverage to enroll in privately run health plans paid for by Medicare, which often come with lower out-of-pocket costs and some enhanced benefits.

These so-called Medicare Advantage plans now enroll more than a third of the 58 million beneficiaries in the Medicare program, a share that grows by the month.

But little is known about the care delivered to these people, from how many services they get to which doctors treat them to whether taxpayer money is being well-spent or misused.

The government has collected data on patients’ diagnoses and the services they receive since 2012 and began using it last year to help calculate payments to private insurers, which run the Medicare Advantage plans. But it has never made that data public.

Officials at the Centers for Medicare and Medicaid Services have been validating the accuracy of the data and, in recent months, were preparing to release it to researchers. Medicare already shares data on the 38 million patients in the traditional Medicare program, which the government runs.

The grand unveiling of the new data was scheduled to take place at the annual research meeting of AcademyHealth, a festival of health wonkery, which just concluded in New Orleans.

But at the last minute, the session was canceled.

In a statement, CMS said there were enough questions about the data’s accuracy that it should not be released for research use. CMS said it will examine the data for 2015 “to determine if it is robust enough to support research use.”

(Health economist Austin) Frakt notes that researchers know “vastly more” about traditional Medicare because the data has been available for decades. “The claim is that private insurers are innovating in ways that traditional program is not. We need to validate that. We need to know what they’re doing for the benefit of everyone. We can’t do that without the data.”

In recent years, private insurers that run Medicare Advantage plans have been under fire for allegedly overcharging Medicare. The Center for Public Integrity reported last year that more than three dozen audits had found that plans overstated the severity of enrollees’ medical conditions to garner more money. (The Center had to file a Freedom of Information lawsuit to access the audits.) In 2014, the Center’s reporting suggested that insurers had collected $70 billion in improper payments from 2008 to 2013.

The Department of Justice recently intervened in two federal lawsuits in Los Angeles (here and here) accusing UnitedHealth Group of providing “untruthful and inaccurate information about the health status of beneficiaries” to boost its revenues.

“The system used to capture encounter data has numerous unresolved operational and technical issues and fails to capture a reliable, comprehensive picture of beneficiaries’ diagnoses,” a spokeswoman for America’s Health Insurance Plans said in an email. “This could put payments at risk, which could also increase premiums and decrease benefits. We look forward to working with Administrator Verma and CMS to improve the encounter data and address these issues.”


We have access to the data for the traditional Medicare program, but the same data have not been available for the private Medicare Advantage plans. We do know that the private plans have been cheating the taxpayers, initially by selectively marketing their products to less expensive, healthier populations while receiving full payments based on average needs, and then, later, by upcoding the diagnoses in order to receive unwarranted higher risk adjusted payments as if the beneficiaries were sicker than they actually are.

Now that CMS is headed by a pro-market ideologue – Seema Verma – the promised release of the data was reversed with the explanation that “there were enough questions about the data’s accuracy that it should not be released for research use.” Yet it is being used to overpay the private plans. Verma has stated repeatedly that the private plans produce higher quality at lower costs, yet she refuses to let us see the data. What data we do have suggest the opposite.

With the overpayments, the Medicare Advantage plans are able to offer their products with lower premiums and cost sharing, obviating the need for patients to purchase Medigap plans. With this perception of a better deal, enrollment in the private plans continues to increase, helping to fulfill the goal of privatizing Medicare. Once the private plans have supplanted much of the traditional Medicare program, the public privatizers plan to decrease the government contribution to the plans (decrease premium support – vouchers) leaving Medicare beneficiaries to pick up more and more of the costs.

Look, it’s our government, our taxes, our Medicare. Keeping us in the dark allows them to surreptitiously inflict their ideology upon us – an ideology that is shifting wealth upwards, away from workers. After listening to the Fourth of July speeches celebrating America, it does not seem that privatizing Medicare is the way we make America great again.

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AHCA or BCRA: “Murder for hire”

Posted by on Wednesday, Jul 5, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

A Health Care War On The Poor

By Kathleen Sebelius and Ron Pollack
Health Affairs Blog, June 27, 2017

Many criticisms have been leveled against the House-passed American Health Care Act (AHCA) and the Better Care Reconciliation Act- the new Senate health bill offered by Majority Leader Mitch McConnell. The unmistakable hallmark of these bills, however, is that they constitute a very cruel war on the poor. By far, no demographic group would be hurt more by these legislative proposals than low-income people. They are the bulls-eye!

As the non-partisan Congressional Budget Office (CBO) found, over the next decade the largest cutback in the Senate and House bills are reductions to the safety-net Medicaid program (a $772 billion cut in the Senate bill, and an $834 billion cut in the House bill).

Additionally, there are significant cuts to the subsidies that were designed to make private insurance premiums and cost-sharing affordable for low- and moderate-income families, with $424 billion cut in the Senate bill and $276 billion cut in the House bill.

These decreases, which would cause enormous harm to low-income families, are obviously not part of an overall scheme to promote fiscal prudence since both the Senate and House bills lavish huge tax benefits to the rich and special interest groups. The Senate provides $541 billion in such tax benefits, and the House provides $664 billion.

According to CBO, the proposals in both the Senate and House bills would cause huge numbers of people to become uninsured within a decade. The Senate bill would cause 22 million to lose coverage, and the House bill would force 23 million into the ranks of the uninsured. In total, at least 49 million would be uninsured – more than the aggregate population of almost half (24) the states in our nation.

The bottom line is clear: While both the House and Senate bills provide unneeded tax help for wealthier people, the Republicans’ war on the poor would cause many and very severe casualties on people with greatest needs. Hopefully senators of good will call for an immediate and complete cease fire.


Health Affairs Reader Response:

By Robert Stone, M.D.

“War on the Poor” is strong language, and sometimes strong language is appropriate to a discussion, even in as sober a journal as Health Affairs. I would use even stronger language. The 6/27/17 Annals of Internal Medicine article “The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly” is the most definitive peer-reviewed publication yet showing that removing healthcare coverage for millions of Americans will lead to thousands of preventable deaths per year. What do we stand for as a nation? This is a murderous bill. The bill, either House or Senate version is a huge tax cut for the wealthy, paid for by the middle class and the poor. Why is there such a rush to pass it without discussion and debate? It appears to me the reason for that is because Senators’ wealthy donors want to see the tax cuts. Therefore, you could call this bill not only murderous, but “Murder for hire.”


Rob Stone is one of us. He has been a very active participant and a thought leader in PNHP for a couple of decades. His message for us today is that we have to start saying it like it is. The fact that so many Senators are on record as being willing to enact legislation that will kill thousands of Americans in exchange for payments from wealthy donors who want the associated tax cuts, that does constitute “Murder for hire.”

The politicians are not alone in this conspiracy. We can no longer accept an “arm’s length” excuse to allow these wealthy donors to escape blame. The work of Gilens and Page has shown that it is these very individuals who drive the process (link below). They are the ones who are hiring the murderers (though Gilens and Page would confine their rhetoric to benign academic language). And, yes, the members of Congress are murderers when they enact policies that they know will kill people.

At PNHP we have been gentlepersons as we advocate for policies that will enhance health, reduce physical suffering, and prevent financial hardship for all residents of America (and next, the world). Yet we see policies perpetuated that inflict so much harm (and, by no coincidence, at a great financial cost), and we complain that their policies are wrong and that we have better policies. Is arguing policy enough when it is devoid of warranted intense emotional expression?

But something has been happening. Americans now understand that the improvements of Obamacare are grossly deficient since too many people are unable to receive or afford the medical care that they need. Bernie Sanders came along and told us that expanding Medicare to include everyone through a single payer system would make health care affordable and accessible to all. Those of us who have long supported those views have joined him a clarion call for health care justice for all.

Although single payer sounded like a pretty good idea to those who hadn’t given it much thought, many were still hoping Trump and the Republicans could bring us health care nirvana through repeal and replace. But now Americans have had a rude awakening in discovering that the repeal and replace movement of the past six years has been a fraud. The Republicans finally had to bring their proposal out from the closet for what they hoped would be quick action before rushing home to pick up their checks from their wealthy donors. But we peeked! The American people have now found out that the replacement would make access and affordability much worse – not at all what they were asking for when they supported the campaign to repeal Obamacare.

Of course we do not want to change our policy positions on single payer. We have what America needs. But it may help to deliver the message if we turn up the volume on our rhetoric, just like Rob Stone has done in today’s message. However, a crucial caveat is that it is absolutely imperative that we be extremely meticulous in the accuracy of our rhetoric in order to maintain the credibility that we have established. This is not a name calling contest. But when policies kill, we need to say so. If in doubt, don’t, but when there is absolutely no doubt, say it.

Many positive terms have been used in the labeling of legislation in order to hide the negative impact: “affordable” when health care remains unaffordable, “better care” when more people lose their care, “access” when increased financial barriers impair access, and even “American” when the policies supported are un-American. Although the words themselves are not bad words, they are tarnished when used in dishonest rhetoric (although “American” still seems to hold its own in spite of current day challenges).

That said, we cannot let negativity drown out our very positive message of  guaranteed, affordable health care for all – the single payer message. That needs to be front and center, but how do we do that? Well, we are already doing it by having been meticulous with the truth. When we say “an improved Medicare for all” people understand that we are referring to a revered program that will be further improved and made available to all. Even the term “single payer” – a neutral technical policy term – has been used extensively as part of the positive message of health care for all.

With our continued efforts to deliver this very positive message, “single payer” and “improved Medicare for all” are rightfully taking their place on the top shelf in the rhetoric library, alongside “Mom” and “apple pie” – a nice thought as we celebrate our nation’s birthday.

Martin Gilens and Benjamin I. Page, “Testing Theories of American Politics: Elites, Interest Groups, and Average Citizens”:

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Polling: How you discuss single payer matters

Posted by on Friday, Jun 30, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

The Economist/YouGov Poll
April 2-4, 2017

81. Do you favor or oppose expanding Medicare to provide health insurance to every American?

60% – Favor strongly or favor somewhat

23% – Oppose strongly or oppose somewhat



The Economist/YouGov Poll
June 25-27, 2017

61. Do you favor or oppose creating a single-payer health care system, in which all Americans would get their health insurance from one government plan that is financed by taxes?

44% – Favor strongly or favor somewhat

31% – Oppose strongly or oppose somewhat


During a time when there is a crescendo of support for single payer/Medicare for All, the Economist/YouGov polls suggest that support declined during the past couple of months. There is a lesson here, but it is not that single payer support is fading.

The single payer policy community would recognize these two questions as being essentially the same from a policy perspective. But the layman hears the first question as being the expansion of Medicare to cover everyone (Medicare for All), whereas the second question is about single payer, government, and taxes (single payer). The first is about a popular insurance program which we have all earned and eventually participate in, and would it be that everyone could be included. The second is about government taking over health care and us being taxed for it when the insurance benefit at work seems to be working just fine, and the boss is already paying for most of it anyway. At least that’s often the perception.

We already knew this. “Medicare for all” polls better than does “single payer.” What is reassuring is that people are beginning to understand the single payer concept well enough such that there is more support than opposition, even if it is a government program for which we will be taxed. The term “single payer” is out there and will be used by friend and foe alike, so people have to understand that it refers to an improved version of Medicare in which everyone gets to participate.

The lesson? We should not only continue with but we should expand our education and advocacy activities through coalitions and grassroots efforts. The people are getting the word. Support is burgeoning. Soon the public will be immunized against the soundbites of the opponents.

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Do members of Congress deserve government subsidized health insurance?

Posted by on Thursday, Jun 29, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Tie Congress’s Paychecks to Our Good Health

By Nicholas Kristof
The New York Times, June 29, 2017

Members of Congress are paid $174,000 a year, while members of Poland’s lower house of Parliament are paid $32,300 a year.

Hmm. It looks as if we’re getting ripped off. Members of Congress seem to underperform compared to members of Parliament in Poland and across the democratic world.

Conservatives are right to worry that feeding at the government trough breeds dependency and laziness. So I suggest we introduce pay for performance, using metrics like, say, health.

I cite Poland because so many Poles (including the Krzysztofowicz family, later renamed Kristof) came to America for a better life, yet today American babies are one-third more likely to die in their first year of life than Polish children are (and twice as likely as Italian, Portuguese and Czech babies!).

Meanwhile, the U.S. spends far more on health care — an average of nearly $10,000 per person — than other countries do. Poland spends just $1,680 per person.

This is a stain on America. Choose almost any modern country, and its people pay less for health care and its children are more likely to survive.

In short, we as taxpayers are getting cheated.

But ultimately the United States should follow the example of every other advanced country and ensure health coverage for all. “We’re going to have insurance for everybody,” President Trump promised a week before taking office. Now he backs plans that would lead to 22 million fewer people having coverage. But if Taiwan, Slovenia, Spain, Japan and just about every other modern country can have coverage for everyone, so can we.

And, members of Congress, here’s the deal: If you ever adopt Medicare for all, I’ll endorse a pay-for-performance pay raise for all of you along with guaranteed, subsidized health insurance.

Oh, never mind. That, you already have.


Right now many members of Congress are fighting the concept that health care should be an entitlement (some would say a right). Not only do they offer no realistic assistance for the 28 million who remain uninsured, some members are supporting policies that would cause another 22 million to lose their insurance. If they really believe that not everyone is entitled to have insurance then why do most of us believe that these well paid members of Congress are somehow entitled to generous health care plans, largely funded by us taxpayers?

I could write much more about this, but isn’t that observation enough? Some deserve health care at our expense and others don’t?

A benefit for the privileged? An entitlement? A right? For a few? For everyone?

Do we really have to play rhetorical games to come to the conclusion that everyone should have health care? If we believe that, and most Americans do, then we need to hire members of Congress who agree with us and get rid of those members who think that they are more entitled to health care than the rest of us.

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The real debate: Single payer vs. ACA/AHCA/BCRA

Posted by on Wednesday, Jun 28, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

The Senate’s Secretly Bipartisan Health Bill

By Avik Roy
The New York Times, June 26, 2017

In 2010, when Democrats passed the Affordable Care Act, Republicans complained that they did so with no Republican support. Democrats responded by pointing out that the centerpiece of their plan — tax credits to buy private insurance — came from a Republican governor, Mitt Romney of Massachusetts.

Something similar is happening today. Democrats are denouncing the partisan nature of the Republican effort to repeal and replace Obamacare. They’re right to note that if the new bill passes the Senate, it will do so along party lines.

But the core planks of the Senate Republicans’ health bill — the Better Care Reconciliation Act — borrow just as much from Democratic ideas as Obamacare borrowed from Republican ones.

The bipartisan heritage of the bill does not eliminate areas of philosophical disagreement between conservatives and progressives. It increases the role of private insurers, and decreases the role of state-run Medicaid programs in covering the uninsured. It reduces federal spending on health care, whereas Obamacare increased it. The Senate bill repeals or rolls back all of the A.C.A.’s tax increases.

But think about it this way. Imagine an alternate universe in which, in 2009, Democrats and Republicans passed a bipartisan health bill. That bipartisan bill — let’s call it the Baucus-Collins Act — expanded coverage to tens of millions of Americans through a system of means-tested, age-adjusted tax credits in a voluntary-but-regulated individual insurance market where insurers were required to charge the same premiums to the sick and the healthy and guarantee coverage for those with pre-existing conditions.

In the Baucus-Collins Act, this increased spending on the uninsured was paid for through reforms of the Medicare program. In addition, the alternate-universe bill enacted a near-replica of Mr. Clinton’s proposal for Medicaid reform in order to make the program fiscally sustainable over the long term. The act also capped the previously unlimited tax break for employer-sponsored health insurance, albeit at a high threshold.

Democrats and Republicans would be celebrating historic reforms that expanded coverage in a fiscally responsible way. Both blue states like California and red states like Texas would see substantial coverage gains. And we might be talking about further bipartisan efforts to strengthen the Baucus-Collins Act.

What I’ve just described as a bipartisan achievement is, in effect, the synthesis of Obamacare and the Senate Republican health care bill.


NYT Reader Comments

By Don McCanne, M.D.

Avik Roy’s framing is that there are two polarized partisan views of reform and that somewhere in the middle is the compromise on which we can all agree. Nonsense.

If we are to use linear polarization to frame the debate, then the two sides are health care policies that benefit the patients – all patients – versus health care policies that cater to special interests, whether they be the medical-industrial complex or the political ideologues.

The similarities noted by Roy are due to the fact that the neoliberal views of the Democrats are not that far from the conservative views of the Republicans, in spite of all the noise generated by this debate. Trying to establish policies that benefit the various special interests results in the profoundly expensive, highly wasteful, inequitable, fragmented, dysfunctional system that we have.

A well designed single payer system takes care of patients first, with much greater efficiency, effectiveness, and equity. The special interests that might otherwise appropriately benefit would do well in such a system though they would have to set aside personal greed and vacuous ideology.



The other reform model: Single payer

“If the GOP does not disengage the country’s health-care system from the disaster of Obamacare, we are headed for the misery of single-payer.”
Hugh Hewitt, The Washington Post, June 27, 2017

“Senator Elizabeth Warren now says Democrats should endorse a government-run, single-payer health insurance system for the upcoming 2018 midterm elections and beyond.”
Boston Globe, June 27, 2017

“Sen. John Thune (R-S.D.) said, ‘If we don’t get this done and we end up with Democratic majorities in ‘18, we’ll have single payer. That’s what we’ll be dealing with.’ Sen. Pat Roberts (R-Kan.) added that Congress has to pass an unpopular far-right bill, no matter what, because the alternative is single payer, ‘and that’s socialized medicine.’”
MSNBC, June 27, 2017

“Republicans have opened up the space for Democrats to go much further than they’ve been willing to before. It’s not impossible to foresee Democrats winning the House in 2018, then taking the presidency and the Senate in 2020 — and then taking the first steps toward making single-payer health care in America a reality.”
Paul Waldman, The Washington Post, June 27, 2017

“It wasn’t long ago that the mere mention of single-payer inspired gasps of horror among centrists and conservatives. Now, not so much.”
Caroline Baum, MarketWatch, June 28, 2017

“Tom (Sullivan) warned that, if the GOP fails to pass a sufficient healthcare plan in the near future, a single-payer healthcare system in the United States could be inevitable.”
Tom Sullivan Show, Fox News Radio, June 27, 2017

“Plans that are not single-payer, quite simply, are motivated by greed and fueled by ignorance. And they are cruel.”
Joshua Gear, Press Herald, June 26, 2017

“Anyone who argues in 2017 that single-payer health care is unfeasible is either ignorant, malignant, depraved enough to rationalize profit from human suffering, or absent of the basic moral imagination to aspire to something better.”
Timothy Faust, Jacobin, June 26, 2017

“With my limited knowledge, I think (single payer) probably is the best system.”
Warren Buffett, PBS NEWSHOUR, June 26, 2017

The issue is simple. The nation is dissatisfied with the deficiencies of the Affordable Care Act, and now they realize that the repeal and replace movement was never founded on sound health policies and would leave us mired in the same old system. The Democratic and Republican politicians are quibbling over details of a dysfunctional, fragmented, inequitable health care financing system that costs too much and delivers too little. Now, more than ever before, the nation is realizing that the other real option is, instead, a single payer national health program – an improved Medicare for all.

Again, the real debate is not between the twins of ACA vs. AHCA/BCRA, but rather it is between our terribly mediocre health care financing system vs. single payer – improved Medicare for all.

The momentum for single payer is greatly intensifying. Next week members of Congress are returning to their districts as they try to reorganize their concepts and strategy on health care reform. They need to hear loudly and clearly our voice on health care justice for all – single payer!

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Insurance rescinded: People will die

Posted by on Tuesday, Jun 27, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

H.R. 1628, Better Care Reconciliation Act of 2017

Congressional Budget Office, June 26, 2017

CBO and JCT estimate that enacting the Better Care Reconciliation Act of 2017 would reduce federal deficits by $321 billion over the coming decade and increase the number of people who are uninsured by 22 million in 2026 relative to current law.

Because nongroup insurance would pay for a smaller average share of benefits under this legislation, most people purchasing it would have higher out-of-pocket spending on health care than under current law.



The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?

By Steffie Woolhandler, M.D., M.P.H.; David U. Himmelstein, M.D.
Annals of Internal Medicine, June 27, 2017


About 28 million Americans are currently uninsured, and millions more could lose coverage under policy reforms proposed in Congress. At the same time, a growing number of policy leaders have called for going beyond the Affordable Care Act to a single-payer national health insurance system that would cover every American. These policy debates lend particular salience to studies evaluating the health effects of insurance coverage. In 2002, an Institute of Medicine review concluded that lack of insurance increases mortality, but several relevant studies have appeared since that time. This article summarizes current evidence concerning the relationship of insurance and mortality. The evidence strengthens confidence in the Institute of Medicine’s conclusion that health insurance saves lives: The odds of dying among the insured relative to the uninsured is 0.71 to 0.97.

From the Discussion

The evidence accumulated since the publication of the IOM’s report in 2002 supports and strengthens its conclusion that health insurance reduces mortality. Several newer observational and quasi-experimental studies have found that uninsurance shortens survival, and a few with null results used confounded or questionable adjustments for baseline health. The results of the only recent RCT, although far from definitive, are consistent with the positive findings from cohort and quasi-experimental analyses.

Several factors complicate efforts to determine whether uninsurance increases mortality. Randomly assigning people to uninsurance is usually unethical, and quasi-experimental analyses rest on unverifiable assumptions. Deaths are rare and mortality effects may be delayed, mandating large studies with long follow-up. Many people cycle into and out of coverage, diluting the effects of insurance. And statistical adjustments for baseline health usually rely on participants’ self-reports, which may be influenced by coverage. Hence, such adjustments may under- or overadjust for differences between insured and uninsured persons.

Our focus on mortality should not obscure other well-established benefits of health insurance: improved self-rated health, financial protection, and reduced likelihood of depression. Insurance is the gateway to medical care, whose aim is not just saving lives but also relieving human suffering.

Overall, the case for coverage is strong. Even skeptics who suggest that insurance doesn’t improve outcomes seem to vote differently with their feet. As one prominent economist (Paul Krugman) recently asked, “How many of the people who write such things… choose to just not bother getting their healthcare?”


Although the precise numbers are somewhat elusive, this comprehensive review of existing studies confirms that health insurance reduces mortality. The Congressional Budget Office concludes that another 22 million people will be uninsured compared to current law if the Better Care Reconciliation Act were enacted and implemented. If this Republican repeal and replace bill becomes law, more people will die as a result.

Obviously the reduction in mortality is not the sole function of insurance. As the authors of this Annals of Internal Medicine article state, “Insurance is the gateway to medical care, whose aim is not just saving lives but also relieving human suffering.” Importantly, it also provides financial protection, which otherwise would deteriorate under the Republican proposal. (The full landmark article by Steffie Woolhandler and David Himmelstein is available for free at the link above.)

If there ever was a time to intensify the policy debate, this is it. The repeal and replace movement became popular because of the acknowledged deficiencies of the Affordable Care Act – leaving millions uninsured, millions more with inadequate financial protection, perpetuation of a dysfunctional insurance market that takes away choices, while failing to remedy the profound administrative waste that uniquely characterizes the U.S. health care financing system.

The Republicans have done us a favor by showing us that replacement policies that assume perpetuation of our fragmented infrastructure of private plans and public programs cannot remedy the profound deficiencies in our system. With six years of debate, the policies proposed do not correct the fundamental flaws in the financing infrastructure and actually would only compound the problems, including increasing mortality caused by being uninsured.

It is not as if we do not understand optimal health policy. We do. A well designed single payer national health program – an improved Medicare for all – would ensure that all of us would have the essential health care services that we need in a system that would be affordable for each of us. And, oh yes, nobody would die simply because they were uninsured.

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New Gallup and Pew surveys show concern and hope for health care

Posted by on Monday, Jun 26, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Cost of Healthcare Is Americans’ Top Financial Concern

By Andrew Dugan
Gallup, June 23, 2017

The cost of healthcare is now the top financial problem facing U.S. families. Concern about healthcare costs is at nearly the same level now as it was in 2007, a time before the recession and the passage of the ACA.

What is the most important financial problem facing your family today (open ended)?

17% – Healthcare costs
11% – Too much debt/Not enough money to pay debts
10% – Lack of money/Low wages
10% – College expenses
9% – Cost of owning/renting a home
8% – High cost of living/Inflation
Other choices 6% or less (see table at link)



Public support for ‘single payer’ health coverage grows, driven by Democrats

By Jocelyn Kiley
Pew Research Center, June 23, 2017

A majority of Americans say it is the federal government’s responsibility to make sure all Americans have health care coverage. And a growing share now supports a “single payer” approach to health insurance, according to a new national survey by Pew Research Center.

Among those who see a government responsibility to provide health coverage for all, more now say it should be provided through a single health insurance system run by the government, rather than through a mix of private companies and government programs. Overall, 33% of the public now favors such a “single payer” approach to health insurance, up 5 percentage points since January and 12 points since 2014. Democrats – especially liberal Democrats – are much more supportive of this approach than they were even at the start of this year.

Among Democrats, 52% now say health insurance should be provided through a single national insurance system run by the government, while fewer (31%) say it should be provided through a mix of private companies and government programs. The share of Democrats supporting a single national program to provide health insurance has increased 9 percentage points since January and 19 points since 2014.

Nearly two-thirds of liberal Democrats (64%) now support a single-payer health insurance system, up 13 percentage points since January.

Two-thirds of adults younger than 30 (67%) say the government has a responsibility to provide health coverage for all, with 45% saying coverage should be provided through a single national program.

Among Republicans, a greater share of those younger than 30 (39%) than those 30 and older (28%) say the government is responsible for providing health coverage for all; more young Republicans than older Republicans favor single payer (22% vs. 10%).

The share viewing this as a government responsibility has increased 9 percentage points since 2016, from 51% to 60%.


Cost of health care is the top financial concern of Americans, and that has been increasing, now as high as it was before the Affordable Care Act was enacted. The more reassuring news is that support for a government responsibility to provide health coverage for all remains high, and preference for a single payer approach is increasing.

That increase in single payer support is greater amongst Democrats, especially liberals, and amongst adults under 30. Although the concept of single payer is less popular amongst Republicans, some do favor it.

We should take advantage of being sure that those not yet sold on single payer understand two things; 1) They are correct that the Affordable Care Act is not satisfactory because it falls far short of universality and it fails to prevent financial hardship, and thus it needs to be replaced, and 2) The six years of vacuous proposals of the Republican legislators have obliterated any hope that a solution lies within the fantasies of a free market health care nirvana. The Republican proposals acknowledge that government involvement is essential, but they propose an emasculated role – the worst kind of government, heavy with bureaucracy but placing our tax funds into the hands of entrepreneurial rent seekers.

More people are realizing that the circuitous route taken by our health care dollars wastes tremendous resources while depriving too many individuals of the health care access and financial protection that they need. Conservatives and the business community are beginning to understand this. We have to make sure that we provide the information to them that they need to have a clearer understanding of optimal health care financing policy. Not only is $3.2 trillion at stake, our health is as well.

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URGENT: Steffie Woolhandler’s message on California

Posted by on Saturday, Jun 24, 2017

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Speaker Anthony Rendon Statement on Health Care

California State Assembly, June 23, 2017

Yesterday, Republicans in the U.S. Senate released a cynical plan to repeal the Affordable Care Act, posing a real and immediate threat to millions of Californians who only have health coverage because of the ACA.

Preparing California to meet this threat must be the top health care priority for the Legislature, Governor Brown, and organizations that advocate for increasing access to health care.

As someone who has long been a supporter of single payer, I am encouraged by the conversation begun by Senate Bill 562.

However, SB 562 was sent to the Assembly woefully incomplete. Even senators who voted for SB 562 noted there are potentially fatal flaws in the bill, including the fact it does not address many serious issues, such as financing, delivery of care, cost controls, or the realities of needed action by the Trump Administration and voters to make SB 562 a genuine piece of legislation.

In light of this, I have decided SB 562 will remain in the Assembly Rules Committee until further notice.

The fight for single payer also is moving forward on other fronts. The head of the Campaign for a Healthy California, an organization created to pass SB 562, has acknowledged their ultimate goal is to get a single payer initiative on the ballot, and there remains ample time for them to pursue that before November 2018.



Support Grows for Single-Payer Medicare-for-All Plan Instead of Massive Cuts to Healthcare

Democracy Now!, June 23, 2017

Dr. Steffie Woolhandler: We’re seeing a lot of public support for the idea of single payer. We’re seeing a big movement for single payer at the state level in California. Obviously we’re getting a whole lot more discussion of single payer now than we’ve ever had before.

Amy Goodman: In California, it’s passed the state Senate. It’s got to go through the Assembly, and then it has to go to Governor Brown. Do you think that he will sign off on it?

Dr. Steffie Woolhandler: OK, well, we’re only going to get single payer if the populace keeps the pressure on the politicians. It’s not going to happen automatically. It’s not going to happen because Governor Brown has occasionally in the past said he likes single payer. It’s going to happen because we have a movement that’s strong enough to counter the political power of these rich people, who are getting these huge tax cuts; of the insurance industry, who would have no place in an efficiently run single-payer system; of Pharma, who thinks that they’re going to have to accept lower prices under single payer. In fact, they’re right. So that’s a lot of political power. And the only way to push through that is to really build a movement. But, you know, that really seems possible right now, with polls showing that two out of every three Americans who have an opinion on health care think we need some sort of Medicare-for-all program. So, now is really the time to be pushing this—in fact, the only way to really counter the Republican momentum at this point.


Holding SB 562, California’s single payer bill, in the Assembly Rules Committee would mean that no further action would take place on it this year. The Republican ACA repeal bill before Congress is no excuse to block California’s progress on single payer, especially since the repeal bill likely will be defeated within a week or so. The fact that SB 562 needs more work is an even greater reason to move forward with it, not to abandon the effort.

Steffie Woolhandler was interviewed on Democracy Now! yesterday just before California Assembly Speaker Anthony Rendon released his statement announcing that he was putting a hold on the single payer bill. Although she was not aware of his decision, her words seem prescient.

Her pronouncement applies not just to California but to the entire nation. We must make every effort, not simply to keep the single payer momentum going, but to escalate it into a movement that would be impossible to repel.

The immediate task for Californians is to demand that Speaker Rendon move the bill out of the Rules Committee and advance it to other committees so that the essential markups that need to be done can be accomplished. Contact him at: 916-319-2063, @Rendon63rd, or assemblymember.rendon@assembly.ca.gov.

And for the rest of the nation? It won’t come from the politicians. It won’t come from the powerful and rich. It won’t come from the medical-industrial complex. As Steffie says, “we’re only going to get single payer if the populace keeps the pressure on the politicians.” We – all of us – have to do it.

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