By Stephanie Innes
Arizona Daily Star, July 15, 2017
Universal health care is far from the plan Republican leaders are proposing, but it’s getting some love in Southern Arizona.
Advocates cite various factors fueling single-payer popularity.
These include fear about recent Republican efforts to repeal and replace the Affordable Care Act (ACA, also called Obamacare), a public that’s more well-versed in health care and a repackaged “Medicare for All” message that they say makes the single-payer concept more understandable and palatable.
Nowhere was local support for that kind of system more obvious than at a standing-room-only health forum hosted by Tucson Medical Center June 26. A question about single-payer health care drew cheers, not from one or two lone voices, but from a chorus across the room of 700 people.
While the response from expert panelists at the forum was tempered, the audience’s enthusiasm was clear. Signs saying “Healthcare not Wealthcare” and “No More Pay Up Or Die Plans!” dotted the entrance to the event. The crowd was energized.
“Back in 2009, I certainly didn’t know what Medicare for All was. Like most Americans, I knew about employer and non-group insurance. I was so naive,” said forum attendee Andrea Witte, a 52-year-old graphic designer who recently became a supporter of Medicare for All. “It’s just being discussed more, and when I go to events, I think people understand health care better.”
Witte says her personal evolution includes now seeing health care as a basic right — a moral imperative, “instead of a commodity to be rationed based on the size of one’s wallet or the profit-seeking of insurance companies.”
Increased support for Medicare for All is not just local — an April 2017 Economist/YouGov poll found a majority of Americans support “expanding Medicare to provide health insurance to every American.”
The Pew Research Center reported in June that 60 percent of Americans say the federal government is responsible for ensuring health-care coverage for all Americans, while 3 percent say it is not the government’s responsibility.
These views are unchanged from January, but the share saying health coverage is a government responsibility remains at its highest level in nearly a decade, the researchers found.
“Many like me who supported the ACA’s modest reforms now realize that keeping for-profit insurers involved still leaves too many Americans uninsured or underinsured and prevents us from controlling our skyrocketing health-care costs,” Witte said.
California recently considered its own form of single-payer health care, and other states are talking about it.
When people refer to single-payer health care, they are not always talking about the same thing, and some people give the various universal plans other names, such as “Medicaid for All,” referring to the government insurance program primarily for low-income people. The general commonality is one public entity handling health-care financing for the entire country.
The Medicare for All movement supports a system like traditional or original Medicare, which covers mostly people over the age of 65.
Such a plan has been introduced in Congress by U.S. Rep. John Conyers, a Democrat from Michigan. Conyers’ bill calls for a progressive tax based on income, similar to one in Canada, to fund expanded Medicare for all Americans. Democrat U.S. Reps. Raúl Gríjalva of Tucson and Ruben Gallego of Phoenix are among the bill’s 113 co-sponsors.
The main Republican argument against single-payer health care is that it is too much big government providing not enough choice for Americans. Sen. Jeff Flake, an Arizona Republican, says he’s against single payer because he believes the best way to provide affordable, quality care for everyone is through “choice and competition in a free-market health-care system.”
Arizona Sen. John McCain says he, too, supports “a free-market solution that would enhance competition, increase choices, drive down costs and improve health-care outcomes.”
Nearly 40 percent of Arizonans already are on government-sponsored insurance — 25 percent on Medicaid and 14 percent on Medicare. That number doesn’t take into account the additional Arizonans who get federal subsidies to help pay for their health insurance through the ACA marketplace.
COMPLEXITY AND COST
Advocates say Medicare for All would provide health coverage to all Americans from birth to death and reduce two major problems with U.S. health care — complexity and cost.
“Health care should be like the fire department. … If your house is on fire, the fire department comes,” Tucson resident Kelly Strachan wrote in a recent letter to Flake and McCain.
“Not everyone’s house will burn, so we can create a big enough risk pool to truly control health-care costs (a large part of which is the profits of the insurance industry),” she wrote.
Eight to 10 years ago, many critics were quick to say socialized medicine would put us on a path to communism, says Strachan, a 56-year-old adjunct Spanish instructor at Pima Community College.
“They immediately would leap to repressive governments,” she said, adding there appears to be less hostility about the concept now.
Strachan frequently posts about single-payer health care on Facebook and chats about it with strangers she encounters in public places like movie theaters. She’s found people are generally willing to talk about it, even if they don’t always agree.
Writing in favor of a single-payer system in the University of Arizona’s Arizona Daily Wildcat on July 3, Andrew Paxton said millennials “would rather pay slightly higher taxes than worry about how to afford insurance, especially as our parents age and medical costs skyrocket.”
GOING BACK TO FDR
Single-payer health care in the U.S. is a concept that goes back as far as the Franklin D. Roosevelt presidency, when publicly funded health care was considered for inclusion in the national Social Security Act.
The public appears to be gaining a new understanding of what it means, says Dr. George Pauk, the Arizona representative on Physicians for a National Health Program. Debate over the Senate and House health bills, as well as the Affordable Care Act, fueled some of the interest, Pauk and others say.
“Almost everyone has a relative struggling to pay or going bankrupt because of medical bills,” said Pauk, a retired endocrinologist from Phoenix who has been campaigning for a single-payer system for 30 years. “We have a segregated health-care system in this country, and there’s been a lot of discrimination in the history of American health care.”
Annual per-capita health expenditures in the U.S. are the highest in the world despite a recent slowdown in spending, the Commonwealth Fund reports.
Insurance companies, acting as middlemen between providers and patients, add a layer of bureaucracy that is not only fueling that cost, but also making health care complicated for consumers, Medicare for All advocates say.
At the same time, the U.S. is not keeping pace on important health measures.
Infant mortality rates here are 5.8 per 1,000 live births, 71 percent higher than the comparable country average and twice the rate of Japan and Sweden, a Kaiser Family Foundation analysis of 2014 data found.
A Kaiser analysis of 2013 data found that for most of the leading causes of death, including disease of the circulatory and respiratory systems, mortality rates are higher in the U.S. than in comparable countries.
Pauk said in general, Americans have been indoctrinated that government is bad and too big.
But insurance companies are also too big, and they are “making a killing on health care,” he said.
It would cost less for doctors to remove insurance companies, he said, and save the U.S. between $300 billion and $500 billion per year.
“The average doctor would not have to have two or three or four people doing billing for them,” he said. “Can you imagine the savings, not having to have those employees?”
Some critics dispute the cost savings.
After Sen. Bernie Sanders proposed a single-payer system during his Democratic presidential run in 2016, the Urban Institute released an analysis that said Sanders’ plan would increase national health expenditures by nearly 17 percent or $6.6 trillion between 2017 and 2026, largely because of the cost of providing additional acute care to non-elderly people who currently have no insurance.
The Urban Institute concluded that physician payments would be squeezed, as would the pharmaceutical and medical-device industries, “perhaps more than is sustainable” and that people could wait longer for care.
The co-founders of Pauk’s group wrote a rebuttal calling the study ridiculous, saying among other things that it ignored the major savings on hospital administration and doctors’ billing that would occur under a streamlined single-payer system.
They also noted that no surge in care occurred in the 1960s when millions of previously uninsured seniors gained coverage through Medicare.
When the single-payer issue came up at the recent TMC forum, Dr. Francisco Garcia, chief medical officer for Pima County, said U.S. individualism “and our reluctance to be told what to do” have always been issues with that route.
Therein lies a huge part of the public’s perception of the ACA — the unpopular mandate that all Americans have insurance, he said.
“That was the rallying cry, ‘I don’t want to be told to buy insurance.’ Whether rightly or wrongly, that has been the downfall,” said Garcia, who is also assistant county administrator for health services.
And yet the ACA was a compromise between those who wanted a single-payer system and people who prefer a more capitalistic, market-oriented approach to health care.
“I actually think that the ACA, with its sometimes significant limitations, was actually a really sane, rational middle-of-the road, market-oriented kind of solution,” Garcia said. “I think that was a good, realistic solution and I long for the day when we can get back there, though I don’t see it yet.”
But Tucson pediatrician Dr. Eve Shapiro says it was a “different time” when President Obama presented his health plan in 2010. Shapiro has advocated for single-payer health care through Physicians for a National Health Program for about 30 years.
“I think he could have gone further in pushing the single payer and ended up with more of a public option,” Shapiro said. “He chose not to. He chose to work with the insurance companies. But I think people are now fed up with the insurance companies.”
Under a pure single-payer system, Americans would pay a progressive tax with no direct health-care costs for premiums, deductibles or co-pays.
That would be cheaper for 90 percent of Americans, said Tucson family physician and University of Arizona professor Dr. Paul Gordon. Gordon is Shapiro’s husband and also a strong supporter of a national single-payer health program.
The public is more likely to support “Medicare for All” versus “single payer,” which is why the messaging is important, Shapiro and Gordon say.
“People think if it’s a government system, the government controls your health care. What we try to explain is that the single payer is a payment system, which means there are no insurance companies and payments go through the government,” Shapiro said.
“But the delivery system is the same — the doctors, hospitals, health centers — that is what we have to make clear to people. Their day-to-day experience of health care wouldn’t change. What would change would be the financing of it.”
One thing is certain — for the more than $10,000 per person the U.S. spends on health care each year, we should be expecting “much better value for the dollar,” says health-policy expert Dr. Dan Derksen, a professor at the University of Arizona’s Mel and Enid Zuckerman College of Public Health.
“In 2015, the U.S. had $3.2 trillion in health expenditures. That’s more than twice what other developed countries spend, yet our population health outcomes are not as good as many countries who spend far less — whether it’s in terms of longevity, maternal and neonatal mortality, access to health care and preventive services, and most other parameters,” Derksen said.
“All of the developed countries except the U.S. have ‘single payer’ systems. Each country’s approach to single payer is quite different. Canada is often described as the country closest to what a ‘Medicare for All’ single-payer system looks like.”
Derksen wasn’t surprised by the enthusiasm he heard for single payer at the TMC forum, where he was a panelist. The audience was primarily made up of people who seemed upset about the House and Senate health bills, so single-payer support was to be expected, he said.
During the 2008 election season, there was a strong push for single payer, he says. But he notes one big difference between then and now — today’s general public is more educated about health care, likely because more people have health insurance.
Before 2014, 48 million Americans were uninsured. That number is now down to about 28 million. The newly insured have had to learn about concepts like deductibles, co-insurance and essential health benefits, and are better equipped to identify shortcomings in the system.
Still, Derksen is skeptical of any Medicare for All law happening in the near future, even with added public awareness.
“We’re some years out from that, pragmatically. Many components of the health industry benefit from keeping the status quo,” he said.
“The insurance industry has record revenues, and their stocks rise as consumer health-insurance protections are now on the legislative chopping block.
“Vested interests generally oppose changes that give the government more leverage in negotiating prices, such as the pharmaceutical industry, who would not want to have a single payer with monopoly power to get significant discounts in medications.”
Grijalva has long been a supporter of Medicare for All. At a July 6 forum he hosted in Tucson, he said the way to achieve it may be through increments, such as initially lowering the Medicare age to 50.
But Witte and others want more sweeping action now.
“Right now is the perfect opportunity to push for it. People have started to see what profit is doing to health care,” said Lee Stanfield, a 74-year-old retiree who started the group Single Payer Now Tucson more than a decade ago.
“It is so complex, and it’s aided and abetted by the insurance industry. They like it that way.”
When attending public events such as the Fourth Avenue Street Fair, Stanfield has been buoyed by the number of people who say they strongly support Medicare for All and are willing to take flyers and even help hand them out.
“In particular, I am encountering far more young people who know about and favor single payer than in years past, when it was hard to even get them to accept a flyer,” she said. “Bernie Sanders really got the young people on board.”
If anything is to happen with universal health coverage, it’s going to come from people like Stanfield who are at the grassroots level, Shapiro predicts.
“Look what is happening at all these senators and representatives’ offices, with people sitting in and protesting,” Shapiro said.
“I think they are getting the message that they have to do something that is real, that will give people coverage.”