The following is a lightly edited, unofficial transcript of the second half of an interview that Dr. Andrew D. Coates gave to Ed “Flash” Ferenc, host of the labor-oriented, Cleveland-based America’s Work Force Radio, WERE AM 1490, on March 30, 2016. Dr. Coates is immediate past president of Physicians for a National Health Program.

In this segment of the interview, Dr. Coates talks about how a single-payer, improved-Medicare-for-All system would benefit everyone who lives in the United States. In the first half of the interview (not transcribed here), Dr. Coates describes how he came to support single payer, how a majority of physicians now support it, and how the Affordable Care Act, despite the gains it has achieved, has failed to resolve the health care crisis in the U.S. and has actually strengthened the hand of the for-profit sectors of health care, whose interests run counter to the nation’s health.

The audio of the entire program is available at http://awfradio.com/todays-show-3-30-16/. The first segment of the interview with Dr. Coates runs from the 17:20-minute mark to 27:30; the second segment, transcribed below, runs from the 30-minute mark to 54:38.

HOST ED ‘FLASH’ FERENC: [We’re speaking with] Dr. Andy Coates, Physicians for a National Health Program. He’s a professor of medicine at Albany Medical College. We’re here to talk about taking Medicare as you know it and expanding it to everybody in America. Now this is not a new system. Other countries have used this system that you’re talking about, that you’re supporting, and it’s working, right?

ANDREW COATES, M.D.: Indeed. Every other industrialized nation has some version of this system. We could talk about a program where the government owns all of the health care infrastructure and pays the caregivers – nurses, doctors, pharmacists, and so on – directly; that would be like the National Health Service in Scotland now or as it used to be in England. There are some other examples.

And there are systems like the Canadian, Taiwanese, New Zealand systems, where the government pays the bills but where the health care infrastructure remains privately owned and operated, but operated on a not-for-profit basis.

Then there are some hybrid models that came from the 19th century, where there is some version of “private insurance,” but the private insurance is usually – as in Germany or other European nations – where the private insurance doesn’t correspond to UnitedHealthcare, Aetna or the kind of insurers in the United States. It’s an insurance fund that came through religious health organizations or through the labor movement, unions, or from communities. These are heavily regulated and controlled by the government to make sure that everybody’s in, and nobody’s out. So to call those systems private insurance systems is really a misnomer.

So the way of organizing the payment of care is, in my view, the beginning of the way to organize the delivery of care. If you don’t have control over the elements that go into the system, then how can you make the system serve the people in the right way? It seems to me that in a modern democracy, health care being so essential to our lives, that we absolutely would have to have control over how everyone in the country has access to the best possible care. That would be a key responsibility of a truly democratic government.

HOST: So the plan that’s on the table right now, this is a piece of legislation that has been introduced, it’s House Resolution 676, it’s called the Expanded and Improved Medicare for All Act: I know it’s been introduced and reintroduced a number of times. John Conyers of Michigan is supporting it. It’s my understanding that there are about 60, maybe 70 members of the Congress that are behind it. It’s just a fraction – you’d need a whole lot more support. But you’re in favor of that bill, which would take essentially Medicare, the way we have it right now, and expand it to everybody – every man, woman and child in the United States – is that right?

COATES: Yes. The Medicare for All Act, or H.R. 676, is a very, very useful document. Listeners should look it up. It’s short; if you print it out, it’s about 30 pages – easy to read. It’s a blueprint of a system that we know, — from the great deal of health policy evidence, — would absolutely work. It would cover all necessary care, there would be no copays or deductibles.

By all necessary care, I’m taking about all prescription drugs – here, I’ll just read it to you: primary care and prevention, dietary and nutritional therapies, inpatient care, outpatient care, emergency care, prescription drugs, durable medical equipment, long-term care, palliative care, mental health services, the whole scope of dental services, including periodontics, oral surgery, and endodontics, but excluding cosmetic dentistry, substance abuse treatments, chiropractic services, not including electrical stimulation, basic vision care and vision correction (other than laser vision correction), hearing services, including coverage of hearing aids, and podiatric care.

So all necessary care. Many of these things are not presently covered by Medicare, so it would expand and improve Medicare.

And this idea would exclude charges due at the point of service by patients. And that’s very important. It’s been very popular for the last decade or so to talk about “skin in the game” – you know, making patients go shopping for care when they’re sick, as the way to drive down prices. This has become a talking point, and this is very much the kind of neoliberal nuttiness that led to the Affordable Care Act, which has the taxpayers subsidizing the private insurance companies. You know, the idea is that if people don’t pay for their care when they’re sick, then they won’t understand how things work. But it turns out that if people are asked to pay charges for necessary care, they will avoid necessary care. There’s a wealth of evidence that will show that, in all kinds of different ways.

So this bill, H.R. 676, will actually work for the patients, and it will take us in the direction that we need to go. On the one hand there’s a big question about how it would be paid for and I’d be glad to talk with you about that. But the other thing that I’d really like to talk to your listeners about is to think about what it would mean for our daily lives if we had a system like this.

HOST: Let’s start with No. 1, how we’re going to pay for it. Because you know the conservatives are going to say, “Oh, we can’t afford it.”

COATES: Well, it’s not just the conservatives. That’s what Hillary Clinton’s advisers have been yelling to the public too. I think that Hillary Clinton’s campaign has come out attacking this idea that we should have a national health program. Look – all of the existing – if you look at the taxpayer money in the United States that is funding health care right now – all of this calculated on a per-person cost basis, a majority of the care is already funded by taxpayers in the U.S. And if you compare the U.S. level of spending with all the other nations on the planet, the United States spends more taxpayer money on health care per person than any other nation spends in total. It’s an astonishing thing. On a per-person basis, we have more taxpayer money spent on health care than any other nation spends in total on health care.

So there’s plenty of money in the U.S. system already, plenty of taxpayer money. If the existing sources in our employer-based system – you know, the employers pay huge amounts into the insurance companies to cover their employees – I’m taking about the big employers that have the big plans, if that money were put into the system, there would be plenty of resources to cover everyone.

But more, there would be enormous savings of hundreds of billions of dollars because there’s an enormous amount of waste in having a myriad, a great big pile of insurance companies fighting over every penny – with the hospitals and doctors’ offices having many people, whole departments to fight for the money. Hospitals might have hundreds of coders and billers trying to fight for the money. There’s this incredible administrative waste, waste that comes down to chasing money in the system.  That would be eliminated, and so there would be hundreds of billions of dollars in savings there.

In addition, in the Conyers bill, H.R. 676, would convert the system to a not-for-profit basis. There’s a spectacular amount of waste in profits and profit-seeking. It might be difficult to make a hefty profit off the care of a sick person, but the effort to do so brings with it a great deal of administration. So when it comes to pharmaceutical prices and medical equipment, all kinds of efficiencies could be found in the system if there were only one payer – in other words, the pharma companies would have to bargain with the people over prices. So the savings in the single-payer system would be spectacular from that point of view, and could liberate all of those resources so we could cover everyone.

There’s also a myth that some of the uninsured and sick patients would come flocking into the system and that would burden the system unduly. It turns out that, for example, when Medicare was built, and that was when the elderly in the United States had no one to pay for their care, it wasn’t the case that patients overwhelmed the system.

Furthermore, the single payer, because now we’d have a way for every patient’s care to be compensated, we could plan to expand our health system – I think of some of the rural counties here in upstate New York that don’t really have hospitals or adequate clinics. Those places could now afford to have them. And so the expansion of care could take place could take place in a planned way.

HOST: If you think back to when Medicare was debated back in the ’60s – Medicare was instituted in 1965 under Lyndon Baines Johnson – the same arguments that you’re hearing today, “Oh, you can’t do that!” In fact, Ronald Reagan, as I recall, was one of the big opponents of Medicare. “It’s socialistic, they do that in communist countries, we can’t do that!” Now, if you ask a senior today what they thought of Medicare, they’d say it’s the best thing since sliced bread. So this would basically take Medicare and expand it to everybody. I tell you, we have a long way to go. We need to educate people on this. Let me ask you one more question before you go. Do you feel, as a doctor, as a medical professional, that eventually this is going to happen – because of the high cost of health care under the Affordable Care Act, that this is the only way to solve the situation of getting access to health care in America? What are your thoughts on that?

COATES: If the goal is to cover absolutely everybody, to make sure that all necessary care is attainable, so we don’t have the undesirable situation where many people are completely left out, lost to medical follow-up, not able to access the clinic … if the goal is to do that, and also to keep the costs from spiraling completely out of control, and to help control costs overall, then, this is the only system that’s going to work.

The other thing I’ve learned though, in my travels around over the last 10 years or so, talking to many different audiences – way beyond some kind of FOX News feature where there’s a phony debate about whether some people “deserve to die” of illnesses that they never asked for – I think virtually everyone believes that if you’re sick, you should be able to get the best possible care. It doesn’t matter if you live in the city or the countryside, if you’re wealthy or poor, in an African American community, Latino – it doesn’t matter.

HOST: Right.

COATES: Because that’s the way it should be. That’s what everyone understands, in some way. I hope what will happen, and I think what will happen, is what we’ll start to understand is how liberating it would be if we didn’t have to get health care through our employer, or through our spouse, or through our parents.

What it would mean to us if we didn’t have to worry about our children being unsafe, meaning without health care – getting out of high school and looking for work – at time of stress and insecurity for them, as they find their way? Imagine how liberating it would be for them not to have to worry about health care.

Imagine what it would mean for the union movement. It’s very hard to organize unions when the thought of a strike means they’ll discontinue your health insurance, and that means that your wife won’t have access, or for a working woman to keep her job because her husband ended up getting multiple sclerosis and she is afraid to leave, the “job lock” phenomenon.

Really, when it comes to health care, there are so many insecurities in our personal lives – for instance with a parent has to transition to nursing home because of a devastating stroke. This should not be a time when the whole family, I mean the expanded family, should have its finances decimated, with brothers and sisters, cousins all drawn into it because of one person’s health care crisis. This is really a terrible situation and undignified and all too common in the United States. 

But if you look at it the other way, how liberating it would be, how proud people would be of this country, if that were not an issue. Proud to know that the system would be there, ready for us, and the system was designed around the patients. I really think that’s completely attainable. I don’t think it’s that radical. I think it’s a very modest reform, if you will. It wouldn’t threaten anything – it would actually enhance life across the board. It would not only work but be a great thing for public pride.

HOST: There you go. Well said. If you want more information on this, here’s the website: pnhp.org, Physicians for a National Health Program. Dr. Coates, we love having you on the show. Let’s keep this conversation going. So maybe one of these days Congress will move forward and do the right thing.

COATES: Also, there are hundreds of unions that have endorsed H.R. 676 and it continues to be a great campaign. Let’s build the word of mouth about it in the union movement. We’re hopeful that the unions can show us the way forward.

HOST: So you keep up the fight, OK?

COATES: Thanks.

http://awfradio.com/todays-show-3-30-16/

By Laura Meckler
The Wall Street Journal, Aug. 16, 2016

Sen. Bernie Sanders, who mounted a strong challenge for the Democratic presidential nomination, said Tuesday that news that a major health insurer was pulling back its participation in the Affordable Care Act exchanges affirms the need for his single-payer, government-run program. He promised to introduce legislation creating “Medicare for all” again next year.

This week, Aetna Inc. said it will withdraw from 11 of the 15 states where it currently offers plans, the latest major national insurer to sharply pull back its participation.

Rather than minimizing the problem, Mr. Sanders cast Aetna’s decision is part of a trend.

“It is disappointing that Aetna has joined other large for-profit health insurance companies in pulling out of the insurance marketplace,” he said in a statement. “Despite the Affordable Care Act bringing them millions more paying customers than ever before, these companies are more concerned with making huge profits then ensuring access to health care for all Americans.”

He added: “The provision of health care cannot continue to be dependent upon the whims and market projections of large private insurance companies whose only goal is to make as much profit as possible.”

The statement makes clear that he intends to continue fighting for his agenda from the Senate, possibly in opposition to a future President Hillary Clinton.

The health exchanges have been attacked from the political right as too much government, but also criticized from the left as not going far enough. Throughout the Democratic presidential primary, Mr. Sanders argued that only a government-run system can guarantee affordable coverage for all. Former Secretary of State Hillary Clinton, who won the nomination, says more modest tweaks to the Affordable Care Act can address its shortcomings.

To win his endorsement, Mrs. Clinton also reiterated her support for a government-run insurance plan to compete with private insurers, but she has said little about that plan on the campaign trail.

http://blogs.wsj.com/washwire/2016/08/16/to-sanders-aetnas-pull-back-from-affordable-care-act-markets-shows-need-for-overhaul/

By Robert Reich
Common Dreams, Aug. 17, 2016

The best argument for a single-payer health plan is the recent decision by giant health insurer Aetna to bail out next year from 11 of the 15 states where it sells Obamacare plans.

Aetna’s decision follows similar moves by UnitedHealth Group, the nation’s largest insurer, and Humana, one of the other giants.

All claim they’re not making enough money because too many people with serious health problems are using the Obamacare exchanges, and not enough healthy people are signing up.

The problem isn’t Obamacare per se. It’s in the structure of private markets for health insurance –- which creates powerful incentives to avoid sick people and attract healthy ones. Obamacare is just making the structural problem more obvious.

In a nutshell, the more sick people and the fewer healthy people a private for-profit insurer attracts, the less competitive that insurer becomes relative to other insurers that don’t attract as high a percentage of the sick but a higher percentage of the healthy. Eventually, insurers that take in too many sick and too few healthy people are driven out of business.

If insurers had no idea who’d be sick and who’d be healthy when they sign up for insurance (and keep them insured at the same price even after they become sick), this wouldn’t be a problem. But they do know – and they’re developing more and more sophisticated ways of finding out.

It’s not just people with pre-existing conditions who have caused insurers to run for the happy hills of healthy customers. It’s also people with genetic predispositions toward certain illnesses that are expensive to treat, like heart disease and cancer. And people who don’t exercise enough, or have unhealthy habits, or live in unhealthy places.

So health insurers spend lots of time, effort, and money trying to attract people who have high odds of staying healthy (the young and the fit) while doing whatever they can to fend off those who have high odds of getting sick (the older, infirm, and the unfit).

As a result we end up with the most bizarre health-insurance system imaginable: One ever more carefully designed to avoid sick people.

If this weren’t enough to convince rational people to do what most other advanced nations have done and create a single-payer system, consider that America’s giant health insurers are now busily consolidating into ever-larger behemoths. UnitedHealth is already humongous. Aetna, meanwhile, is trying to buy Humana.

Insurers say they’re doing this in order to reap economies of scale, but there’s little evidence that large size generates cost savings.

In reality, they’re becoming very big to get more bargaining leverage over everyone they do business with – hospitals, doctors, employers, the government, and consumers. That way they make even bigger profits.

But these bigger profits come at the expense of hospitals, doctors, employers, the government, and, ultimately, taxpayers and consumers.

So the real choice in the future is becoming clear. Obamacare is only smoking it out. One alternative is a public single-payer system. The other is a hugely-expensive for-profit oligopoly with the market power to charge high prices even to healthy people – and to charge sick people (or those likely to be sick) an arm and a leg.

Robert Reich, one of the nation’s leading experts on work and the economy, is Chancellor’s Professor of Public Policy at the Goldman School of Public Policy at the University of California at Berkeley. He has served in three national administrations, most recently as secretary of labor under President Bill Clinton.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License.

http://www.commondreams.org/views/2016/08/17/aetna-shows-why-we-need-single-payer

By Shefali Luthra
Kaiser Health News, Aug. 12, 2016

One in five Americans is estimated to have a mental health condition at any given time. But getting treatment remains difficult — and it’s worse for children, especially those who identify as black or Hispanic.

That’s the major finding in research published Friday in the International Journal of Health Services. The study examines how often young adults and children were able to get needed mental health services, based on whether they were black, Hispanic or white. Using a nationally representative sample of federally collected survey data compiled between 2006 and 2012, researchers sought to determine how often people reported poor mental health and either saw a specialist or had a general practitioner bill for mental health services.

“No one is necessarily bigoted — and yet we have a system that creates the kind of discrimination we see in the paper,” said Steffie Woolhandler, a professor at City University of New York School of Public Health, and one of the study’s authors. “Kids are getting half as much mental health treatment — and they have the same level of mental health problems.”

Young people in general aren’t likely to see mental health specialists. But the numbers fell further when racial and ethnic backgrounds were factored in. About 5.7 percent of white children and young adults were likely to see a mental health specialist in a given year, compared with about 2.3 percent for black or Hispanic young people.

Put another way: Even when controlling for someone’s mental health status, insurance and income, black and Hispanic children saw someone for treatment far less often than did their white counterparts — about 130 fewer visits per thousand subjects. Black young adults visited a mental health specialist about 280 fewer visits per thousand; Hispanics had 244 fewer visits per thousand.

But the data indicate that mental illness incidence rates are generally consistent across racial groups, according to the study. Of adults between the ages of 18 and 34, between 4 and 5 percent indicated having fair or poor mental health, regardless of racial background. For children, white and black subjects were reported to need care at about the same rate — between 11 percent and 12 percent — compared with about 7 percent of Hispanic children.

The paper outlines a few possible reasons for this disconnect. Different communities may attach greater stigma about mental health care, or they may place less trust in the doctors available. Plus, there is a shortage of child psychiatrists across the country, and black and Hispanic families often live in the most underserved areas.

“There are problems of access all around,” said Harold Pincus, vice chair of psychiatry at Columbia University’s College of Physicians and Surgeons. “We have to change the way we do things.”

The findings suggest that lawmakers have focused on trying to improve access to mental health care, but “we can’t rest on our laurels,” said Pincus, who wasn’t affiliated with the study. He also noted that treating white children’s level of access as the golden standard is probably unwise, since research suggests they also receive inadequate care.

One of the study’s clear messages, argued Woolhandler, is that racial minorities received markedly less care — regardless of socioeconomic or health status. The gap suggests a targeted intervention is needed.

The study highlights a need to ensure doctors know how to counsel patients of different racial backgrounds and will do so, said Benjamin Le Cook, an assistant professor of psychiatry at Harvard Medical School, who was also not affiliated with the study. Ending racial and cultural disparities in access to care is a more pressing concern than erasing the stigmas about mental illness in minority communities, he said.

That’s especially relevant given minorities are less likely to be treated by doctors of their ethnicity. In addition, research suggests that mental health specialists sometimes discriminate based on race when seeing patients.

“It has to do with experiences people in the community have had that haven’t matched their expectations or aligned with problems they’re having,” LeCook said. “Cultural stigma is a factor, but not the main one.”

Beyond better training, more funds are needed for resources like community health centers, which often serve black and Hispanic patients, Woolhandler said.

“I see these great people trying to work in community mental health, but they need more resources to do their job,” she said.

But, the research doesn’t account for other areas where minorities may access mental health services, Pincus noted. Churches and social service agencies, for instance, may be filling some of the void and wouldn’t be accounted for by the survey data.

Researchers and policymakers should explore those sectors, he said, to see if they could be better leveraged to help people get connected to care they’ll actually trust. As experts try to bolster the mental health system — both to improve access across the board and also to close race-based gaps — they need to use a multipronged approach, pulling in different kinds of caregivers than those who might normally treat mental illness.

“There’s all kinds of ways by which the mental health system doesn’t play a role in helping people,” he said. “Family and community supports, social services — they’re all part of the picture.”

http://khn.org/news/race-ethnicity-affect-kids-access-to-mental-health-care-study/