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By David Woods
The Philadelphia Inquirer, May 16, 2016

One hears these days mutterings by disaffected Americans that if Donald Trump becomes president, they will pack their bags and leave for Canada. One assumes, of course, that no wall will be built along the border to thwart their exit.

I made the reverse trip. Having emigrated from Britain to Canada, where I became the editor in chief of the Canadian Medical Association Journal, I opted to come to the United States in 1988 for personal reasons.

But I was also taken with American rugged individualism and a health-care system focused on market forces and competition. I wrote articles for the Economist Intelligence Unit and other periodicals on the wonders of the American system. In print, I debated longtime advocates of single-payer national health insurance, extolling the virtues of the health-care market that others abhorred.

Gradually, though, I too began to have doubts about market-driven health care. Over the 25 years that I’ve lived on the U.S. side of the border, I’ve come to the view that the American health-care system – which still leaves 11 percent of the population uninsured, despite the Affordable Care Act – is inferior to the health systems in Canada and the United Kingdom.

One of the ACA’s architects, Dr. Ezekiel Emanuel, describes the U.S. health system as a “terribly complex, blatantly unjust, outrageously expensive, grossly inefficient, error-prone system.” Unfortunately, that’s still true, six years after the ACA’s passage.

The reform didn’t address the fundamental problem in U.S. health care: It’s more about profit than patients.

Controlling health-care costs is essential to the long-term financial health of the United States. A single-payer system would make truly universal coverage affordable, costing no more than we already spend on health care. Of the $3.1 trillion the United States will spend on health care this year, 63 percent is taxpayer-financed, funding Medicare, Medicaid, and Veterans Affairs, along with private coverage for government employees and tax subsidies for employers.

Because of its fragmented, profit-driven system, the United States spends 18.1 percent of gross domestic product on health care, compared with about 8 percent in Britain and 11 percent in Canada. Much of U.S. health spending is simply wasted. For example, 25.3 percent of hospital expenditures go to administrative costs, compared with 12.4 percent in Canada, where there is a single payer in each province and hospitals are mainly funded on a global or lump-sum basis.

Canadians also save money by training a higher percentage of primary-care doctors relative to specialists, negotiating drug prices with pharmaceutical companies, and prohibiting drug companies from advertising directly to consumers. These measures would save Americans billions annually. Americans spend $1,010 per capita on pharmaceuticals; Swedes spend less than half that, according to the Organization for Economic Cooperation and Development. The reason? Sweden doesn’t pay the list price.

Lobbying and influence-peddling by the pharmaceutical and insurance industries keeps the United States from adopting a single-payer health system. Several presidential candidates this season seemed completely under their hypnotic sway. The private insurance industry brazenly tells me, now a U.S. voter, which doctors I can see, charges me astronomical premiums, not to mention co-pays and deductibles, and then wants me to believe that having publicly funded health care that would allow me to go to any doctor in the United States without a $5,000 deductible would be “socialism.”

And don’t believe the widely held U.S. notion that Canadians suffer long waits for care. That’s a canard. We are not going to cut U.S. health spending to Canadian levels. With our much higher level of spending, waits would not be an issue, even with the population aging. Japan and many countries in Europe already have higher percentages of elderly citizens than the graying of the baby boomers is projected to produce.

In his book “In Search of the Perfect Health System,” British economist Mark Britnell notes that the British love their single-payer National Health Service because of its fairness; it’s available to everyone. He even quotes a former U.K. finance minister who said that the NHS is the closest thing the English have to a religion. Their single-payer system keeps quality indexes up and costs down for the population at large. This enables the British to invest additional funds in education and economic stimulation, areas that also contribute to health and well-being.

The United States should take a lesson from the example of nations with single-payer systems. They offer a measure of hope and optimism that high-quality health care can be the right of all Americans, if they demand it.

David Woods is a former editor in chief of the Canadian Medical Association Journal. hmi3000@comcast.net

http://www.philly.com/philly/health/20160516_Commentary__Single-payer_essential_to_controlling_health-care_costs.html

At a time doctors to the south are looking to Canada for answers, we are at risk of losing the health advantage we have

By Karen Palmer
Toronto Star, May 15, 2016

In a dramatic show of physician support for deep health care reform in the U.S., more than 2,200 physician leaders have signed a “Physician’s Proposal” calling for sweeping change.

The proposal, published May 5 2016 in the American Journal of Public Health, calls for the creation of a publicly financed, single-payer, national health program to cover all Americans for all medically necessary care.

If that sounds familiar, it should. These American doctors are calling for Canadian-style medicare. They want a decisive break from the expensive and inefficient private insurance industry at the heart of the U.S. health care system.

How ironic that at the same time U.S. physicians are calling for a single-payer health system like ours, Canada is in the midst of a legal battle threatening to pave the way for a multi-payer system resembling what has failed Americans.

What’s at stake? A trial about to begin in British Columbia threatens to make the Canada Health Act unenforceable.

The Canada Health Act is federal legislation that guides our health care system. It strongly discourages private payment for medically necessary hospital and physician services covered under our publicly funded medicare plans. This includes out-of-pocket payments in the form of extra billing or other user charges. Legislation in most provinces further prohibits private insurance that duplicates what is already covered under provincial plans.

If patients are billed for medically necessary hospital and physician care, the federal government is mandated to withhold an equivalent amount from federal cash transfers to provinces or territories violating the Act.

At least that’s what supposed to happen.

Unfortunately, the last decade saw a proliferation of extra billing in several provinces, and few instances of government clawing back fiscal transfers. Perhaps, things will change. Health Minister Jane Philpott recently said the government will “absolutely uphold the Canada Health Act.”

In B.C.’s upcoming trial, the plaintiffs — including two for-profit investor-owned facilities, Cambie Surgery Centre and the Specialist Referral Clinic — are attempting to have the court strike down limits on private payment. They support the creation of a constitutionally protected right for physicians to bill patients, either out-of-pocket or through private insurance, for medically necessary care, while also billing the public plan.

In other words, the plaintiffs want to undo our elegantly simple single payer system for hospital and physician care, creating instead a multi-payer system like the U.S. If their constitutional challenge is successful, the door will swing wide open in BC — and across Canada — for insurers to sell what will amount to “private queue jumping insurance” for those who can afford it, potentially harming the rest of us who can’t.

The outcome of this trial could be that those who can pay for care would jump the queue, drawing doctors and other resources out of the public system. Those who can’t pay would likely wait longer. Rather than a solution for wait times, private payment in the Canadian context would make them worse.

Global evidence shows that private insurance does not reduce public system wait times. The Achilles heel of health care in several European countries, such as Sweden, has been long waiting times for diagnosis and treatment in several areas, despite some private insurance. After Australia introduced private insurance to save the government money, those with private insurance have faster access to elective surgery than those without. Divisions in equitable access to care is one of the biggest challenges now facing countries that have adopted multi-payer systems.

Multi-payer systems are administratively complex and expensive, explaining why the U.S. health insurance industry spends about 18 per cent of its health care dollars on billing and insurance-related administration for its many private plans, compared to just 2 per cent in Canada for our streamlined single payer insurance plans. Hospital administrative costs are lowest in Canada and Scotland — both single payer systems — and highest in the U.S., the Netherlands, and the U.K. — all multi-payer systems.

For all of its warts in how we deliver health care in Canada, the way in which we pay for care — a single public payer in each province or territory — avoids the high administrative costs of multi-payer systems.

Abundant evidence shows private insurance is at the root of what ails the U.S. system. Dr. Marcia Angell, co-author of the Physicians’ Proposal, Harvard Medical School faculty and former editor-in-chief of the New England Journal of Medicine, sums it up: “We can no longer afford to waste the vast resources we do on the administrative costs, executive salaries, and profiteering of the private insurance system.”

A Canadian-style single payer financing system would save the U.S. about $500 billion annually.

Meanwhile, in Canada, abandoning our single payer health care system for a U.S.-style multi-payer system would be the worst possible outcome for Canadians. Let’s hope the evidence convinces the judge. The trial begins in September.

Karen Palmer is an advisor with EvidenceNetwork.ca, a health policy analyst, and adjunct professor in the Faculty of Health Sciences at Simon Fraser University.

https://www.thestar.com/opinion/commentary/2016/05/15/why-american-doctors-are-calling-for-canadian-style-medicare.html

By Steffie Woolhandler & David U. Himmelstein
The Hill, Congress Blog, May 12, 2016

Many months before Bernie Sanders entered the presidential race, we (along with Dr. Adam Gaffney, an energetic younger colleague, and Dr. Marcia Angell, the former editor of the New England Journal of Medicine) convened a nonpartisan group of 39 leading physicians to envision health care reforms that would fix the glaring problems that remain despite the Affordable Care Act (ACA).

After the Supreme Court removed the final roadblock to the law in 2015, President Obama declared that at last “in America, health care is not a privilege for a few, but a right for all.” Yet doctors on the ground knew that wasn’t entirely true. We continue to see patients who dangerously delay their care because of cost concerns or insurance obstacles.

At least 27 million Americans remain uninsured, and for tens of millions with insurance, sky-high copayments and deductibles (which average $5,300 in the bronze plans sold on the ACA exchanges) mean they’d be bankrupted by a serious illness. Many more people have narrow network coverage that won’t pay for care at top cancer centers or academic hospitals.

Meanwhile, giant insurers and hospital conglomerates with a single-minded focus on their bottom line increasingly dominate health care. And doctors and nurses contend with insurers’ growing demands for mind-numbing electronic documentation. These trends predated the ACA, but the law accelerated them. The ACA has also fueled medical merger-mania and the health system’s administrative complexity and cost.

The alternative we and our colleagues developed (which has now been endorsed by 2,227 other physician colleagues) appears in the current issue of the American Journal of Public Health. It calls for radical change: a single-payer national health program, essentially an expanded and improved version of Medicare for all, much along the lines that Bernie Sanders has advocated.

The single-payer plan we propose would cover everyone for all medically necessary care – including dental care, prescription drugs and long-term care – without copayments or deductibles. In contrast to private insurers’ narrow networks that restrict patients’ choice of doctors and hospitals, the single payer would cover care from any doctor or hospital.

Our nation can readily afford such expanded and improved coverage if we replace the current wasteful patchwork of insurers with a streamlined single-payer system. At present, private insurers’ take 12.3 percent of total premiums for their overhead; only 88 cents of every premium dollar ever reaches a doctor, hospital or pharmacy. And insurers inflict massive paperwork on doctors and hospitals, which spend about one-quarter of their revenues on billing and administration.

In contrast, insurance overhead is only 1.8 percent in Canada’s single-payer system, about the same overhead as in our Medicare program. And Canadian hospitals have administrative costs less than half those of their U.S. counterparts. That’s because Canadian hospitals are paid annual global budgets, like U.S. fire departments, instead of billing separately for each Band-Aid and aspirin tablet. Billing is also simple and inexpensive for Canadian physicians.

Overall, a single payer would save about $500 billion annually by trimming administrative spending to Canadian levels. Moreover, as in other nations, the single payer could use its purchasing power to lower drug prices, saving tens of billions more each year. These savings could fully cover the new costs of the coverage expansions we propose, a conclusion in keeping with past estimates by the Government Accountability Office, the Congressional Budget Office, and private consulting groups (including one that’s owned by an insurance company).

Contrary claims, including those contained in a report published by the Urban Institute this week, are fraught with flawed assumptions and grossly underestimate the savings a single-payer system would assure.

We and our colleagues recognize that, despite widespread public support for Medicare for all, passage of our proposal is unlikely absent sweeping changes in the makeup of Congress. But the same can be said about any salutary health reform; Congress has resisted even modest tweaks to the ACA.

Yet as physicians we feel obliged to offer our best advice. Our health care crisis can be solved. We have the resources needed to provide excellent care for all Americans; an abundance of hospitals and sophisticated equipment; superbly trained doctors and nurses; prodigious research output; and generous health care funding. Yet only thoroughgoing single-payer reform can realize the healing potential that is currently thwarted by our dysfunctional health care financing system.

The authors are internists who teach at the City University of New York at Hunter College and Harvard Medical School. They co-founded Physicians for a National Health Program, a nonpartisan organization that advocates single-payer reform.

http://thehill.com/blogs/congress-blog/healthcare/279508-doctors-single-payer-prescription-for-health-care-reform

PNHP note: This article, with many hyperlinks included, was also published at The Huffington Post on May 18.