By Joel A. Harrison, Ph.D., M.P.H.
August 10, 2018

Introduction

Our current fragmented, dysfunctional, for-profit health care system is broken. Internationally we rank poorly in both process and outcomes; yet, we are by far the most expensive health care system in the world. Not only we do we not get a bang for our bucks; but for many of us from a moral perspective we are morally bankrupt, allowing far too many people to suffer and die unnecessarily.

The solution is a non-profit single-payer healthcare system, Medicare for All, which has been proposed federally by Senator Bernie Sanders (2016), introduced in The House of Representatives as H.R. 676 (Wikipedia. National Health Care Act), and, for instance, in California as Senate Bill 562 (California Legislative Information, 2017; California OneCare, 2017; jpmassar, 2017; Morone, 2017; Pollin, 2017). The obstacles are enormous, basically going up against right-wing market ideology and legislatures bought and paid for by our for-profit health industry and their lobbyists. Whether federally or by state, the fact that obstacles exist does NOT change the fact that our current system is broken, that we are ALL at risk (e.g., Barlett, 2004; Brill, 2013).

We Are All At Risk

I could write an entire paper just documenting numerous cases where people who thought they were well-insured, discovered all too late they weren’t. The following are just a few examples:

1. Patient negotiates fees with surgeon, anesthesiologist, hospital, assuming assistant surgeon, as customary, will be paid by surgeon. Assistant surgeon bills $117,000 for 3-hour surgery and gets it (Rosenthal, 2014).

2. A woman doubled over with pain goes to emergency department at hospital. After multiple tests discovered not appendicitis; but ovarian cyst. Insurance company refused to pay as they determined wasn’t emergency. The person was supposed to diagnose herself, ultimately stuck with $12,596 hospital bill. I guess she could have waited, if appendix burst, well, that’s her bad luck. The policy of not reimbursing emergency room visits if turn out not be an emergency is growing (Kliff, 2018; see also: Abelson, 2018; Chou, 2018).

3. Between 33 percent and 80 percent of cancer survivors exhaust their savings to finance medical expenses. Up to 34 percent borrow money from friends or family to pay for care. For those who fall into debt, the level of debt is substantial. Bankruptcy rates among cancer survivors are 260 percent higher than among similar households without cancer (Ramsay, 2016).

4. “It’s not uncommon for patients who visit an in-network hospital to learn later that they’ve been treated by out-of-network providers, resulting in thousands of dollars in charges. And while the Affordable Care Act generally caps what consumers must spend out of pocket when using providers within their plan’s network, it doesn’t protect consumers from large bills from outside providers. Those providers may be free to charge the consumer for the balance of the bill that the insurer did not pay, known as ‘balance billing’” (Bernard, 2013).

5. “A long night spent struggling with what turned out to be a whooping cough infection left the Encinitas resident so exhausted that he fell and hit his head. He was taken to a hospital emergency department by ambulance. Doctors there recommended that he stay overnight for observation, a precaution to make sure he did not have a more serious injury. After leaving on Feb. 5, everything seemed fine until he received an $18,700 bill in the mail. He learned that, although he had spent the night in a bed at Scripps Memorial Hospital La Jolla, he was never technically admitted as an inpatient. Medicare pays less for observation stays than it does for people who are admitted, and Scripps was billing him for the remainder of the costs he incurred (Sisson, 2016).”

6. And, as a final example, an outrageous one, the treatment of 9/11 First Responders. Most were police or fire department employees, covered by insurance; yet, their insurances didn’t cover much of their care. Finally, Congress passed legislation 10 years later to cover them, though only certain conditions, too little too late for many who had already died and those remaining who had suffered. These were our heroes. If anyone deserved top quality care, it was them (Wikipedia. Health effects arising from the September 11 attacks).

Above is just the tip of the iceberg. Read on.

U.S. Health Care in International Comparisons

Given the power of the health insurance industry we are basically inundated with lies about other nation’s health care systems. International studies rank the U.S. poorly on numerous measures. Not only we rank poorly on infant mortality and life-expectancy; but on chronic conditions. For instance, diabetics do better in the United Kingdom (Mainous, 2006). The list goes on (Chen, 2016; Garrett, 2018; Harrison, 2018; Institute of Medicine, 2013; OECD, 2017; Sawyer, 2017; Schneider, 2017; Tikkanen, 2017). Statistics on cancer ranking the U.S. at the top are deceptive. We do much more screening than other nations, catching cancers at earlier stages, sometimes this is beneficial; but often just involves treatments that are costly and can even lower our quality of life (Wikipedia. Lead time bias; Wikipedia. Length time bias). Pap smears detect cell dysplasias (abnormalities). Most won’t progress to cancer. Prostate cancers are often so indolent that men will die years before they would have had an effect. Early interventions may save some lives; but result in infection, pain, impotence, and incontinence. According to the National Breast Cancer Coalition:

For every 2,000 women invited for screening over a 10 year period, one will have her life prolonged and 10 healthy women, who would not have been diagnosed if they had not been screened, will be treated unnecessarily. The evidence of a mortality reduction from screening is conflicting and continues to be questioned by some advocates, scientists, policy makers and members of the public. In fact, the absolute risk of a woman dying from breast cancer is less than 1% without any screening. Looking at this another way, 995.6 out of 1,000 50-year-old women will not die of breast cancer within the next ten years. This number rises to 996 out of 1,000 with regular mammography screening (National Breast Cancer Coalition, 2013; see also: Houssami, 2017).

The evidence is mounting that for those insured in the U.S., both over-diagnosis and over-treatment are often as threatening to our health as under-treatment of those who are underinsured or uninsured (e.g., Brownlee, 2007; Welch, 2011).

However, if the monies wasted on our current system were re-directed to actual treatment, where current interventions for cancer are advantageous, they would be covered. And, as discussed below, the data from a single-payer system has the potential to be used for improving health care.

Myths About Canadian Health Care

A recent article in The Atlantic stated if we were to adopt the Canadian health care system: “5,400 fewer babies would die in infancy, and we’d save about $1.3 trillion dollars in health care spending. . . And, perhaps as a result, more than 50,000 preventable deaths would be avoided.” The article does point out slightly longer wait times for non-emergency/urgent care; but this is based partly on their lower spending. If we were to maintain our current level of spending, this could be avoided (Khazan, 2014; Cecere, 2009). As a specific example. average life-expectancy for cystic fibrosis is 10 years longer in Canada than U.S. (Stephenson, 2017). On almost every measure of health care outcomes Canada does as well or better than the U.S. (Eisenberg, 2005; GAO, 1991; OECD, 2017; Robinson, 2008; Sawyer, 2017; Schneider, 2017; Tikkanen, 2017).

Canadians Seeking Health Care in U.S.: Of course Canadians get health care in the U.S. Most are either working here, attending university, touristing, or retirees wintering in Florida to escape the harsh Canadian winters. The same can be said of Americans falling ill or suffering injuries while abroad. In fact, “The U.S. Centers for Disease Control and Prevention has estimated that about 750,000 U.S. patients travel abroad each year for medical treatment. That’s a larger proportion of the U.S. population than even the highest estimates of Canadians seeking treatment abroad” (Martin, 2017).

However, the question is how many Canadians seek health care in the U.S. while residing in Canada and the answer is very few and many of these are for highly specialized health care, which, is often paid for by the Canadian single-payer health care system (Katz, 2002; Lee, 2016; McCann, 2014). Only a few years ago, the only place to receive a heart-lung transplant was Pittsburgh. Is that proof that health care everywhere else in the U.S. was deficient? It is more cost-effective with better outcomes for highly specialized care to have centers of excellence in areas such as heart surgery, cancer care, neonatal intensive care, and others, so Canadians seeking highly specialized care can seek it in the US or elsewhere in Canada, sometimes the travel distance is much shorter to the U.S. (Hillner, 2000; Luft, 1990; Jollis, 1997).

Exaggerated Wait Times: Exaggerated estimates of wait times come from studies by the Fraser Institute, a right-wing think tank with substantial funding from the Koch brothers and US Pharmaceutical Companies (Wikipedia. Fraser Institute). The Fraser Institute studies use a highly flawed methodology (McCann, 2014). Though wait times can be longer in Canada than in the US, that is, for Americans who are highly insured, there is NO evidence they compromise health outcomes. Emergency and life-threatening conditions are cared for within appropriate time parameters and over the past decade Canada has successfully implemented programs to reduce wait times for elective procedures, and the effort continues (Canadian Institute for Health Information, 2017; Health Council of Canada, 2011; Longhurst, 2016).

Canadian Doctors Moving to U.S.:  The number of Canadian doctors moving to the U.S. is actually quite small and many return to Canada (Canadian Health Services Research Institute, 2008; Freeman, 2016). And many American doctors are moving to Canada. Reasons include dealing with insurance company bureaucracies, “In the US, thanks to insurance company loopholes and technicalities, American family physicians aren’t paid up to 30% of the time, whereas under a single-payer system, only about 2% of billings aren’t covered . . .  Even referrals are a headache since insurance companies often pay only for specific hospitals and specialists” (Glausser, 2014). In Canada, doctors don’t have to worry about whether patients can afford care and can focus on their medical needs instead of their finances (CTVNews.ca Staff, 2015; Luthra, 2017; Palmer, 2017).

Though on most measures the Canadian Health Care System is superior to ours, international rankings place Canada above the U.S.; but below several other nations (Chen, 2016; Garrett. 2018; Institute of Medicine, 2013; OECD, 2017; Sawyer, 2017; Schneider, 2017; Tikkanen, 2017). According to 2015 data, $5,782 dollars per person (10.4% OF GDP) were spent by Canada, compared to the U.S. $11,916 (16.9% of GDP) (Canadian Institute for Health Information, 2018). According to Palmer (2017):

No system is perfect but that said, the Canadian system has the framework and the organization to be able to solve what problems exist and to solve the health care problems for Canadians. That structure doesn’t exist in the US. And that’s a big problem. ‘What we have in place in the United States is a structure that is chaos. There are multiple insurance companies, multiple payers all acting under different rules that they set for themselves. Also acting under the premise that a virtually unregulated free market can effectively and efficiently [deliver] health care – and that’s just not true. Health care is just not a field in which a free market works well.’ (Palmer, 2017)

For more about the Canadian health care system and innovations that could improve it, innovations easier to carry out in a single-payer system, see Rachlis, 2005.

Funding, Cost, and Administrative Waste

According to a recent 2018 Milliman Research Report, the cost to a family of four for an average employer-sponsored preferred provider organization plan is $28,166. Since inflation has been minimal, comparing the 2016 data from the United States Census Bureau which found the median income for families with four people to be $90,746, the cost of health care, on average is greater than 30% of total income (Garrett, 2018; Girod, 2018; Institute of Medicine, 2013; OECD, 2017; Papanicolas, 2018; Schneider, 2017; Tikkanen, 2017; United States Census Bureau, 2017, Table F-8: Size of Families).

If one includes Medicare, Medicaid, VA, Military, Tricare for military families, Indian Health Service, health insurance for employees of all levels of government, and health insurance covered by contract with companies doing business with various levels of government, approximately 65% of health care in the U.S. is funded through taxes (Harrison, 2008). As a percent of GDP this equals the next most expensive health care systems which cover everyone with high quality care. Over 10% of doctor office and hospital costs involve the excess administration necessary to deal with multiple payers (Casalino, 2016; Himmelstein, 2014; Ubel, 2016) and at least 20% of health care costs go to for-profit health insurance companies, including bloated salaries, stock dividends, and administrative bureaucracies (Frakt, 2018). An average doctor devotes 15 hours per week to the excess paperwork demanded by our fragmented, dysfunctional, for-profit system, hours that could be devoted to actual patient care. Much of the equipment in hospitals and especially rural hospitals is paid for by Medicare and Medicaid (Alexander, 2018; Ross, 2018). And Medicare pays for residency training of specialists (Rampell, 2013). It is impossible that the 30% or more of health care dollars that go to excess administration and profit could deliver equal or better care than if the monies were actually directed to health care (Harrison, 2008). In fact, the current system limits our choices, delays care in many cases, forces people to choose between seeing doctors and/or buying medications or paying basic necessity bills. And Illness and medical bills contribute to a large and increasing share of US bankruptcies (Dobkin, 2018; Himmelstein, 2005; Himmelstein, 2009; Sanger-Katz, 2018). So, basically, we pay for our healthcare through our taxes and then pay again both monetarily and health-wise. As for Medicaid, one paper found that some insurance companies are reaping spectacular profits off the taxpayer-funded program in California, even when the state finds their patient care is subpar (Terhune, 2017).

Given the excess administrative costs built into our healthcare system (Frakt, 2018), by just removing these, the costs of hospital stays and other medical costs will be substantially reduced. Just one absurd example should be enough, according to Professor Uwe Reinhardt: “We have 900 billing clerks at Duke. I’m not sure we have a nurse per (each) bed, but we have a billing clerk per bed…it’s obscene (Putsch, 2008).” However, a non-profit single-payer system will actually provide a global budget for hospitals based on a careful analysis of their operations, so, the risk of hospitals closing is pure propaganda from the for-profit industry, not a valid claim.

In other nations sick and injured people and their loved ones can focus on getting better. In the US we are deluged with bills, paperwork, and fighting with insurance companies, a never ending nightmare just when we are at our most vulnerable (Rice, 2018). A non-profit single-payer system WILL NOT COST MORE THAN OUR CURRENT SYSTEM. IT WON’T INVOLVE NEW DOLLARS. People don’t understand that “benefits” included with our jobs are really part of our total compensation (Heathfield, 2018; New Mexico State Personnel Office, 2014). Whether an employer offers health insurance or not affects our salaries. In the past few years wage increases have flattened out and/or changes in health insurance, premiums and deductibles have grown. So, remove the employer from the equation and have a modest percentage of income, smaller than our share of premiums, covering our entire families, with no deductibles and copays, NO PAPERWORK. By rolling Medicare, Medicaid, and a percent tax on incomes, similar to the current taxes for Social Security (FICA) and Medicare, into one system, we could achieve universal coverage with access and choice determined by us and for the vast majority costing less than our current system. Additional sources of revenue have been proposed, such as a modest tax on financial transactions (Friedman, 2013; Friedman, 2017a; Friedman, 2017b; Sanders, 2016). Of course, given the power of the insurance lobby, Washington may refuse; but the money is there and we should fight for it.

We are the only health care system in the world designed first and foremost to make a profit, not to care for people. In the past few years, for instance in California, health care costs have increased by 240% compared with 40% for the Consumer Price Index (California Health Care Foundation, 2017; Huffman, 2017). In no way can the introduction of newer technologies come close to explaining this. In fact, one study found after adjustment for price inflation, 50% of the increase could not be explained by increases in population size, aging of the population, changes in disease prevalence or incidence, or service utilization (Dieleman, 2017).

Extortionist Level Drug Pricing

The recent scandal of raising Epipen prices to $800 is just one example. But even the original $400 for a packet of two Epipens was outrageous given they cost between an estimated $8 – $30 for a two-pack and sell in the UK for $69. In fact, the Epipen was developed for our military (Bloomberg, 2016; Mangan, 2016; Nutting, 2016; Ramsey, 2016; Seipel, 2017; White, 2016). Numerous studies have shown that claims by pharmaceutical companies of the cost of developing new drugs are grossly exaggerated (Light, 2011; Medecins Sans Frontieres, 2014; Prasad, 2017; Public Citizen, 2001; Public Citizen, 2017; Relman, 2002). In fact, over 95% of the basic research is funded by the government and even 50% of new classes of drugs (Light, 2005). The pharmaceutical industry is among the most profitable industries, only equaled by banks; but outdistancing carmakers, oil and gas, and media (Anderson, 2014).

The FDA’s patent of a drug creates a monopoly.

A monopoly exists when a specific person or enterprise is the only supplier of a particular commodity. . . Monopolies are thus characterized by a lack of economic competition to produce the good or service, a lack of viable substitute goods, and the possibility of a high monopoly price well above the seller’s marginal cost that leads to a high monopoly profit (Wikipedia. Monopoly).

The object of patents is to encourage research and innovation in order to benefit the public. The public is certainly does NOT benefited from extortionist level prices and profits. A single-payer health care system will be able to negotiate drug prices, allowing reasonable, not extortion level profits.

In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act. Billy Tauzin, as chair of the U.S. House Committee on Energy and Commerce, which oversees the drug industry, played a key role in shepherding the bill through Congress, including prohibiting the government from negotiating lower drug prices and banning the importation of identical, cheaper, drugs from Canada and elsewhere. Even with bargaining the pharmaceutical industry would have increased profits from the addition of a large number of people able to purchase drugs; but greed has no bounds. Tauzin resigned from Congress after the bill was passed and became head of the Pharmaceutical Research and Manufacturers of America at a salary estimated at $2 million per year. Does this raise any red flags (Ludwig, 2015; Wikipedia. Medicare Prescription Drug, Improvement, and Modernization Act)? The VA, Kaiser Permanente, Blue Cross, everyone else pays less for drugs than Medicare because they can negotiate. In fact, some drugs are actually cheaper if purchased directly from a local pharmacists, bypassing the profits and additional administrative costs from the Pharmacy Benefits Managers created by the bill (Ornstein, 2017). Gag orders often prohibit a pharmacist from discussing pricing with customers (Pear, 2018). By negotiating prices the Medicare donut hole could be eliminated (Congressional Budget Office, 2007a; Consumer Union, 2006; Families USA, 2007; Gaffney, 2018; Health Markets, 2018; Light, 2012; Light, 2013).

Complete Coverage, Dental, Home Health Care, Nursing Homes

A non-profit single-payer system will also include dental care, home health care, nursing homes and skilled nursing facilities. Poor painful teeth lead to poor nutrition which affects our diet which affects overall health. It affects our self-image, our ability to concentrate, our productivity, whether as students or workers, and, of course increases the need for health care (CDC, 2018). Quality home health care, allowing people to stay in their homes, is both cheaper than nursing homes and maintains a better quality of life (Ball, 2018; Gerace, 2011; NPR, 2018). With global budgets, nursing homes will have the requisite number of trained health care providers rather than employees in billing offices. Currently new hospitals are being built where each patient will get his/her own room. We could do the same for nursing homes. Just because one is infirm shouldn’t mean the loss of privacy and dignity. We could have such a system given that the monies now going to profits and bloated salaries for administrators, even for non-profit nursing homes, would go to actual care (Zimmerman, 2011).

Good For Business

A non-profit single-payer system will reduce job lock. Currently, many talented individuals are stuck in jobs that are not a good match because they need to maintain health insurance. Imagine some talented individuals wanting to start their own firm, one has a chronic health condition or ill child, the cost of health insurance for individuals or small firms would either be prohibitive or come with high deductibles and copays, not leaving monies for investing in the company, so they stay with their current company (Baker, 2015). Health insurance reduces the competitiveness of American companies in international competition, both upping the overall production costs and devoting time and energy in negotiating yearly insurance contracts for employees. Especially small businesses, the backbone of our economy and largest employer overall, are negatively affected by our current system. If one chooses to ensure its employees, the increased costs put it at a disadvantage against those who choose not to (Johnson, 2012; Leenson, 2017; Reinhardt, 1989).

Why Should Immigrants, including Undocumented, Be Covered?

For those opposed to undocumented aliens receiving health care, numerous studies have found that they contribute significantly to our economy and pay taxes. In fact, an Institute of Medicine study estimated the productivity loss to our economy due to lack of insurance at up to $130 billion in 2000 and if insured the cost of care at up to $69 billion, both would be much higher today (Institute of Medicine, 2003). The Institute of Medicine series of studies on the effects of uninsurance included immigrants, both documented and undocumented (Institute of Medicine, 2009). So, it costs our economy more to not insure everyone. If injured on the job, a job contributing to our economy, shouldn’t they receive care? More importantly, despite President Trump’s push to build a wall, it would be virtually impossible to eliminate them, so, we risk exposure to infectious diseases, e.g., in restaurants, day care centers, in elevators, etc. If not a moral obligation, then enlightened self-interest should prefer they be treated rather than remain contagious (Congressional Budget Office, 2007; Edsall, 2016; Federal Reserve Bank of Dallas, 2003). Not only immigrants use disproportionately less medical care than their representation in the U.S. population would indicate (Goldman, 2006); but they actually contribute to Medicare’s solvency (California Healthline, 2015; Flavin, 2018; Zallman, 2013).

Surveys have shown that the majority of Americans support a non-profit single-payer health care system; but only if it doesn’t include illegal immigrants (Rasmussen, 2009). U.S. law requires providing emergency care to anyone (Wikipedia. Emergency Medical Treatment & Labor Act). Unfortunately, the uninsured “receive fewer needed services, worse quality care, and have a greater risk of dying in the hospital or shortly after discharge,” even from trauma care (Institute of Medicine, 2002).  And as the number of uninsured increases, the quality of health services in a community decrease (Institute of Medicine, 2009).

Besides the fact that they have contributed to the system, besides the risks of infectious diseases, besides the immorality, besides the effects of uninsured on availability of quality care in a community, denying care to anyone lacking proof of insurance could put us all at risk in an emergency. Imagine you suffer a heart attack or an injury and have no proof of insurance. The uninsured get less follow-up care, so their risk of another emergency is high. So, besides the immorality, it isn’t rational to be against a program that will benefit us and our loved ones just to ensure that others don’t benefit as well, enlightened self-interest.

Healthcare Doesn’t Meet the Assumptions of a Market Model

Healthcare DOESN’T fit into a market-based system, regardless of how hard those who profit from it at our expense try to fit a square peg into a round hole (Arrow, 1963). Market economics require “free” access to information and, of course, the ability to evaluate it; but how many of us with cancer understand the basics of medicine, can evaluate peer-reviewed journal articles, know how to search the literature, even have the time or ability to focus when ill? And if in a car accident or suffering a heart attack, how many will be able to call around to various emergency departments to price shop? And how would one even price shop, not knowing once there what will be necessary (e.g., Mehrota, 2017)? And, as explained above, we already pay through our taxes what covers everyone in several other nations with a high level of quality care. It would take a separate article just to explain why health care doesn’t fit in market economics. And how does 65% of health care costs from tax dollars fit into a free market model? One excellent book explains the basic assumptions of a market model and why health care just doesn’t fit into it:

Thomas Rice (2015). “The Economics of Health Reconsidered,” Fourth Edition. Health Administration Press. Used copies of earlier editions are available on Amazon marketplace at reasonable prices. The basics don’t change between editions, just more up-to-date examples, and criticisms of earlier editions are dealt with.

Non-Profit Single-Payer is NOT Socialized Medicine

A non-profit single-payer system is NOT socialized medicine. It is Medicare for All. Delivery of health care will be by non-profit hospitals and clinics and private practicing physicians. Rather than choosing an insurance plan, if possible, or taking that offered by ones employer, one will be able to actually choose the hospital, clinic, and health care practitioner, without being locked into any network determined by the profit motive of health insurers. Unfortunately, all too often words like “socialism” are used to arouse emotions that stop people from further investigating a policy. Socialism DOES NOT apply to a non-profit single-payer healthcare system, though, as the saying goes: “A lie told often enough becomes the truth.” I have lived in both Sweden and Canada. Swedish healthcare is socialized medicine. Facilities, hospitals and clinics, are owned and run by the government and medical personnel are salaried, except for dentist who operate private practices. In Canada, hospitals and clinics are privately owned and physicians work in private practices. Dental and long term care are not universally covered; but some Provinces do cover them for specific groups, e.g., dental care for children and seniors and home health care and nursing homes for seniors. International studies show both systems superior to ours; but, given American culture, a non-profit single-payer system would be more acceptable.

Non-Profit Single-Payer is NOT a Ponzi Scheme

A non-profit single-payer system is NOT a Ponzi, pyramid, scheme transferring money from the young to the old and sick. A pyramid scheme is one-way, those at the top benefit and those at the bottom lose (Wikipedia. Ponzi scheme). A single-payer system is more like a revolving door, first one is outside, then inside. All of us will eventually grow old and at some time in our lives suffer injury or illness and none of us can be held responsible for our genetics, a roll of the dice. Young people do suffer injuries, cancer, and other illnesses. If they are uninsured, they still receive at least emergency care and, thus, we pay for it. As discussed above, the level of care will be less. By removing the excess administrative costs and profits, our parents, grandparents, and others are covered as we will be in turn. When I was in elementary school, my father’s taxes paid into the system as did others. Even when he was unemployed I continued with my education. When I became an adult, my taxes paid into the system so that the next generation of children would be educated and I gladly did this despite having no children of my own (Reuss, 2012).

Potential Health Services Research, Improved Care

Despite literally billions of dollars spent on medical and pharmaceutical research, problems still exist, including grandfathered interventions. Questions regarding which interventions for which conditions work still exist. Even with the absolute best clinical trials, the risk of rare but serious side-effects will not be found. Our drug laws allow any drug, once approved by the FDA for one condition, be used “off-label” by physicians for any condition. Sometimes the off-label use of a drug really does work; but often it doesn’t. We don’t know how many physicians prescribe an off-label drug for a specific condition, how many discontinued its use due to lack of efficacy or side-effects, nor even if improvements followed, if one could attribute them to the off-label drug or other factors. Circa 20% of all drug sales involve off-label use which adds to our overall cost of health care (Carr, 2017; GAO, 2008; Orac, 2012; Wikipedia. Off-label use). With a non-profit single-payer system, either one standardized database for entry of all patient demographics, conditions, and treatments or a linking system for several already existing databases, has the potential to improve healthcare by assigning teams to investigate everything from surgeries to drugs, FDA approved usage as well as off-label, and vaccines. Numerous large studies have found that the risk from vaccines is minuscule compared to benefits (CDC, 2017); but having data for literally all children could allow one to look at any rare increased risk from “pre-existing conditions” and assuage the fears of parents reluctant to vaccinate their children. Of course, strong laws and enforcement will need to be developed to protect patient confidentiality; something not well-protected with employer-based health insurance.

Conclusion

Sooner or later all of us will face injury or illness. No system is perfect and there will always be anecdotes of one or a few cases where failures occurred. Unfortunately, as with the red flag of labeling something as “socialist,” anecdotes play on our emotions and we fail to ask the question: “Compared to what?” For every anecdote about a case example of poor care in a Western technologically advanced nation offering universal health care, whether single-payer or socialist, one can find a far greater number in the U.S. A non-profit single-payer health care system ensures that we will be able to choose our doctors and hospitals, get the highest quality of care, without fighting with insurance companies, without being inundated with paperwork, and without worrying about finances. In addition, regardless of our employment, our families will be covered.

The choice is simple: Do we continue to fund through our taxes a system to enrich a few or adopt a non-profit single-payer system that numerous international studies have shown to cover everyone at a high level of care?

Joel A. Harrison, Ph.D., M.P.H., a native San Diegan, is a retired epidemiologist. Dr. Harrison has lived and studied in both Canada and Sweden. Dr. Harrison has been a long-time supporter of a non-profit single-payer health care system/Medicare for All and a strong supporter of vaccinations wherein he has, as a volunteer, been writing articles for Every Child by Two, a nonprofit founded in 1991 to promote vaccinations. You can find his articles here and here.

References

Note that I use Wikipedia in the references. I only do this if the Wikipedia article includes references that I have checked out. Thus, rather than listing even more references, this supplies a convenient shorthand.

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By Steffie Woolhandler, M.D., M.P.H., David U. Himmelstein, M.D., and Adam Gaffney, M.D.
The Nation, August 10, 2018

Last week, Charles Blahous at the Koch-funded Mercatus Center at George Mason University published a study suggesting that Bernie Sanders’s single-payer health-care plan would break the bank. But almost immediately, various observers—including Sanders himself—noted that according to Blahous’s own estimates, single payer would actually save Americans more than $2 trillion over a decade. Blahous doubled down on his argument in The Wall Street Journal, and on Tuesday, The Washington Post’s fact-checker accused Democrats of seizing “on one cherry-picked fact” in Blahous’s report to make it seem like a bargain.

The Post is wrong to call this a “cherry-picked fact”—it’s a central finding of the analysis—but it is probably right that single-payer supporters shouldn’t make too much of Blahous’s findings. After all, his analysis is riddled with errors that actually inflate the cost of single payer for taxpayers.

First, Blahous grossly underestimates the main source of savings from single payer: administrative efficiency. Health economist Austin Frakt aptly demonstrated the “bewildering complexity of health care financing in the United States” in The New York Times last month, citing evidence that billing costs primary-care doctors $100,000 apiece and consumes 25 percent of emergency-room revenues; that billing and administration accounts for one-quarter of US hospital expenditures, twice the level in single-payer nations; and that nearly one-third of all US health spending is eaten up by bureaucracy.

Overall, as two of us documented recently in the Annals of Internal Medicine, a single-payer system could cut administration by $500 billion annually, and redirect that money to care. Blahous, in contrasts, credits single payer with a measly fraction of that—or $70 billion—in administrative savings.

Our profit-driven multi-payer system is the source for this outlandish administrative sprawl. Doctors and hospitals have to negotiate contracts and fight over bills with hundreds of insurance plans with differing payments rates, rules, and requirements. Simplifying the payment system would free up far more money than Blahous estimates to expand and improve coverage.

Next, Blahous lowballs the potential for savings on prescription drugs. He assumes that a single-payer system couldn’t use its negotiating clout to push down drug prices, ignoring the fact that European nations and the US Veterans Affairs system achieve roughly 50 percent discounts relative to the US private sector. (Single payer’s only drug savings, he argues, will come from shifting 15 percent of brand-name prescriptions to generics.) Hence Blahous foresees only $61 billion in drug savings in 2022, even though tough price negotiations would likely achieve threefold higher savings.

Third, Blahous underestimates how much the government is already spending on health care. For instance, he omits the $724 billion that federal agencies are expected to pay for employees’ health benefits over the 10 years covered by his analysis, which would simply be redirected to Medicare for All. He also leaves out the massive savings to state and local governments, which would save nearly $3.6 trillion on employee benefits and another $5.3 trillion on Medicaid and other health programs. Hence, much of the “new money” needed to fund Sanders’s reform is already being collected as taxes.

Yes, there will need to be some new taxes—albeit much less than Blahous estimates. But those new taxes would just replace—not add to—current spending on premiums, co-pays, and deductibles. Additionally, at least some of the new taxes would be virtually invisible. For instance, the $10 trillion that employers would otherwise pay for premiums could instead be collected as payroll taxes. Similarly, Medicare for All would relieve households of the $7.7 trillion they’d pay for premiums and $6.3 trillion in out-of-pocket costs under the current system.

It’s easy to get lost in the weeds here. But at the end of the day, even according to Blahous’s errant projections, Medicare for All would save the average American about $6,000 over a decade. Single payer, in other words, shifts how we pay for health care, but it doesn’t actually increase overall costs—even while providing first-dollar comprehensive coverage to everyone in the nation. The Post’s fact-checker is wrong: Single-payer supporters can and should trumpet this important fact.

Of course, the most important benefits of single payer are altogether invisible in economic analyses like the one performed by Blahous. No matter what injury or illness we faced, we would be forever freed from one great worry: the cost of our care. It’s hard to put a price tag on that kind of freedom. Yet, paradoxically, even the slanted analysis of a libertarian economist provides evidence that it would be fiscally responsible.

Steffie Woolhandler is a Distinguished Professor of Public Health at the City University of New York at Hunter College.

David U. Himmelstein is a Distinguished Professor of Public Health at the City University of New York at Hunter College.

Adam Gaffney is a pulmonary and critical care specialist at the Cambridge Health Alliance and Harvard Medical School, and President-elect of Physicians for a National Health Program.

https://www.thenation.com…

By Dylan Scott
Vox, August 10, 2018

The muscle of the health industry lobby — pharma, health plans, doctors, and hospitals — is gathering to stop single payer.

The Hill’s Peter Sullivan had the report on Friday morning. The industry’s influence can’t be underestimated: It stopped Clintoncare. And, for better or worse, it was a boon for passing Obamacare that the industry mostly supported the legislation.

The industry’s disparate interests fight over a lot of issues, but Medicare-for-all unites them. That is going to be a factor if we get to 2021 with a Democratic Congress and president, and they decide to pursue single-payer health care.

That moment really might come. A sign times are changing: A Republican health care lobbyist called me recently to ask whether all-payer rate setting would be a better alternative to single payer, by causing less disruption. (I quibbled that you would need some kind of coverage component, given the moral urgency that is animating the left on health care.)

Still, a Republican almost endorsing price controls. That is a pretty strong indicator of where our health care debate seems to be heading.

Payment cuts for health care providers, if we eliminate private insurance and move everybody to Medicare rates, are going to come up a lot in this debate.

Those cuts are an easy thing for industry lobbyists to target and for Republicans to run ads on. Cuts could be overstated, depending on how much legitimate waste single payer can actually eliminate by consolidating the administration of health care, but the projections for Medicare for All plans are going to anticipate big cuts.

That explains the industry’s lobbying position. But reality on the ground is more complicated than that. There are absolutely health care providers who support single payer. Quite a few of them sent me emails after I asked for their thoughts last week.

Here are some of the most interesting responses. From a registered Republican working at a next-gen gene sequencing company:

Medicare is, without question, the most reliable, most predictable payer that we deal with. And for somebody like me it would be a dream to only have to deal with them. Yes, they are pretty heavily regulated. And yes, they have pretty strict guidelines for who to cover. But unlike other payers, who make life virtually impossible for smaller providers because they’re in the for-profit game (the not paying for care game), Medicare at least adheres to a clear set of rules. Other payers put up an endless set of traps against reimbursement, contracting, and other parts of the revenue life cycle that add substantial cost to services and thus increase cost to the consumer. I can say with near certainty that parties in my industry would provide services at a materially lower price and with more predictable out of pocket costs if every payer was as reliable and consistent as Medicare.

As such, I’m now, despite growing up a conservative afraid of such government largesse as “Medicare for all,” convinced that a single public payer, either as rate setter or as a true single payer, is needed. In contrast, I remain a staunch defender of private medical care, where companies such as my own and our competition do battle to increase quality and lower patient cost.

So I guess you could count me as pro-Medicare for all, a sentence I never thought I’d write 15 years ago.

From a retired neurosurgeon, who had also thought of himself as a Republican:

I practiced neurosurgery in Texas and retired 20 years ago. I started out as a pretty solid, but non-thinking, Republican, opposing perceived intrusions of Medicare into my practice. I read Himmelstein and Woolhandler’s NEJM articles and thought they were Harvard hippie Communists. Over time, I came to see that they were right, that we really need a universal health care system, as so many of my patients weren’t getting needed care. I was a bit embarrassed making as much money as I did, and would have done it for half of that.

From a radiation oncologist of more than 20 years, in Chicago and for the military:

I left full-time medicine a few years ago after getting fed up with continuously fighting insurance companies for pre-authorization and for the right to practice medicine the way I was trained within the standard published guidelines. I now work part-time seeing primarily uninsured and Medicaid patients.

A 2011 Health Affairs study found that the average US physician spends nearly $83,000 a year interacting with insurance plans. And a 2010 American Medical Association Study found the average doctor spent 20 hours a week on pre-authorization activities. This has only gotten more expensive and much worse. Under a single payer plan, this would be much easier and far less expensive.

In addition, we know that the major cost of malpractice coverage is for the continued medical care of the patient that was harmed. A single payer system would insure that any such patient would be covered for the rest of their lives and as a result, malpractice coverage would also be dramatically lower.

While reimbursement under a single payer plan most likely would be less, so would the headaches and administrative hassles and costs. And I would be able to see far more patients instead of being on the phone fighting with a case manager, while my office and malpractice coverage costs would be far less.

From a Texas oncologist still early in their career:

My general view of Medicare-for-all is that it would moderately contribute to remedying our health care spending problem, but by no means fix it.

My understanding is that the biggest savings would come from getting rid of the huge administrative dead weight in our private insurance system. However, that in and of itself would not fix the fact that billing rates are through the roof here in the US. Saving a few percent on overhead would be great, but MRIs and appendectomies are still going to cost 2x-4x here than in other OECD countries.

I am definitely heterodox among physicians in believing that our salaries (mainly among specialists such as myself) ought to be significantly lower. The greater bargaining power that a single, government payer might have could potentially rein in some of that.

On the other side, from an anesthesiologist intern in Chicago, fiscally liberal but socially conservative, who has some concerns about how single payer would handle Catholic hospitals:

The one part of a more single-payer system that worries me relates to the socially conservative opinions I have. I’m sure you have seen the series FiveThirtyEight has had the past week on the effects of Catholic hospitals coming to predominate more rural areas and even some cities. (As someone who grew up in a small town, I can say the main health care provider in the area is a Catholic hospital.) I don’t fear a single-payer system would result in individual providers being required to provide services they individually oppose for religious beliefs.

However, I do worry about whether or not there would be requirements for Catholic hospitals to provide services contrary to Catholic teaching, generally surrounding abortion or end of life care, in order to be eligible for billing Medicare. I do presume a Medicare-for-All system would pass on a party-line vote with only Democrat support and could see them trying to expand abortion coverage–either directly in a law or through regulation like many abortion coverage issues have been changed–at the same time since that issue has also grown much more partisan in the past decade.

https://www.vox.com…

By Leo Eisenstein, B.A.
New England Journal of Medicine, August 9, 2018

The clinician who coined the term “burnout” was not a primary care physician buried under paperwork, nor an emergency physician beset by an unwieldy electronic health record. He was Herbert Freudenberger, a psychologist working in a free clinic in 1974.¹ Discussing risk factors for burnout, he wrote about personal characteristics (e.g., “that individual who has a need to give”) and about the monotony of a job once it becomes routine. He also pointed to workers in specific settings — “those of us who work in free clinics, therapeutic communities, hot lines, crisis intervention centers, women’s clinics, gay centers, runaway houses” — drawing a connection between burnout and the experience of caring for marginalized patients.

In recent years, burnout has become a chief concern among physicians and other front-line care providers. But somewhere along the way, the concept was separated from its original free-clinic context. The link between marginalized patients and clinician burnout seems to have gotten lost.

As a fourth-year medical student, I have received ample warning about the sources of burnout: death by a thousand clicks, too many hours at work, feeling like a cog in a machine, too many bureaucratic tasks. As a newcomer to medicine, I feel intimidated by it all. But from what I’ve observed — both during medical school and before enrolling, when I spent several years working in safety-net clinics — Freudenberger’s free-clinic context points to another source of burnout that receives insufficient attention. It is the experience of caring for patients when you know that their socioeconomic and structural circumstances are actively causing harm in ways no medicines can touch.² As medical students, we are educated about the social determinants of health and increasingly warned about burnout, yet little is made of how the former may contribute to the latter — for example, how clinicians may feel worn down by the poverty and oppression their patients face; may feel powerless when they cannot offer more than, say, a form letter to a landlord explaining that turning off a patient’s heat would be deleterious to her health; and may feel demoralized when they realize that their instruction “Do not take this medication on an empty stomach” translates into patients taking their medications only sporadically because they don’t have enough to eat.

This contributor to burnout is not unique to physicians’ work. In medical school, though, I’ve seen an additional problem that may make it especially painful: we are led (and allow ourselves) to believe that we as individuals have more power than we do. Despite a shift toward team-based care, the image of physicians as singular heroes, as saviors, remains deeply embedded in medical culture.³ To many people, the white coat and the prescription pad represent the highest form of individual agency, the very picture of social power. But eventually, a physician will encounter patients whose health problems derive from a wicked, multigenerational knot of poverty and marginalization, and even the most astute, excellent physician may well find herself outmatched. Facing patients’ adverse social circumstances as an individual clinician is a recipe for disillusionment: the physician who believed she was maximizing her individual agency comes to feel utterly powerless. No longer the lone hero — just alone.

In this link between social determinants of health and burnout, I see a problem, but also a way forward. If individual powerlessness is the crux of this source of burnout, then organizing toward collective action should be part of the solution. Each of us can advocate for our homeless patients to be put on waiting lists for public housing. But what would happen if all doctors with homeless patients organized to demand more affordable housing?

Organizing is both strategic and therapeutic — strategic because our collective labor and voice are greater than the sum of their parts; therapeutic in the sense that the activist Grace Lee Boggs articulated: “Building community is to the collective as spiritual practice is to the individual.” When we recognize ourselves not as individual actors each isolated in an exam room, but as a collective joined in common cause, we start to feel less alone.

Some researchers have asked whether physician advocacy should be seen as a professional obligation or an aspirational goal.⁴ For me, the link between physician burnout and patient marginalization changes the terms of this debate. Beyond whether we must or should do it for our patients, collective advocacy to address the harmful social determinants of health can buoy physicians’ morale and thus be an act of self-care; organizing toward collective action means looking after both our patients and ourselves.

You have probably heard this parable before: A group of friends comes upon a fast-moving river where they find people drowning. The friends jump in headlong to save as many people as they can. But the drowning people keep coming. As soon as the friends rescue one, another comes into view. Eventually, one friend starts heading upstream. Another, exhausted, yells after her: “Where are you going?” The first one says, “I’m going to find out what’s throwing all these people into the river.”

The classic reading is that this parable is about prevention, but it also points to how upstream determinants contribute to burnout. Here is, I imagine, what happened to the friend who headed upstream: she saw the unending flow of drowning people coming their way. She deduced that there must be some force, hidden around the bend, that was sending people to drown. She noticed herself and her friends getting exhausted, all on the brink of burnout from the urgent, unending work. So she mobilized her friends to go upstream, for the drowners’ sake and for their own.

Obviously, it is not new for front-line clinicians to get fed up, organize, and start heading upstream. It’s what happened when physicians built collective-action organizations like Physicians for Social Responsibility and Physicians for a National Health Program; it’s what happened when clinicians joined the Moral Mondays demonstrations in North Carolina to fight for Medicaid expansion; and it’s what happens every Sunday morning in Boston, when residents and attendings, faced with an overdose epidemic, organize with the group SIFMA NOW to advocate for supervised injection facilities as a harm-reduction strategy.

In SIFMA (Supervised Injection Facilities–MA) NOW, health professionals organize side by side with harm-reduction advocates and people who use drugs. The group enables participants to build solidarity and take action in an otherwise overwhelming crisis. Dinah Applewhite, a resident at Massachusetts General Hospital, reflected at a recent meeting on how organizing can be a balm for her as a physician: “Despite my best efforts in clinic, I’ve had too many patients overdose, get endocarditis, or contract hepatitis C or HIV from unsafe injection practices. Being part of a community of advocates empowers me to fight for solutions to this crisis. It means that I’m energized and grounded, rather than burnt out, by these preventable tragedies.”

The social determinants of health — and physicians’ sense of powerlessness in the face of them — seem crucially missing from the discussion of burnout. This kind of burnout is the feeling you get when you’re trying to rescue the drowning people but they keep coming. And you’re torn between competing exigencies: the proximal needs of the people drowning, and the distal need for naming, fighting, and demanding accountability for the upstream forces that are causing harm.⁵ Medical students are trained to think from a vantage point of individual agency, and we become stuck there: “What can I do?” begins as an earnest, ambitious question, but it so often spoils to a cynical one. If medical schools and residency programs are serious about burnout, they have to teach us about collective action — teach us to ask, “What can we do?” To fight burnout, we should never worry alone about the social determinants of health that patients face. To fight burnout, organize.

https://www.nejm.org…

References

1. Freudenberger HJ. Staff burn-out. J Soc Issues 1974;30:159-165.

2. Hood CM, Gennuso KP, Swain GR, Catlin BB. County health rankings: relationships between determinant factors and health outcomes. Am J Prev Med 2016;50:129-135.

3. Berwick DM. Moral choices for today’s physician. JAMA 2017;318:2081-2082.

4. Gruen RL, Pearson SD, Brennan TA. Physician-citizens: public roles and professional obligations. JAMA 2004;291:94-98.

5. Krieger N. Proximal, distal, and the politics of causation: what’s level got to do with it? Am J Public Health 2008;98:221-230.