The Best Way to Save Obamacare

By Jacob S. Hacker
The New York Times, October 27, 2016

The Affordable Care Act has faced a rocky six months. First, major national insurers scaled back their participation, leaving about one in five people buying coverage through health exchanges with only one plan to choose from. Then this week, the Obama administration announced that exchange plans would post an average premium increase of more than 20 percent (though most enrollees would be insulated from the full increase by subsidies for their coverage).

As someone involved in the debate over the Affordable Care Act from the start, I don’t find these unhappy events all that surprising. From the outset, I’ve argued that without a public option — a Medicare-like plan that would be available to all Americans buying health insurance — insurance competition would dwindle and premiums would skyrocket. Now that they have, it’s time to do now what we should have done then: take the simplest route to a more stable and affordable health care system.

Critics of the public option are convinced it’s a one-way ticket to single payer (the government alone provides coverage). History suggests the opposite: The public option isn’t a threat to a system of broad coverage through competing private plans. Instead, it’s absolutely critical to making such a system work.

We’re already heading toward single payer in sections of the nation — only it’s a private plan doing the paying. Next year, five states will have only one insurer in their exchanges, the online marketplaces set up to allow uninsured Americans to buy subsidized coverage. Nine more states will have just two insurers.

The diminishing number of choices doesn’t just hurt consumers; it also makes it harder for regulators to use antitrust tools to push back against this consolidation. Who wants to be the official accused of causing an insurer to leave the exchanges? It’s a perverse equation: As the number of insurers goes down, the leverage they have over regulators goes up.

These problems are what motivated proposals for a public option in the first place. Major parts of the country lacked enough insurer competition to keep costs in line, especially with rapidly consolidating providers. And the proposed alternatives to a public option, like the insurance “co-ops” eventually included in the 2010 law, did not have the bargaining power and reach that a Medicare-like plan would have (and most of them have since gone out of business).

The argument by public-option supporters wasn’t that it would or should replace private insurance. It was that having a public plan as a benchmark and backup was essential to make competition among private plans work. The models we have of successful competing health plans have a public or quasi-public option. That’s true in Medicare, where private plans operate alongside the traditional program. And it’s true in the federal employees’ health system, where a majority of enrollees choose Blue Cross-style nonprofit plans that are overseen by the government to ensure they remain viable.

Having a public plan alongside private plans won’t merely ensure that everyone has a choice. It will also pull more people into the system, creating a broader pool for all the plans. In polls conducted in 2009 and 2010, substantial majorities of Americans said they would feel better about being required to have coverage if they had the choice of a public plan.

A public plan is attractive in part because it can offer a broader network of providers. As exchange plans increasingly move toward very narrow networks, this would be another enormous draw — especially for more affluent consumers who have so far shunned the exchanges.

The public plan can also improve the overall system. Medicare has pioneered innovations in reimbursement, and it has improved hospital quality by imposing new penalties for readmissions. A public option could build on these breakthroughs and extend them to Americans under Medicare age.

The biggest advantage of the public plan, however, is its greater ability to restrain prices. As rapidly as the insurance market is concentrating, medical providers are consolidating faster, driving up prices and creating huge differentials even within regions. Medicare hospital reimbursements vary much less — and they’re typically much lower. As a result, Medicare has experienced slower per-person cost growth than private plans, particularly in recent years.

On the other hand, private plans are much better poised to develop integrated systems that closely monitor outcomes for a smaller circle of providers. Just as in Medicare, public and private plans can complement each other as they compete.

The public option is an ambitious policy. But it’s not hard to explain or advocate for — Americans love Medicare — and it has the potential to build powerful grass-roots support. Pressure from a coalition of left-leaning groups led by the Progressive Change Campaign Committee (a group that fought for the public option in 2009) has encouraged 33 Senate Democrats, including the party’s leadership, to call for a public option. President Obama has started advocating for it again, and Hillary Clinton has embraced it.

Republicans have actually shown how it can be done. Changes in Medicare pushed by President George W. Bush in the 2000s created more competition between public and private plans and guaranteed a fallback public option for prescription drug coverage.

This year, Senate Republicans, providing another lesson, passed legislation that repealed the Affordable Care Act through the budget process, which isn’t subject to a filibuster. (President Obama vetoed it.) If that’s possible under the budget rules, creating a public option should be, too — especially since it could reduce the deficit by tens of billions of dollars a year.

If things keep going as they are, Americans are certain to demand greater regulation of private plans to make them operate more like public plans. Instead, we should make them compete with a public option.

Jacob S. Hacker, a professor of political science and director of the Institution for Social and Policy Studies at Yale, is an author of “American Amnesia: How the War on Government Led Us to Forget What Made America Prosper.”

http://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Jacob Hacker deeply believes in a better America for all of us. As a political scientist, he understands the difficulties of moving the process in that direction. During the health care reform process, he recognized the lack of political feasibility of enacting a single payer Medicare for all program, but, with good reason, he decided that a public option – offering the option to purchase Medicare instead of private insurance – was feasible. In fact, it almost happened. Since so many problems still exist six years after enactment of the Affordable Care Act (ACA), we should listen to Jacob Hacker to see what he has to recommend.

First, let’s go back and look at the process that led up to ACA. The dysfunction in our system had become unbearable – runaway costs, too many uninsured and underinsured, preventable financial hardship and physical suffering continued – something had to be done. The policy and political communities understood the superiority of single payer Medicare for all, but the politics were polarized. It was decided that the feasible approach would be for the Democrats, who were in control, to lead by supporting the Republican proposal of building on the existing system. Although the progressive community initially was disappointed, they decided that the only feasible approach was to join the (ACA) bandwagon, especially when it included the public option that many thought would eventually transform into a single payer system once the public realized how much better government insurance was compared to private insurance. Although the process emasculated the public option, one Senator was able to block it altogether.

Fast forward to today. After six years, the feasible approach has not turned out so well. Yes, many more now are covered, but little realized how much insurers could still innovate, for their own benefit, in a more regulated environment. To make premiums affordable, plans had to be offered with a lower actuarial value – accomplished by increasing the deductibles and offering credits and subsidies for lower income individuals (which left middle income individuals more exposed to medical debt). But many did not realize the rapidity and intensity with which the insurers would jack up the deductibles. And now the policy of high deductibles is corrupting the part of the market they were trying to protect – the employer-sponsored plans. Also they wanted to protect the “gains” of managed care, which really is not much more than negotiating lower rates for provider panels in exchange for granting them exclusivity. Once again, most did not anticipate the rapid move to ultra-narrow networks that serve the insurers so well while impairing access for their enrollees. Higher deductibles and narrow networks can hardly be described as successes of ACA since most people are worse off.

So now we are again facing the same political dilemma. Do we embark on a process to establish single payer Medicare for all, or do we take the politically feasible route of enacting a public option which would fix our system by requiring private insurers to complete with a vastly superior public plan, or so they would have us believe? Well, the decision has already been made. The progressive community is already totally on board with the public option. The tragedy is not so much that on this path we will end up with a public plan that will be only one more feeble player in the dysfunctional market of private plans, but rather that we will, once again, have walked away from single payer, perhaps for decades, because of this meme about lack of political feasibility.

So let’s look more closely at what Jacob Hacker has to offer in his truly sincere effort to cure our health care system.

* From the outset, I’ve argued that without a public option — a Medicare-like plan that would be available to all Americans buying health insurance — insurance competition would dwindle and premiums would skyrocket.

The insurance industry’s control of Congress would prevent a public option that could out-compete the private plans. Our traditional Medicare program is already being out-competed by the private Medicare Advantage plans because Congress has continued to support policies that give the private plans an unfair advantage while rejecting measures that would provide the much-needed expansions in the currently deficient package of Medicare benefits. That’s why Medicare must be improved before we consider it as a program for all of us.

* Critics of the public option are convinced it’s a one-way ticket to single payer (the government alone provides coverage). History suggests the opposite.

Currently we are being inundated with threats from the conservatives that if we enact a public option it will lead to the left’s dream of a single payer system. Yet the progressives have jumped on board precisely because they believe a public option will lead to their dream of a single payer system. Yet Hacker now says that history suggests the opposite. He says that the public option is not a threat to a system of competing private plans. Will the progressives really be satisfied with perpetuation of the current dysfunctional system as long as the few who buy their plans through the exchanges will be able to choose a feeble public option?

* We’re already heading toward single payer in sections of the nation — only it’s a private plan doing the paying. Next year, five states will have only one insurer in their exchanges.

Yes, so many plans have pulled out that there is only one private insurer left in many of the exchanges. But it is sad to see Hacker characterize these lonely private plans as single payer when the highly dysfunctional multi-payer system remains in place. He understands the single payer model better than most, yet his passion for the public option model drives him to play rhetorical games that glibly dismiss the true meaning of single payer (though he may actually be threatening the conservatives with this bastardized form of “single payer”).

* The diminishing number of choices doesn’t just hurt consumers; it also makes it harder for regulators to use antitrust tools to push back against this consolidation.

Politicians and the policy community are fixated on market competition as a means of controlling costs, yet Nobel laureate Kenneth Arrow half a century ago explained to us how markets do not work in health care. The United States has relied more on markets than other nations and we have the highest costs that has only brought us mediocrity. A publicly administered single payer system is much more effective at controlling costs throughout the system.

* A public plan is attractive in part because it can offer a broader network of providers.

Can it? Since the public option is just another player in a market of private plans, it would be funded by premiums rather than taxes. As the provider panels are increased the premiums would have to be increased since they can no longer offer exclusivity, making the public option less competitive, not to mention that broader panels would be attractive to patients with greater needs. Death spiral?

* Medicare has pioneered innovations in reimbursement, and it has improved hospital quality by imposing new penalties for readmissions. A public option could build on these breakthroughs and extend them to Americans under Medicare age.

Current Medicare innovations such as ACOs, MACRA, MIPS, and APMs have not proven to be very effective and are causing grief amongst the health care professionals. Besides, private insurers also adopt Medicare innovations, but only those that have been proven to be effective.

* The biggest advantage of the public plan, however, is its greater ability to restrain prices.

If the differential between public and private prices is too great, providers will reject the public programs in favor of the private. Many physicians will not accept Medicaid payments because of the low payment rates, especially specialists. Having a ticket to a public option is not very helpful if there is no one there to care for you.

* Pressure from a coalition of left-leaning groups led by the Progressive Change Campaign Committee (a group that fought for the public option in 2009) has encouraged 33 Senate Democrats, including the party’s leadership, to call for a public option. President Obama has started advocating for it again, and Hillary Clinton has embraced it.

Point made on the contention that the progressives are jumping on board.

* This year, Senate Republicans, providing another lesson, passed legislation that repealed the Affordable Care Act through the budget process, which isn’t subject to a filibuster. (President Obama vetoed it.) If that’s possible under the budget rules, creating a public option should be, too.

If a public option can pass only by squeaking it through in the reconciliation process, that doesn’t say much for expecting broad support in a divided Congress and a divided nation.

* If things keep going as they are, Americans are certain to demand greater regulation of private plans to make them operate more like public plans. Instead, we should make them compete with a public option.

Uwe Reinhardt has frequently said that a system of competing private plans – like they have in Switzerland – can work if they are very heavily regulated. Yet an OECD/WHO report on the Swiss system revealed that they still have many of the problems that we have in the United States. So keeping private plans in the system is still a problem. Instead of making them compete with a public option, we should get rid of them and establish our own single public plan.

Feasible? Is it really better to just give up and perpetuate uninsurance, underinsurance, high costs, high deductibles, narrow networks, inequities, financial hardships, impaired access, and more physical suffering and even deaths? What’s not feasible about trading all that in for a system that works?

Let’s Treat Our Patients, Not Trick Them with Private Insurance

By Emily Kirchner
Common Dreams, October 27, 2016

This Halloween, medical students are refusing to endorse the horrifying for-profit healthcare system as it exists

A few days ago, I was studying a medical diagram in a coffee shop when a man in his mid-forties walked in. His face was red, he was sweating, he looked upset.

“Please, can anyone help me?” he asked. “My daughter is at Children’s Hospital for seizures and she needs medicine. My credit card is maxed out. I need $16.50.”

A few weeks ago, I was listening to a friend describe a Pennsylvania Insurance Department hearing on proposed rate hikes for marketplace health insurance premiums.

“One insurance company representative actually asked the department to consider the health of the company,” he said. After this hearing, all six insurance firms received rate increases, often more than the rate increases they had requested.

A few months ago, I was standing in the operating room. The attending surgeon was instructing the resident about how to deal with a patient who had insurance difficulties.

“Well, the patient is going to say, ‘My insurance says they won’t pay for it,'” he said. “You say, ‘That’s not my problem. I gave you my advice.'”

Before you dismiss the coffee shop encounter as a panhandler pestering customers, consider that we live in a country where some medications have unaffordable copays, that many people go without needed medicines, and that people often have to make a choice between seeing the doctor and paying their utility bill.

Before you dismiss the big premium increases by pointing to Obamacare’s subsidies, consider that we live in a country where insurance firms helped write the Affordable Care Act, that millions of people remain uninsured despite the ACA, and that copays and deductibles are sharply rising.

Incidentally, the “health of the company” is not the kind of health I give a damn about.

Before you dismiss the attending surgeon’s callous attitude as difficult reality in a changing practice environment, consider that our current inefficient health care system harms patients, that doctors spend hours of their time demanding necessary tests and procedures from health insurance corporations that deny medical care because it threatens their bottom line, and that burnout contributes to hundreds of physician suicides each year.

This picture is horrifying. So horrifying that medical students like me believe that this Halloween is the perfect time to once again focus attention on our fractured health care system.

Our message: Private health insurance is a trick. We just want to treat our patients.

Our demand: An improved, expanded, “Medicare for all” national health program. It’s the only way to provide affordable, quality care for everyone.

Students for a National Health Program (SNaHP) is sponsoring the Second Annual Medicare-for-All National Student Day of Action on October 31, dubbed #TreatNotTrick. More than a few of us will be wearing Halloween costumes.

The actions are co-sponsored by the American Medical Student Association, the Latino Medical Student Association, White Coats for Black Lives, and many regional and local groups.

In Boston, students will host a public demonstration and call-in asking Rep. Mike Capuano to sign on to the single-payer bill, H.R. 676. In Ohio, medical students will visit Sen. Sherrod Brown and ask him to sponsor a Senate single-payer bill. In Philadelphia, students will rally and memorialize the lives lost to uninsurance and underinsurance with a candlelight vigil.

From California to Minnesota to Tennessee, no less than 33 medical schools are hosting campus events, rallies, lobby visits and demanding attention for improved, expanded Medicare for All right before the November elections.

This Halloween, medical students are refusing to endorse the horrifying system as it exists. We will don our white coats and witches hats, publicly and politically demanding the ability to #TreatNotTrick. Join us.

Emily Kirchner is a medical student at Lewis Katz School of Medicine at Temple University. She is a student member of the Board of Directors of Physicians for a National Health Program, and is also active in Students for a National Health Program.

http://www.commondreams.org…

SNaHP – Students for a National Health Program
https://student.pnhp.org

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Comment:

By Don McCanne, M.D.

It can be a perpetual downer to read, week after week, month after month, year after year, about the health care injustices that characterize the most expensive yet most dysfunctional health care system in the industrialized world – ours. That is why it is a very refreshing break to read what our medical students are doing. They are the future of health care in America. We’ll be in good hands.

The Slowdown in Employer Insurance Cost Growth: Why Many Workers Still Feel the Pinch

By Sara R. Collins, David Radley, Munira Z. Gunja, Sophie Beutel
The Commonwealth Fund, October 26, 2016

Abstract

Issue: Although predictions that the Affordable Care Act (ACA) would lead to reductions in employer-sponsored health coverage have not been realized, some of the law’s critics maintain the ACA is nevertheless driving higher premium and deductible costs for businesses and their workers.

Goal: To compare cost growth in employer-sponsored health insurance before and after 2010, when the ACA was enacted, and to compare changes in these costs relative to changes in workers’ incomes.

Methods: The authors analyzed federal Medical Expenditure Panel Survey data to compare cost trends over the 10-year period from 2006 to 2015.

Key findings and conclusions: Compared to the five years leading up to the ACA, premium growth for single health insurance policies offered by employers slowed both in the nation overall and in 33 states and the District of Columbia. There has been a similar slowdown in growth in the amounts employees contribute to health plan costs. Yet many families feel pinched by their health care costs: despite a recent surge, income growth has not kept pace in many areas of the U.S. Employee contributions to premiums and deductibles amounted to 10.1 percent of U.S. median income in 2015, compared to 6.5 percent in 2006. These costs are higher relative to income in many southeastern and southern states, where incomes are below the national average.

Employee Premium Contribution and Deductible as Percent of Median Household Income

2006 – 6.6%
2010 – 8.4%
2015 – 10.1%

From the Conclusion

But the findings also offer evidence as to why many insured Americans view their health care costs as unaffordable. While growth in employee premium contributions have slowed along with premiums, deductibles continue to proliferate and their annual growth rate exceeds premium growth by a wide margin. Compounding this trend, growth in median family incomes — despite a recent surge — has lagged health insurance cost growth. Middle-income families continue to see a growing share of their household budgets going to health care. Where employees have less generous health plans as well as lower median incomes, the combination is particularly toxic. People with high deductibles relative to income are far more likely to avoid getting needed care than those with more affordable out-of-pocket costs. For those who do get health care, large medical bills can quickly exceed assets.

http://www.commonwealthfund.org…

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Comment:

By Don McCanne, M.D.

With all the talk this week about double-digit percentage increases in premiums for plans offered in the ACA exchanges, there is risk that this report my be lost in the background, though, for most Americans, this report is of far greater importance. For employer-sponsored health plans – where most individuals receive their health coverage – the percentage of household income used to pay premiums and deductibles has increased sharply in the last decade – from 6.6% to 10.1%.

To quickly dismiss the concern about premium increases in the ACA exchanges, although the average increase will be about 25%, of the 10.5 million enrolled only about 1.5 million in the exchanges will see the full increase since the others will be protected by premium subsidies. It may also impact the 7 million who buy individual plans outside of the exchanges. That 8.5 million combined is about 2.7% of the population, though most will have the option to shop for lower premium plans. Besides, these increases do not represent health care inflation but are rather due to intrinsic defects with the business model of competing private health plans. Healthier individuals are less inclined to enroll, making the risk pools more expensive, but it is likely that the greater factor was the insurers low-balling the initial premiums in an attempt to gain greater market share (though they will never admit this).

In contrast, about 154 million people – 57% of the U.S. population under 65 – obtain their insurance through their work – a far larger group than those who buy plans on the exchanges. But look at what is happening to them. Their share of insurance costs are consuming an ever larger percentage of their incomes. This financial burden on the typical working family is great enough to prevent them from receiving some of the essential health care services that they should have – impairing access due to lack of affordability.

Note that this is not due to the Affordable Care Act. These individuals and families do not buy their plans through the exchanges, and they receive no public subsidies (except for regressive tax expenditures unfairly benefiting primarily higher income individuals). Rather than blaming the Affordable Care Act, we need to blame legislators and the policy community who insisted that we keep this dysfunctional health care financing system in place.

While rejecting single payer, some of our political leaders are suggesting that we fix what we have – tweak the system until it works. One candidate for president suggests enacting a refundable tax credit of up to $5000 to help pay excessive out-of-pocket health costs, and that would help these individuals. But the problem is that it only pours more tax funds into our overpriced and administratively-burdened system without correcting any of the defects that have made our financing system so dysfunctional. And who pays those taxes? A bit of a shell game, I’d say.

We’ve had a lull in spending, but that was partly due to the recession. The other important factor that has slowed spending is what this report is all about. Regardless of ACA, health care costs are being shifted to plan beneficiaries strictly to protect the markets for the insurers by slowing the rate of premium increases. This has the deleterious effect of slowing spending by reducing the affordability of care and thus reducing access to the care that patients should have. Bad policy.

The solution is really simple. Fund a single universal risk pool with equitable taxes that everyone can afford, and then use that risk pool to pay for all necessary health care for everyone. Why didn’t those single payer people think of that? Oh. They did.

Why the U.S. Still Trails Many Wealthy Nations in Access to Care

By Aaron E. Carroll
The New York Times, October 24, 2016

Many are still unhappy with Obamacare.

The main intent of the Affordable Care Act was to expand the safety net (Medicaid), regulate the non-employer-based private insurance market (the insurance exchanges) and help people buy that insurance (subsidies) in order to reduce the number of Americans who are uninsured.

On those metrics, it appears to be succeeding.

First and foremost, Obamacare was about improving access to health care. While it did improve access to insurance, in many, many other ways the United States is falling short. Things are likely to get worse before they get better.

Even with Obamacare, the United States still ranks poorly among comparable countries in insurance coverage. Even in 2016, when the rate of insured is the best it has ever been in the United States, Americans still have a greater percent of the population uninsured than pretty much any other industrialized nation in the world.

Access is about more than insurance, though. Every few years, the Commonwealth Fund conducts an international survey of patients. The last time the fund fielded the survey was in 2013, and it sampled patients in 11 different countries, all of them on the high end of the worldwide socioeconomic spectrum.

When asked if patients could get a same-day or next-day appointment with their provider when they were sick or needed care, 52 percent of Americans said no. This placed the United States next to last among these countries. Only Canada (59 percent) was worse.

When asked whether it was “somewhat” or “very easy” to get care after regular working hours, the United States placed eighth, beating France, Canada (again) and Sweden. Because of this, at least in part, Americans are more likely to use the emergency room for care.

Primary care physicians feel this pinch as well. When the Commonwealth Fund surveyed them in 10 countries, doctors in the United States ranked ninth (ahead of Canada) in being “well prepared” to manage the care of patients with complex needs. They ranked last in whether staff made home visits. They also ranked last, by far, in whether practices had arrangements so that patients could see a doctor or nurse after hours without going to the emergency department.

Why is this? One of the reasons is manpower. The United States, for all its spending, has fewer general practitioners per population than any of these other countries.

The biggest access problem in the United States is the expense of obtaining care. More than one third of Americans said they did not fill a prescription they were given, did not visit the doctor they should have or did not get the tests that were ordered because of the cost.

Perhaps most telling, when adults were asked about their views of the health care system in 2013, 75 percent of Americans said that it needed fundamental change, or that it needed to be completely rebuilt. This percentage was higher than for any other country surveyed, Canada included. Primary care physicians feel similarly. Yet years after the Affordable Care Act was passed, Americans are still litigating whether to return to the previous system.

Access was a problem before. Access is a problem now. Americans can’t seem to have a discussion on how to make that better. Without that, it’s hard to see how things will improve.

http://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

The point here is that, although the Affordable Care Act (ACA) did expand the percentage of people with some form of health insurance, it still leaves us worse off than other nations in the percent of individuals remaining uninsured, and it didn’t fix other problems such as impaired access to health care.

Canada also scored poorly, near the United States, on some of these measures. This is partly due to our similar cultures, and both nations need to improve. In fact, Canada is making a concerted effort to address its problems with queues. But it is important to note that this does not mean that Canada’s single payer system has failed them. Not reported here are much more important measures in which Canada is clearly superior to the United States as a direct result of their single payer financing system: universality, equity, portability of coverage, elimination of financial barriers through first dollar coverage, reduction of administrative waste through public administration, and other efficiencies that have resulted in much lower per capita spending.

This month there is a campaign to tout the successes of ACA in order to reduce concerns about the announcement of the double digit increases in premiums for the ACA exchange plans. But when you objectively evaluate the successes, with the exception of the expansion of Medicaid, these improvements are almost negligible when compared to the improvements that Canada already has in place by virtue of the Canada Health Act that provides support for the single payer systems in their provinces.

As Aaron Carroll states, if we want improvement, we need to have a discussion on how to make the system better. Since ACA is falling so short, that discussion needs to center around truly effective reform, including a single payer national health program.

Struggling to Serve at the Nation’s Richest University

By Rosa Ines Rivera
The New York Times, October 24, 2016

I’ve been at Harvard University for 17 years, but I’ve never been in a classroom here. I’m a cook in the dining halls. I work in the cafeteria at the T.H. Chan School of Public Health, where every day I serve amazing students studying medicine, nutrition and child welfare, as well as the doctors and researchers who train them.

While I’ve earned no college credits here, I’ve had a lesson in hypocrisy.

On my way to work each morning, I pass a building with the inscription: “The highest attainable standard of health is one of the fundamental rights of every human being.” If Harvard believes this, why is the administration asking dining hall workers to pay even more for our health care even though some of us pay as much as $4,000 a year in premiums alone?

I serve the people who created Obamacare, people who treat epidemics and devise ways to make the world healthier and more humane. But I can’t afford the health care plan Harvard wants us to accept.

That’s why I have been on strike with 750 co-workers for more than two weeks. That’s why the other day, co-workers and I were arrested after we sat down in Harvard Square, blocking traffic, in an act of civil disobedience. And that’s why the medical school students, in their white coats, have been walking the picket line with us in solidarity.

Medical students analyzed Harvard’s proposal and found that the cost of premiums alone could eat up almost 10 percent of my income.

The students say that Harvard’s proposal is unaffordable for nearly all of us according to state government guidelines. If it goes through, I will keep avoiding the doctor to save that money for my kids’ co-pays. Any increase puts me at the breaking point.

Harvard is the richest university in the nation, with a $35 billion endowment. But I can’t live on what Harvard pays me. I take home between $430 and $480 a week, and this August, I fell behind on my $1,150 rent and lost my apartment. Now my two kids and I are staying with my mother in public housing, with all four of us sharing a single bedroom.

I know that health care costs are going up everywhere, and I don’t have all the answers. But there must be some way not to shift costs onto Harvard’s poorest workers.

If good health is truly “one of the fundamental rights of every human being,” then shouldn’t that also apply to the human beings working in Harvard’s cafeterias?

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Published comment:

By Don McCanne, M.D.
San Juan Capistrano, CA

In my work, volunteering as a health policy fellow for Physicians for a National Health Program, I follow the health policy literature, including that produced by Harvard’s T.H. Chan School of Public Health.

They devote much of their research to tweaking the highly flawed policies that have resulted in the most expensive health care system but one that is infamous for its mediocre performance for far too many. In spite of the Affordable Care Act, tens of millions remain uninsured or underinsured, creating for them financial hardship and impaired access.

The academic community is quite aware that a well designed single payer system funded with the 3 trillion dollars that we are already spending would provide high quality, comprehensive care for everyone with no financial barriers such as those that are being forced upon their dining hall workers.

It is reassuring for our future that the students seem to understand, but it is astonishing that too many of the academics seem to be oblivious. They should be leading the protest, not only at Harvard, but throughout the nation.

President Obama gave a great speech this past week defending our dysfunctional system while once again dismissing single payer, yet he cited many deficiencies that would be adequately corrected only with comprehensive reform and not mere tweaks. He knows that single payer is the way to go, and he need only look at the dining hall workers at his alma mater as a reminder of why we need to take that course.

http://www.nytimes.com…