By Miranda Dietz Laurel Lucia, Dylan H. Roby, Ken Jacobs, Petra W. Rasmussen, Xiao Chen, Dave Graham-Squire, Greg Watson, Ian Perry, Gerald F. Kominski
UC Berkeley Labor Center and UCLA Center for Health Policy Research, November 2018

California’s successful implementation of the Affordable Care Act (ACA) resulted in historic increases in health insurance coverage. Over one million Californians have subsidized insurance through Covered California, the state’s ACA marketplace. The state’s Medicaid program (Medi-Cal) now covers approximately one out of three Californians, millions more than prior to the ACA.

Despite this success, 10.4 percent of non-elderly Californians (those under age 65) lacked insurance in 2016. Without state action to protect and build upon these coverage gains, we project that the uninsurance rate could grow to 11.7 percent in 2020, or approximately 4.02 million people, and to 12.9 percent in 2023, or 4.4 million people. These rates are based on a definition of insurance that excludes restricted-scope Medi-Cal for undocumented Californians.

The federal law zeroing out the ACA individual mandate penalty beginning in 2019 will result in lower individual market and Medi-Cal enrollment, but significant uncertainty exists about how much enrollment will decline in California. Using our California Simulation of Insurance Markets (CalSIM) microsimulation model and a range of assumptions about the extent to which the penalty influences enrollment decisions, we project that between 150,000 and 450,000 more Californians will be uninsured in 2020, growing to between 490,000 and 790,000 more uninsured in 2023, compared to the projected number if the ACA penalty had been maintained. The most substantial enrollment changes will occur in the individual market, where we project enrollment will decline by 10.1 percent in 2020 and 14.4 percent in 2023.

To protect the progress made under the ACA in expanding health coverage and to reduce the remaining coverage gaps, the state could expand Medi-Cal to all low-income residents regardless of immigration status, provide state subsidies to improve affordability of individual market premiums and out-of-pocket costs, implement a state individual mandate, and continue to support and strengthen outreach and enrollment efforts, among other strategies. As federal decisions threaten to reverse health coverage gains around the country, these policies would help to ensure that California continues to build on its successes and drive toward its goal of achieving universal health coverage.

http://laborcenter.berkeley.edu…

Comment:

By Don McCanne, M.D.

California has been a leader in implementing the Affordable Care Act. As such, it would be useful to estimate the impact of the law that is eliminating the penalty for not having health insurance. This meticulous study estimates that five years from now over half a million additional Californians will be uninsured when compared to estimates were the penalty to remain in place.

Many studies have demonstrated that being uninsured results in impaired physical and financial health for far too many individuals who lose their insurance. Obviously we need to pursue different policies that instead would improve access and affordability of health care.

The primary criticism of this otherwise excellent report is that the authors’ recommendations, though reducing the negative impact of eliminating the individual mandate penalty, would still fall far short of the goals of reform. Many would still be uninsured. Many would still face financial hardship due to underinsurance. Many would be deprived of their choices of health care professionals and institutions because of the perpetuation of restricted provider networks. We would all be paying more because of the costs of administrative excesses which would only increase under the authors’ recommendations, not to mention the burden placed on us by having to comply with these excesses.

So the primary defect in this 32-page report is that they left out any discussion of a proposal that would meet the crucial goals of reform: Single Payer Medicare for All. We can only speculate that the reason is that these distinguished policy experts still limit their recommendations based on their perceptions of political feasibility. It is true that President Trump and the Republican-controlled Senate would be barriers to such comprehensive reform, but with certainty only for the next two years. That is a very short time to mobilize the public into a frenzy that offers politicians no choice but to fulfill the wishes of the majority: enact Single Payer Medicare for All.

If we can show success in grassroots organizing, these authors would no doubt concur that Single Payer Medicare for All is the way to go. These policy wonks certainly understand the different impacts of a policy that financially penalizes a person for being uninsured versus a policy that automatically insures absolutely everybody for life. In fact, you don’t even have to be a policy wonk since that’s a no-brainer.

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By Lydia Ramsey
Business Insider, November 2, 2108

Dr. Steven Corwin knows what he does is expensive.

Corwin is the CEO of NewYork-Presbyterian Hospital. Surgeries, intensive care, and other costly procedures are constantly taking place within its walls. Hospital care cost about $1.1 trillion in 2016 — that’s 32% of health spending in the US.

“We do a lot of very expensive things,” Corwin told Business Insider. “We have to figure out how to reduce our costs.”

“We have to have universal coverage,” Corwin said. “Let’s forget the mechanism of getting universal coverage, but I think everybody’s gotta be insured.”

While Corwin doesn’t support Medicare for All, it’s a concept he has on his mind, in part because of how much simpler what is known as a single-payer system would be on the administrative side of the hospital. Instead of worrying about the variability in different plans, hospitals would have only one plan to keep in mind.

But to him, there are two big questions around Medicare for All:

Logistically, what’s the tax structure the US would need to support that?

Does Medicare for All makes sense for the US as a country?

“I think we should have that debate,” Corwin said.

https://www.businessinsider.com…

A group of students at Weill Cornell and Columbia explain why their CEO is wrong to oppose ‘Medicare for All’

Business Insider, Letter to the Editor, November 26, 2018

In a recent article, NewYork-Presbyterian Hospital CEO Dr. Steven Corwin commented on rising healthcare costs. He stated that “We do a lot of very expensive things…We have to figure out how to reduce our costs.” In the same article, he stated that he opposes “Medicare for All,” but that “We have to have universal coverage,”

As medical students training at the institution Dr. Corwin leads, we agree: we do need it – and we need it urgently. Unlike Dr. Corwin, we, along with a growing number of hospital leaders, believe “Medicare for All” is the only solution for universal coverage and cost reduction.

Medicare for All is a universal, comprehensive single-payer system in which healthcare is financed by one public agency but privately delivered. It would cover all medically necessary services and eliminate co-pays, premiums, and deductibles, leading to improved financial security when individuals or families get sick. It would also give patients the freedom to choose their doctor.

HR 676, a bill introduced in the US House of Representatives with 123 Democratic co-sponsors last year, and the NY Health Act, a state bill that has passed the New York State Assembly in each of the past four years, would both establish such a system.

In his interview, Dr. Corwin first asks “what’s the tax structure the US would need to support [Medicare for All]?” Both HR 676 and the NY Health Act have well-defined funding mechanisms. Each proposes a progressively graduated payroll tax paid by employers and employees, as well as a progressive tax on non-employment income such as capital gains. HR 676 also includes an increase in personal income taxes on the top 5% of earners and a small tax on stock and bond transactions.

While many recent headlines claim that Medicare for All comes with a hefty price tag for taxpayers, it is vital to understand that this increase will be more than offset by the elimination of co-pays, premiums, and deductibles, resulting in net savings for 95% of U.S. households. Studies on the fiscal feasibility of HR 676 and the NY Health Act predict that the proposed funding mechanisms will sustain a Medicare for All system while saving billions of dollars annually.

The business community is also warming up to the idea of Medicare for All. Employer spending on healthcare continues to rise dramatically: the average employer contribution to premiums per worker has risen nearly 70% in the past decade.

Despite repeated claims of government inefficiency, Medicare currently operates at roughly 2% overhead cost, compared to 12.4% overhead for private insurers. These lower administrative costs, along with reasonable limits on drug prices, procedures, and devices will result in billions of dollars of savings for businesses and consumers that can be redirected into the private sector.

Dr. Corwin also asked “Does Medicare for All make sense for the US as a country?” We believe it does—as do 70% of Americans, including 84.5% of Democrats and 51.9% of Republicans.

Medicare is a national treasure: before age 65, when most Americans are insured by private companies, the U.S. has the worst mortality rates of any comparable countries; shortly after 65, when Americans become eligible for Medicare, the U.S. shoots to the top of the rankings. Additionally, Medicare beneficiaries have much higher satisfaction rates than those insured by private companies. Medicare for All will expand these benefits to the entire country.

Medicare for All is something all Americans can get behind, because it is for all Americans. It is bigger than any one hospital, insurer, or patient. As future physicians, our goals align with Dr. Corwin’s: we want universal healthcare coverage and we want to reduce costs. Medicare for All will do both. Is it time for Medicare for All in the U.S.? Dr. Corwin said “I think we should have that debate.” We wholeheartedly agree.

Sincerely,

William Ford, Emilie George, Alex Irace, Rachel Madley, Graham Wehmeyer, and Michael Zingman; Students at Weill Cornell Medicine and Columbia University Vagelos College of Physicians & Surgeons, Members of Students for a National Health Program (SNaHP)

https://www.businessinsider.com…

A personal message:

By Don McCanne, M.D.

The future of health care in America rests with the nation’s students in medicine and in the other health professions. When you read the letter above written by members of Students for a National Health Program (SNaHP) you can be assured that the future is in very good hands.

Those of us at Physicians for a National Health Program (PNHP) who worked with Nicholas Skala were very impressed with “his incisive mind, wide-ranging knowledge and formidable skills of argument that were devoted entirely to bringing about a better world for everyone.” He was “an extremely witty and compassionate human being, and a great source of inspiration and encouragement.” He was so gifted that I personally thought that his name someday would be widely associated with the single payer Medicare for All program that would eventually be enacted. We are still reeling from his loss due to a cardiac event. We remember his legacy through multiple programs, including the Nicholas Skala Health Activist Award, Memorial Fund, and Student Scholarship Program.

On Giving Tuesday it seems appropriate to consider the contributions of Students for a National Health Program, and I am doing so through a contribution to the Nicholas Skala Student Activist Scholarship Fund. Before you decide that you are receiving too many requests today, do just one thing. Click on the following link, look at Nick’s portrait, and then just try to say no. I couldn’t. I hope you’ll join me.

https://pnhp.salsalabs.org…

Peace.

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By Robert Pear
The New York Times, November 24, 2018

The Trump administration has labored zealously to cut federal regulations, but its latest move has still astonished some experts on health care: It has asked for recommendations to relax rules that prohibit kickbacks and other payments intended to influence care for people on Medicare or Medicaid.

The goal is to open pathways for doctors and hospitals to work together to improve care and save money. The challenge will be to accomplish that without also increasing the risk of fraud.

With its request for advice, the administration has touched off a lobbying frenzy. Health care providers of all types are urging officials to waive or roll back the requirements of federal fraud and abuse laws so they can join forces and coordinate care, sharing cost reductions and profits in ways that would not otherwise be allowed.

Federal health officials are reviewing the proposals for what they call a “regulatory sprint to coordinated care” even as the Justice Department and other law enforcement agencies crack down on health care fraud, continually exposing schemes to bilk government health programs.

“The administration is inviting companies in the health care industry to write a ‘get out of jail free card’ for themselves, which they can use if they are investigated or prosecuted,” said James J. Pepper, a lawyer outside Philadelphia who has represented many whistle-blowers in the industry.

Federal laws make it a crime to offer or pay any “remuneration” in return for the referral of Medicare or Medicaid patients, and they limit doctors’ ability to refer patients to medical businesses in which the doctors have a financial interest, a practice known as self-referral.

These laws “impose undue burdens on physicians and serve as obstacles to coordinated care,” said Dr. James L. Madara, the chief executive of the American Medical Association. The laws, he said, were enacted decades ago “in a fee-for-service world that paid for services on a piecemeal basis.”

Melinda R. Hatton, senior vice president and general counsel of the American Hospital Association, said the laws stifle “many innocuous or beneficial arrangements” that could provide patients with better care at lower cost.

Hospitals often say they want to reward doctors who meet certain goals for improving the health of patients, reducing the length of hospital stays and preventing readmissions. But federal courts have held that the anti-kickback statute can be violated if even one purpose of the remuneration is to induce referrals or generate business for the hospital.

The premise of the kickback and self-referral laws is that health care providers should make medical decisions based on the needs of patients, not on the financial interests of doctors or other providers.

Doctors, hospitals and drug companies are urging the Trump administration to provide broad legal protection — a “safe harbor” — for arrangements that promote coordinated, “value-based care.” In soliciting advice, the Trump administration said it wanted to hear about the possible need for “a new exception to the physician self-referral law” and “exceptions to the definition of remuneration.”

“Good providers can work within the existing rules,” said Joel M. Androphy, a Houston lawyer who has handled many health care fraud cases. “The only people I ever hear complaining are people who got caught cheating or are trying to take advantage of the system. It would be disgraceful to change the rules to appease the violators.”

https://www.nytimes.com…

Comment:

By Don McCanne, M.D.

This article demonstrates some of the undesirable consequences of blindly continuing down the pathway of value-based health care through practice arrangements such as accountable care organizations. The system should be structured to serve the health care interests of patients first but these models are serving primarily the financial interests of physicians and hospitals. They are endorsed by the AMA and the American Hospital Association which seems to explain why these organizations are on the wrong side of the the debate over Single Payer Medicare for All.

The laws, rules and regulations that are being addressed by the proposed rules that would relax enforcement exist because the health industry did engage in activities that placed the financial interests of the providers above the health care interests of patients – activities that were often unethical and immoral. It is ironic that the business models being pursued today are claimed to increase value when, in fact, they bring back old behaviors that have been considered to be illegal, and for good reason. Maybe we’ve abandoned some of the old language – fee-splitting, kickbacks, ghost surgery, etc. – but the alternative payment models are bringing back arrangements that represent similar compromises in medical ethics.

Houston lawyer Joel Androphy says, “Good providers can work within the existing rules. The only people I ever hear complaining are people who got caught cheating or are trying to take advantage of the system. It would be disgraceful to change the rules to appease the violators.”

The effort of the Trump administration to relax the rules of ethics to take care of the providers is wrong, though there certainly is need to back off on their efforts to expand the dysfunctional value-based models that they are advancing.

We need a change, but a change that better serves the interests of patients – like, for instance, a Single Payer Medicare for All program. That would work better for the providers as well, except maybe for the very few who are primarily driven by greed. Besides, if we remove the opportunities for greed, then greed disappears (except for the relatively rare, hardcore, mafioso-type Medicare crooks).

Single Payer Medicare for All – where the rules serve the interests of patients first.

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By Lee Fang and Nick Surgey
The Intercept, November 20, 2018

Now that the midterms are finally over, the battle against “Medicare for All” that has been quietly waged throughout the year is poised to take center stage.

Internal strategy documents obtained by The Intercept and Documented reveal the strategy that private health care interests plan to use to influence Democratic Party messaging and stymie the momentum toward achieving universal health care coverage.

Over the summer, leading pharmaceutical, insurance, and hospital lobbyists formed the Partnership for America’s Health Care Future, an ad hoc alliance of private health interests, to curb support for expanding Medicare.

The campaign, according to one planning document, is designed to “change the conversation around Medicare for All,” then “minimize the potential for this option in health care from becoming part of a national political party’s platform in 2020.”

Behind the scenes, the group attempted to sway candidates during the midterms, encouraging several of them to focus on shoring up the Affordable Care Act instead of supporting single-payer health care.

In several competitive races, the Partnership pressed candidates to use industry-crafted talking points when speaking about health care.

Several of the candidates who agreed to embrace the Partnership’s messaging and policy ideas came up short on Election Day. But soon after Election Day results came in, the Partnership went on the offensive, informing reporters that candidates who embraced “Medicare for All” had also lost, pointing to the defeat of progressives such as Kara Eastman in Nebraska. The group also relied on research from the business-friendly Democratic think tank Third Way to argue that victorious pro-“Medicare for All” candidates couldn’t attribute their success to having supported “Medicare for All” because few Democrats explicitly mentioned the policy in their campaign advertisements.

The growing momentum for “Medicare for All” could raise expectations for the next time Democrats are in full control of power in Washington, industry groups worry. They are already pressuring conservative-leaning caucuses in the House of Representatives, such as the Blue Dogs and New Democrats Coalition, to push back against insurgent progressives’ demands.

The campaign has worked with advertising agencies to draw up a series of messages to convince select audiences. Several of the messages, categorized as “positive,” are dedicated to educating the public on more minimal reforms that do not include expanding Medicare. Other messages, categorized as “persuasion” and “aggressive,” are designed to instill fear about what could happen if “Medicare for All” passes.

In the coming weeks, the Partnership plans to ramp up a campaign designed to derail support for “Medicare for All.” The group, working with leading Democratic political consultants, will place issue advertisements to target audiences, partner with Beltway think tanks to release studies to raise concerns with the plan, and work to shape the public discourse through targeted advocacy in key congressional districts.

In one planning document circulated over the summer, the Partnership suggested a series of messages to wean Americans away from supporting single payer. The talking points emphasize that the current system provides “world-class care,” and that any move away from the Affordable Care Act would be “ripping apart our current system.”

The strategy exploits familiar themes that have long been used by business groups against new government health care programs, calling for allies to say lines such as “bureaucrats in DC have no understanding of a person’s medical situation and will be making decisions about your health care instead of doctors.”

The Partnership plans to form a speakers bureau of former Democratic elected officials who can leverage the media to make the case that expanding Medicare is bad politics and policy. The memo names former Democratic Majority Leader Tom Daschle, now a health insurance lobbyist at the law firm Baker Donelson, as one such potential surrogate.

The memo points to early success in shaping media coverage, citing several “earned media” columns such as one published in August by former Rep. Jill Long Thompson, D-Ind., which argues that Democrats should only focus on small reforms to the Affordable Care Act, and warns against wasting political capital on pursuing a “government-controlled health insurance system.”

Adam Gaffney, president-elect of Physicians for a National Health Program, a national coalition that advocates in favor of “Medicare for All,” said he is not surprised by the messaging.

“What we’re seeing is the wages of success: With single payer on the rise, it was only a matter of time before the insurance companies, big pharma, and other big-money groups came out swinging,” said Gaffney, who also serves as an instructor at Harvard Medical School.

“The smear of ‘socialized medicine’ has been used a thousand times and has lost its bite,” he added.

Influencing the 2020 Democratic Field

“We’re all focused on 2020,” Lauren Crawford Shaver, a partner at Forbes-Tate who is helping to manage the Partnership campaign, recently told the National Association of Health Underwriters in a podcast produced by the group.

Shaver, a former top staffer for the Hillary Clinton presidential campaign, explained to the group that she is working to peel support away from the “Medicare for All” bill sponsored by Sen. Bernie Sanders, I-Vt. The Sanders bill is currently sponsored by several rumored 2020 Democratic presidential candidates, including Sens. Elizabeth Warren, D-Mass.; Kamala Harris, D-Calif.; and Kirsten Gillibrand, D-N.Y.

“The No. 1 thing we need to focus on is that there are a lot of likely candidates that currently support the Senate bill,” said Shaver. “We need to make sure we educate the public, we educate both parties, and we educate all the campaigns about both the policy and political challenges.”

Shaver encouraged health care companies concerned about the growing popularity of “Medicare for All” to mobilize opposition among clients, customers, and employees. Industry groups will likely have workers or customers residing in key districts who can be tapped to influence wavering lawmakers on Capitol Hill.

The Partnership plans to “take stories of how these proposals would directly impact your clients and the constituents of the policymakers who are voting for or against these proposals,” Shaver said.

AHIP, the insurance trade group behind the 2008 plan, is also a sponsor of the Partnership’s 2020 campaign, along with the Federation of American Hospitals, Pharmaceutical Research and Manufacturers of America, the Blue Cross Blue Shield Association, the Biotechnology Innovation Organization, and the American Medical Association.

Despite a pledge by many Democratic candidates to eschew corporate PAC donations, health care lobbyists have funneled cash to many incoming lawmakers through the New Democrats PAC, the Blue Dog PAC, and other centrist committees. Unsurprisingly, the centrist New Democrats Coalition, the caucus of business-friendly centrist Democrats, has worked to depress momentum for “Medicare for All,” reprising the role centrist Democrats played in killing the public option during the Obama administration.

Immediately following the midterm elections this month, the Washington Post published a column by Third Way warning that “Medicare for All” “failed the Hippocratic Oath” because opposition to the plan helped Republican candidates, thus causing “harm” to the long-term health interests of voters.

But advocates for “Medicare for All” are feeling optimistic.

“In terms of tactics, it sounds like they will just be updating the same lines they used in the 1990s to sideline reform efforts and in the ACA fight to keep single-payer health care off the table,” said Eagan Kemp, a health care policy advocate with Public Citizen. “The Partnership for America’s Health Care Future would be more accurately titled the ‘Partnership for Profiting Off America’s Health Care.’”

Private health care interests will certainly have much more money, media attention, and political resources with which to campaign. Advocates, however, are hoping Americans see past the public relations smokescreen and support health care as a human right.

“There is no brand loyalty to insurance companies, which are rightly seen as parasitic,” Gaffney, the PNHP leader, said.

“Once single payer is widely understood as a program that covers everyone, that doesn’t impose copays and deductibles, that has more comprehensive benefits than existing plans, and that doesn’t employ restrictive insurance ‘networks,’ support will only grow,” he added.

https://theintercept.com…

Comment:

By Don McCanne, M.D.

Man your battle stations. The messaging war has begun. It’s our message of “lifetime affordable health care for everyone” versus their message of “don’t take my private insurance away.” Let me keep my high premiums, high deductibles, restrictive provider networks, and uncertainty of coverage related to my employment or lack thereof.

It seems like the battle should be no contest. The policies behind our message should clearly prevail: health care for everyone versus perpetuation of the perversities of the private insurance industry. But the hundreds of millions of dollars the opponents of Medicare for All will spend can purchase some very slick government-can’t-do-anything-right messages, ignoring the fact that health care delivery would be predominantly in the private sector.

Winning the message war means that our message must be out there. We have work to do.

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By Louise Marie Roth
The Hill, November 16, 2018

I was in Canada this past June when I broke my wrist and had to go to the ER. They were fast and professional and the bill was much lower than what American ERs charge you just for walking in the door.

Under single-payer health care, you can see the savings on administrative costs with your own eyes. When you walk into physicians’ offices in Canada, they have a small administrative staff, often consisting of one person behind the counter.

They don’t need to employ extra people to fill out dozens of different forms for various insurers with multiple plans, all with different copays, deductibles and coverage. There are no copays or deductibles and everyone knows the rules for what is covered and how to bill the provincial insurance plan. They don’t need staff to spend hours fighting with insurers about which services or medications they will cover or how much they will pay.

Meanwhile, the U.S. pays more than twice as much per capita for health care ($10,348 in 2016) than Canada ($4,752), Australia ($4,708), or the UK ($4,192), but has lower life expectancy and higher infant and maternal mortality rates even compared to some less developed countries.

As someone who grew up in Canada and moved to the United States more than two decades ago, I have seen firsthand that American health care is expensive, unequal and inhumane – and that there is a better way that costs less, is more equitable and covers all pre-existing conditions. It’s time to solve this problem with single-payer health insurance, so that everyone gets care regardless of their ability to pay.

In this year’s midterm elections, health care was a top issue for American voters and nearly 60 percent favored Medicare-for-all. Now that the Democratic Party is poised to take over the House, it’s time to move forward. The most likely next speaker, Nancy Pelosi, said that all health-care options are “on the table,” and 123 Democratic representatives in the House are co-sponsors of Medicare for All legislation.

Even though the ACA was an inferior solution compared to single-payer, the result is that a growing number of Americans once again lack adequate health insurance.

Of course, Republicans, including President Trump in a recent USA TODAY oped found to have many fact errors, are fighting Medicare for All by calling it “socialism.” But when I ask my students if they would prefer a capitalist fire department, where firefighters only put out a fire if you have up-to-date private insurance or can pay the bill, they think that a taxpayer-funded socialized fire department is a much better idea. They do, however, worry that single-payer health care would not work in the U.S. because of its larger population. They usually don’t know that the U.S. already has socialized medicine in the form of Medicare and Medicaid, which covers more than 30 percent of the population. If federal and state governments can cover more than 30 percent, then why can’t they simplify the whole system and cover everyone?

Single-payer is simply the most efficient and most humane way to cover everyone, including those with pre-existing conditions, which many people have through no fault of their own.

My oldest son had a vascular malformation in his brain and needed brain surgery when he was six. Fortunately he is doing fine now but, as the federal government removes more and more of the protections under the ACA, I wonder if he will be insurable when he is no longer covered under my insurance. Why should he be unable to get insurance or have to pay exorbitant premiums when he did nothing to cause his medical history? Luckily he has an anchor mom – he can always move to Canada. Not everyone has that option.

Dr. Louise Marie Roth is an associate professor of sociology at the University of Arizona and a Public Voices Fellow with The OpEd Project. She teaches medical sociology and is writing a book about maternity care in the United States.

https://thehill.com…

Comment:

By Don McCanne, M.D.

The author is an academic sociologist from Canada who lives and teaches in the United States. Her lightly edited op-ed is reproduced here since it represents a highly credible, expert view on why the United States should enact and implement a Single Payer Medicare for All system much like Canada’s rather than perpetuate our overpriced and underperforming health care financing system based on ACA.

Would it be that we were all as intelligent and discerning as her, we would make the change now.

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