By David A. Ansell, M.D.
The Washington Post, September 13, 2017

Sarai was 25 years old when she died of Wilson’s disease, an inherited disorder that causes liver failure. A liver transplant could have cured her, but she was uninsured and was denied an appointment at two prominent Chicago transplant hospitals, including my own. Sarai’s plight was brought to my attention when a local religious group held a hunger strike advocating transplant access for Sarai and other uninsured patients. When she died, her congregation marched seven miles, holding her photograph and lugging coffins emblazoned with her name, to launch a sit-in in front of Northwestern University Hospital. Her death certificate named liver disease as her cause of death, but that’s not true. The real cause was inequality. If the United States had a Medicare-for-all health insurance system, she might have been saved.

In nearly 40 years as a doctor, I witnessed time and again how inequality kills. Those without health insurance, such as Sarai (there are almost 30 million in the country), often cannot access the most basic care, let alone complex specialty care. But the problem is more serious than a simple lack of health insurance. What insurance card you hold can literally be a matter of life and death.

Consider how our current multi-payer health insurance system affects hospitals, clinics and patients. I have practiced at three hospitals along a two-mile strip of Ogden Avenue in Chicago. I spent 17 years at Cook County Hospital, now the John H. Stroger Jr. Hospital of Cook County, rising from intern to chief of general medicine. When I practiced at Cook County Hospital, it was largely a hospital for the uninsured.  Despite many improvements, largely because of Medicaid expansion under the Affordable Care Act, many services, such as screening colonoscopies and hip replacements, are still beyond reach for patients and their doctors. I spent a decade at Mount Sinai Hospital, a not-for-profit hospital for the poor in North Lawndale, a neighborhood of concentrated poverty in Chicago. Sinai cares for a mostly minority population that is mostly uninsured or on Medicaid. In my 27 years at these two safety-net hospitals, not one of my patients received an organ or bone marrow transplant. Yet the organs that fed the transplant centers across the region came from the dying patients in these hospitals. Our patients — the poorest of the poor — gave, but they never received.

For the past 12 years, I have practiced at Rush University Medical Center, an academic medical center replete with the finest care biomedicine can offer. Because my hospital serves a variety of patients with different insurance types — many with private insurance, Medicare or Medicaid, and some uninsured — it is able to afford and offer a vast array of services. But those with the wrong insurance card cannot access the care at my hospital. In contrast, hospitals that only serve the poor and uninsured, such as my two prior hospitals, are more limited in their scope because the payment systems for the uninsured and those on Medicaid constrain their ability to buy new equipment or invest as they need.  Compared with Cook County and Mount Sinai, Rush felt like a different planet my patients and I had landed on, where previously out-of-reach medical care was now available.

I realized that all the doctors and nurses in the world could not cure health-care inequity if the insurance system itself was the problem.

I call my experience on Ogden Avenue “one street, two worlds” because that short stretch of asphalt separates two very different worlds of health and health care: one for those institutions who have patients with better health insurance, and one for those for hospitals who largely serve patients with limited or no insurance.

My experiences also reflect the observations of Princeton economist Angus Deaton, who noted that the United States virtually has an apartheid health-care system. As structural racism has concentrated black and brown poverty into certain Zip codes, the hospitals and clinics serving minority neighborhoods often face severe resource challenges compared with those serving affluent neighborhoods of concentrated advantage. This inequity is only magnified by the way health insurance has been distributed across America. But it not just the poorest who are at risk. Our current multi-payer for-profit health insurance system perpetuates premature death by putting many people at an extreme disadvantage when it comes to affording care. Those who have better health insurance policies can access better care. However, even patients with insurance cards face skyrocketing co-pays, deductibles and pharmaceutical prices that keep them from seeking care. Last year, 27 percent of Americans said they had postponed or avoided getting care they needed because of the cost; 23 percent said they had skipped a recommended test or treatment due to cost; and 21 percent said they had chosen not to fill prescriptions for medication because they couldn’t afford it.

Death rates tell the same story. Since 1980, there have been dramatic gains in life expectancy for the top 20 percent of U.S. earners. At the same time, the poorest 20 percent have seen their life expectancy plummet. While access to health insurance is not the only cause, it certainly contributes to the life expectancy gap. In Canada, with its single-payer health insurance, the life expectancy gap between the rich and the poor narrowed during the same period.

There are three fundamental problems with the patchwork U.S. health insurance landscape that a Medicare-for-all system would resolve. First, our current reliance on for-profit insurance forces working families to pay increasingly burdensome prices for health services and prescription drugs. The Affordable Care Act was never a viable solution, because it relies on the for-profit insurance industry, which is geared to maximize shareholder returns rather than high-quality, low-cost care for all. Meanwhile, taxpayers have funneled billions of dollars to support premiums for individuals and subsidies for insurance companies. Second, Medicaid, the health insurance program for the poor, shares many of these same flaws. The quality of the program varies by state and is a major burden on state budgets. Finally, the current system is inequitable for low-income or uninsured patients. Every day, people such as Sarai die when they could have been saved.

The best solution is a national solution; one that has been implemented by nearly every other developed nation. Medicare, the popular insurance program for those over 65 and people with disabilities, has a 90 percent satisfaction rate. Under a Medicare-for-all program, every worker and business in America would pay into the system through a combination of payroll and other taxes and fees, just as we pay taxes and fees for schools, water and the military. There would be no complex health insurance payments to navigate, no prohibitive co-pays and deductibles, no corporate welfare to boost insurance company profits. Untangling health care from employment would not only free workers to change jobs or start new businesses, but would also eliminate the largest and most stealthy tax loophole in the U.S. tax code: the $250 billion annual tax-free subsidy of employer-based health insurance.

Medicare for all would solve the problems of health-care access for the poor and rural. Such a system would allow hospitals and clinics to survive at a time when many of them — often the largest employers in their communities — are threatened with extinction. Moreover, it creates the opportunity for America to eliminate health inequities and improve life expectancy because, by design, everyone will be in and no one will be left out.

As a doctor, I have a moral obligation to care for patients regardless of their insurance status or ability to pay. But America’s fragmented, for-profit health system forces doctors to violate their Hippocratic oath, the moral contract requiring  us to treat health as a basic human right. I speak for many American physicians when I say I am sick and tired of a health insurance system that harms our patients, many of whom are sick and tired themselves.

The right to health care in America is not an issue of the left or the right. It’s a matter of right and wrong. Winston Churchill reportedly said, “You can always count on the Americans to do the right thing … after they have tried everything else.” Today, Sen. Bernie Sanders (I-Vt.) will introduce a bill in the Senate that will provide a path forward for Medicare for all. Let’s do the right thing. We have tried everything else.

Dr. David A. Ansell is a professor of internal medicine, senior vice president for community health equity at Rush University Medical Center in Chicago, a member of Physicians for a National Health Program, and author of “The Death Gap: How Inequality Kills.”

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By Adam Gaffney, M.D.
The Washington Post, September 13, 2017

Single-payer universal health care — once cast as a radical daydream — has moved with staggering swiftness from purported fantasy to palpable possibility. Today, Sen. Bernie Sanders (I-Vt.) released his long-awaited single-payer bill, and a slew of senators now numbering in the double digits have announced their support. This bill will serve as a potent Senate counterpart to Rep. John Conyers Jr.’s (D-Mich.) single-payer bill, now co-sponsored by 117 representatives — a historic and unprecedented majority of House Democrats.  Far from being an impossibility, the idea that we might create a right to health care is starting to feel like an inevitability.

Just last week none other than former senator Max Baucus — a central player in drafting the Affordable Care Act and a previous foe of single-payer reform — embraced single-payer as the next step. As Baucus, quoted by the Bozeman Daily Chronicle, put it: “It’s going to happen.”

But is it? Probably not tomorrow. The regressive right-wing government that recently came within a hair’s breadth of repealing the ACA and gutting the existing health-care safety net — an undertaking it could attempt again — is rather unlikely to pass sweeping single-payer legislation anytime soon. So why do bills like this one deserve any attention?

For one reason: because aspirations structure reality.  And also because this political epoch will end, and with it the intensely unpopular presidency of Donald Trump, which will one day be a distasteful memory. Political change will thus invariably — even if only for a while — make transformative reform possible. And when it does, bills like that of Conyers and Sanders might move from ambition to achievement at a hurried pace.

This has happened before. Shortly after World War II, in 1945, the British Labour Party won a historic parliamentary victory, a contest tantamount to a mandate for a new Britain in which — as historian Donald Sassoon has written — the “citizenship rights which had been the rallying cry of the liberal-democratic condition…would be supplemented by new socio-economic rights” — including the right to health care. The following year, the Labor Parliament passed the National Health Service Act, and two years after that, the National Health Service went into operation: Everyone in that nation thereafter gained access to free, comprehensive health care — an advance that can be described without hyperbole as a civilizational breakthrough.

Circumstances there were, of course, unique. Could something similar happen in the United States? It could — and it has. In 1964, Democrats swept the congressional elections, and the following year, Lyndon B. Johnson signed Medicare and Medicaid into law.  Implementation of Medicare was even more rapid than that of the NHS: Within a year of the law’s signing, 99 percent of the nation’s seniors were enrolled in the universal part of the program.

There is simply no good reason (much less some titanium law of nature) that precludes us from universally expanding Medicare today, which is precisely what some of its architects had in mind decades ago. Nor must this necessarily hinge on some historic electoral sweep: As Baucus’s astonishing single-payer turn demonstrates, when activists transform the narrative around an issue — when they push a policy to center-stage — smart politicians will follow.

Feasibility, of course, is a separate issue from desirability — and what Americans desire is what is quickly changing, as our values evolve.

The gaps in the U.S. health-care system are simply too large to be plugged by the half-measures on offer. Even with the ACA, 28 million — or nearly 9 percent of the nation — remains uninsured. Single-payer would fix that, but covering the uninsured is far from its only goal: What single-payer is uniquely well-suited to do is reduce inequalities imposed by income, race, gender and a host of other factors.

Economic inequality and health inequality are deeply interwoven in 21st-century America. It was for a good and humane reason that the architects of the NHS — like the designers of the Canadian public health-care system — envisioned a universal program with “no charges, except for a few special items,” as an explanatory leaflet sent to each and every residence in Britain shortly before the launch of the service put it.  By covering everyone, while also eliminating co-payments and deductibles — as both bills prudently do (with the exception of prescription drugs in the Sanders’ bill) — we ensure that all receive care depending of their health needs, not their wealth.

But there are also some particularly American health-care inequalities — in race and gender — that must be addressed, and that single-payer could do much to diminish. For instance, today, Hispanics and blacks remain uninsured at substantially higher rates than whites. Moreover, it seems likely that racial minorities — in light of vastly lower average household wealth — are also harder pressed, dollar for dollar, by deductibles or co-payments, as noted in the Harvard Public Health Review.

And additionally, for all the enormous good done by Medicaid, its lower rates of provider payments sometimes contribute to a lower level of access, longer waits for appointments, and — in some instances — effective health-care segregation for the program’s mostly minority participants. Such inequities could be mitigated with a truly universal, single-tier program.

Then there are gender inequalities, namely inadequate access to reproductive health care, especially abortion. Admittedly, a number of policy reforms are needed in this area, but single-payer could make an enormous difference. For a variety of reasons, even insured women can face major barriers in obtaining abortions, and very infrequently rely on private insurance: In 2008, a mere 12 percent of women obtaining an abortion used private insurance to cover the cost, according to the pro-choice Guttmacher Institute. A single-payer program that included access to comprehensive reproductive health care while overriding Hyde — as Sanders’ bill appears to do — would represent an important step toward greater gender equity in health care.

Thus, taken together, the raison d’etre of single-payer reform, are primarily ethical, and only secondarily economic.  Indeed, rising support for single-payer should be seen as part of a larger shift toward more egalitarian values on a host of social and economic issues in America, including on gender and racial equity. At single-payer’s core is the age-old principle of basic human equality, translated to the arena of health. “Health care is a basic human right,” Sen. Elizabeth Warren wrote in an email to her supporters (quoted in Vox) announcing her support of Sanders’ bill, “and it’s time to fight for it.”

The movement for universal health care is, of course, an old one, with many defeats in the past. “Our new Economic Bill of Rights,” Harry S. Truman once said while advocating for a national health insurance program shortly after World War II, “should mean health security for all, regardless of residence, station, or race — everywhere in the United States.” But while Cold War-era scare tactics doomed that effort, they need not sink this one. The sheer popularity of single-payer (53 percent of Americans favor it) and the number of serious politicians now behind it show that we’re changing as a country — for the better.

Dr. Adam Gaffney is an Instructor in medicine at Harvard Medical School and a pulmonary and critical care physician at the Cambridge Health Alliance and serves on the board of directors of Physicians for a National Health Program. Follow him on Twitter @awgaffney.

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