PNHP

Doctors group welcomes national debate on ‘Medicare for All’

Doctors group welcomes national debate on ‘Medicare for All’

Nonpartisan physicians group calls single-payer reform ‘the only effective remedy’ for nation’s continuing health care woes and urges focus on facts, not rhetoric

FOR IMMEDIATE RELEASE, January 22, 2016
Contact: Mark Almberg, PNHP communications director, (312) 782-6006, mark@pnhp.org

Physicians for a National Health Program, a nonprofit, nonpartisan organization of 20,000 doctors who support single-payer national health insurance, released the following statement today by its president, Dr. Robert Zarr, a Washington, D.C., pediatrician.

The national debate on single-payer health reform, or “Medicare for All,” that has emerged in the course of the presidential primaries is a welcome development. But unfortunately a number of misrepresentations about single-payer national health insurance – and the prospects for its attainment – have crept into the dialogue and are potentially misleading the public.

Most of these misrepresentations, or myths, have been decisively refuted by peer-reviewed research. They include the following:

Myth: A single-payer system would impose an unacceptable financial burden on U.S. households. Reality: Single payer is the only health reform that pays for itself. By replacing hundreds of insurers and thousands of different private health plans, each with their own marketing, enrollment, billing, utilization review, actuary and other departments, with a single, streamlined, tax-financed nonprofit program, more than $400 billion in health spending would be freed up to guarantee coverage to all of the 30 million people who are currently uninsured and to upgrade the coverage of everyone else, including the tens of millions who are underinsured. Co-pays and deductibles, which have been rapidly rising under the Affordable Care Act, would be eliminated. Further, the single-payer system’s bargaining clout would rein in rising costs for drugs and medical supplies. Lump-sum budgets for hospitals and capital planning would control costs even more.

A recent study shows 95 percent of U.S. households would come out financially ahead under an improved version of Medicare for all. The graduated, progressively structured tax burden would be based on ability to pay, and the heavy cost to average U.S. households of private insurance premiums, co-pays, deductibles, and many currently uncovered services would be eliminated. Patients could go to the doctor or hospital of their choice, and would no longer be restricted to proprietary networks. Multiple studies over a period of several decades, including by the General Accountability Office and the Congressional Budget Office, show that a single-payer system would provide universal coverage at a much lower cost, per capita, than we are spending now. International experience confirms it. Even our traditional Medicare program, which falls short of a true single-payer system, has much lower overhead than private insurance, and shows that publicly financed programs can deliver affordable, reliable care.

A single-payer system would also greatly diminish the administrative burden on our nation’s physicians and hospitals, freeing up physicians, in particular, to concentrate on doing what they know best: caring for patients.

Covering everyone for all medically necessary care is affordable; keeping the current private-insurance-based system intact is not.

Myth: The U.S. has a privately financed health care system. Reality: About 64 percent of U.S. health spending is currently financed by taxpayers. (Estimates that are lower than this exclude two large sources of taxpayer-funded care: health insurance for government employees and tax subsidies to employers and individuals for purchasing private health plans.) On a per capita basis, the amount of government-funded health care in the U.S. exceeds the health spending of nations with universal health systems, e.g. Canada. We are paying for a national health program, but not getting it.

Myth: A single-payer system would overturn the gains won under the Affordable Care Act and provide inferior coverage to what people have today. Reality: A single-payer system would go far beyond the modest improvements that the ACA made around the edges of our current private-insurance-based system and ensure truly universal care, affordability and health security. For example, H.R. 676, the Expanded and Improved Medicare for All Act, would guarantee coverage for all necessary medical care, including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental, mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care and correction, hearing services including hearing aids, chiropractic, durable medical equipment, palliative care, podiatric care, and long-term care. It would eliminate financial barriers to care like co-pays and deductibles and eliminate restrictive networks. It would end the steady erosion of job-based coverage under our current arrangements and disconnect insurance coverage from employment. H.R. 676 currently has 61 sponsors.

Myth: The American people don’t support single payer. Reality: Surveys have repeatedly shown that an improved Medicare for All is the remedy preferred by about two-thirds of the population. A recent Kaiser Family Foundation survey yielded similar results, showing 58 percent of Americans support Medicare for All. A solid majority of the medical profession favors such an approach, as well, as do more than 600 labor organizations, and many civic and faith-based groups.

Myth: The goal of establishing a single-payer system in the U.S. is unrealistic, or “politically infeasible.” Reality: It’s true that single-payer health reform faces formidable opposition, especially from the private insurance industry, Big Pharma, and other for-profit interests in health care, along with their allies in government. This prompts some people to conclude that single payer is out of reach and therefore not worth fighting for. While such moneyed opposition should not be underestimated, there is no reason why a well-informed and organized public, including the medical profession, cannot prevail over these vested interests. We should not sell the American people short. At earlier points in U.S. history, the abolition of slavery and the attainment of women’s suffrage were considered unrealistic, and yet the movements to achieve these goals were ultimately victorious and we now wonder how those injustices were allowed to stand for so long.

What is truly “unrealistic” is believing that we can provide universal and affordable health care, and control costs, in a system dominated by private insurers and Big Pharma.

We call upon our nation’s lawmakers and the political leaders of all political parties to heed public opinion and to do the right thing by acting swiftly to bring about the only equitable, financially responsible and humane cure for our health care ills: single-payer national health insurance, an expanded and improved Medicare for all.

Physicians for a National Health Program (www.pnhp.org) has been advocating for single-payer national health insurance for three decades. It neither supports nor opposes any candidates for public office.

Is a Single-Payer Health Insurance Program Feasible?

Two letters: Alan Meyers, M.D., and Jim Recht, M.D.
The New York Times, Letters, Jan. 21, 2016

To the Editor:

Re “Health Reform Realities” (column, Jan. 18):

I’m glad to see that Paul Krugman acknowledges that “if we could start from scratch, many, perhaps most, health economists would recommend single-payer, a Medicare-type program covering everyone.” His argument that we should not work for it now is unconvincing.

Just because private insurers are powerful doesn’t mean a concerted national campaign can’t overcome their well-funded opposition. Already a majority of the general public (58 percent in a recent Kaiser poll) supports single-payer. Cost will never be controlled until we do away with the bloated administrative expenses of our hopelessly complex financing arrangements and for-profit medicine.

And while the Affordable Care Act has indeed been a great help for many seeking health insurance, it has left over one-fourth of Americans ages 18 to 64 with problems paying their medical bills. As you have reported, that can be the case even for those with insurance (“Medical Debt Often Crushing Even for Insured,” The Upshot, Jan. 5).

We can do better, as every other developed nation has demonstrated.

ALAN MEYERS

Dr. Alan Meyers resides in Boston. He is a professor of pediatrics at Boston University School of Medicine and a founding member of Physicians for a National Health Program.

To the Editor:

Paul Krugman argues that perhaps the “most important” reason not to pursue single-payer health care financing is that it “would impose a lot of disruption on tens of millions of families who currently have good coverage through their employers.”

As a physician who happens also to be an employee of a large Boston-area human services agency, I can tell you from personal experience, as well as from the (frequently desperate) experiences of my patients, that “good” is not how any of us would describe our coverage.

Premiums are jaw-droppingly high (and projected to increase anywhere from 6.8 to 16.5 percent this year); high-deductible and other “Swiss cheese” insurance policies have become the norm, resulting in increasing out-of-pocket co-pays and deductibles; and obstacles to care, from arbitrary “prior authorization” requirements to restricted panels, regularly prevent people from receiving the care they need. Along with so many of my patients and colleagues, I am convinced that single-payer is right for us, right now.

JIM RECHT

Dr. Jim Recht resides in Cambridge, Mass. He is an an assistant professor of psychiatry at Harvard Medical School.

http://www.nytimes.com/2016/01/22/opinion/is-a-single-payer-health-insurance-program-feasible.html?partner=rssnyt&emc=rss&_r=0

PNHP response to national debate on ‘Medicare for All’

Doctors group welcomes national debate on ‘Medicare for All’

Nonpartisan physicians group calls single-payer reform ‘the only effective remedy’ for nation’s continuing health care woes and urges focus on facts, not rhetoric

Physicians for a National Health Program, a nonprofit, nonpartisan organization of 20,000 doctors who support single-payer national health insurance, released the following statement today by its president, Dr. Robert Zarr, a Washington, D.C., pediatrician.

The national debate on single-payer health reform, or “Medicare for All,” that has emerged in the course of the presidential primaries is a welcome development. But unfortunately a number of misrepresentations about single-payer national health insurance – and the prospects for its attainment – have crept into the dialogue and are potentially misleading the public.

Most of these misrepresentations, or myths, have been decisively refuted by peer-reviewed research. They include the following:

Myth: A single-payer system would impose an unacceptable financial burden on U.S. households. Reality: Single payer is the only health reform that pays for itself. By replacing hundreds of insurers and thousands of different private health plans, each with their own marketing, enrollment, billing, utilization review, actuary and other departments, with a single, streamlined, tax-financed nonprofit program, more than $400 billion in health spending would be freed up to guarantee coverage to all of the 30 million people who are currently uninsured and to upgrade the coverage of everyone else, including the tens of millions who are underinsured. Co-pays and deductibles, which have been rapidly rising under the Affordable Care Act, would be eliminated. Further, the single-payer system’s bargaining clout would rein in rising costs for drugs and medical supplies. Lump-sum budgets for hospitals and capital planning would control costs even more.

A recent study shows 95 percent of U.S. households would come out financially ahead under an improved version of Medicare for all. The graduated, progressively structured tax burden would be based on ability to pay, and the heavy cost to average U.S. households of private insurance premiums, co-pays, deductibles, and many currently uncovered services would be eliminated. Patients could go to the doctor or hospital of their choice, and would no longer be restricted to proprietary networks. Multiple studies over a period of several decades, including by the General Accountability Office and the Congressional Budget Office, show that a single-payer system would provide universal coverage at a much lower cost, per capita, than we are spending now. International experience confirms it. Even our traditional Medicare program, which falls short of a true single-payer system, has much lower overhead than private insurance, and shows that publicly financed programs can deliver affordable, reliable care.

A single-payer system would also greatly diminish the administrative burden on our nation’s physicians and hospitals, freeing up physicians, in particular, to concentrate on doing what they know best: caring for patients.

Covering everyone for all medically necessary care is affordable; keeping the current private-insurance-based system intact is not.

Myth: The U.S. has a privately financed health care system. Reality: About 64 percent of U.S. health spending is currently financed by taxpayers. (Estimates that are lower than this exclude two large sources of taxpayer-funded care: health insurance for government employees and tax subsidies to employers and individuals for purchasing private health plans.) On a per capita basis, the amount of government-funded health care in the U.S. exceeds the health spending of nations with universal health systems, e.g. Canada. We are paying for a national health program, but not getting it.

Myth: A single-payer system would overturn the gains won under the Affordable Care Act and provide inferior coverage to what people have today. Reality: A single-payer system would go far beyond the modest improvements that the ACA made around the edges of our current private-insurance-based system and ensure truly universal care, affordability and health security. For example, H.R. 676, the Expanded and Improved Medicare for All Act, would guarantee coverage for all necessary medical care, including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental, mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care and correction, hearing services including hearing aids, chiropractic, durable medical equipment, palliative care, podiatric care, and long-term care. It would eliminate financial barriers to care like co-pays and deductibles and eliminate restrictive networks. It would end the steady erosion of job-based coverage under our current arrangements and disconnect insurance coverage from employment. H.R. 676 currently has 61 sponsors.

Myth: The American people don’t support single payer. Reality: Surveys have repeatedly shown that an improved Medicare for All is the remedy preferred by about two-thirds of the population. A recent Kaiser Family Foundation survey yielded similar results, showing 58 percent of Americans support Medicare for All. A solid majority of the medical profession favors such an approach, as well, as do more than 600 labor organizations, and many civic and faith-based groups.

Myth: The goal of establishing a single-payer system in the U.S. is unrealistic, or “politically infeasible.” Reality: It’s true that single-payer health reform faces formidable opposition, especially from the private insurance industry, Big Pharma, and other for-profit interests in health care, along with their allies in government. This prompts some people to conclude that single payer is out of reach and therefore not worth fighting for. While such moneyed opposition should not be underestimated, there is no reason why a well-informed and organized public, including the medical profession, cannot prevail over these vested interests. We should not sell the American people short. At earlier points in U.S. history, the abolition of slavery and the attainment of women’s suffrage were considered unrealistic, and yet the movements to achieve these goals were ultimately victorious and we now wonder how those injustices were allowed to stand for so long.

What is truly “unrealistic” is believing that we can provide universal and affordable health care, and control costs, in a system dominated by private insurers and Big Pharma.

We call upon our nation’s lawmakers and the political leaders of all political parties to heed public opinion and to do the right thing by acting swiftly to bring about the only equitable, financially responsible and humane cure for our health care ills: single-payer national health insurance, an expanded and improved Medicare for all.


Physicians for a National Health Program (www.pnhp.org) has been advocating for single-payer national health insurance for three decades. It neither supports nor opposes any candidates for public office.

https://pnhp.org/news/2016/january/doctors-group-welcomes-national-debate-on-‘medicare-for-all’

The concept of a single payer national health program – Medicare for all – has become part of the political debate leading up to the presidential primaries. To no surprise, the rhetoric has been driven by politics which characteristically reduces important concepts to sometimes meaningless or deceptive sound bites. The media, including liberal pundits who should know better, have made the debate a battle of words rather than ideas. We at PNHP believe that facts should guide the national debate, and thus this release.

Tax Dollars Pick Up Two-Thirds of Healthcare Tab

By Joyce Frieden
MedPage Today, Jan. 21, 2016

Taxpayers funded nearly two-thirds of all U.S. health expenditures in 2013, and that figure is expected to rise even higher by 2024, a study has found.

The percentage of federal, state, and local taxpayer funding of healthcare expenditures rose from 59.8% in 1999 to 64.3% in 2013, and is projected to increase to 67.1% by 2024, according to David Himmelstein, MD, and Steffie Woolhandler, MD, MPH, both of City University of New York School of Public Health at Hunter College in New York City. The study appeared online in the American Journal of Public Health.

“The big thing that went up was Medicare [spending], and that went up about 2.5 [percentage] points,” Woolhandler told MedPage Today in a phone interview. “The rest pretty much stayed the same. We expected over the next decade that Medicaid was going to be the piece that goes up, but in fact the thing going up was the Medicare program.”

To estimate their numbers, the researchers added up three types of expenditures:

* Direct government payments for Medicare, Medicaid, and other public programs such as the Veterans Health Administration, the NIH, and public health departments
* Government agencies’ expenditures for public employees’ health insurance coverage
* Federal, state, and local tax subsidies to healthcare

They found that tax-funded health expenditures totaled $1.877 trillion in 2013 — out of total expenditures of $2.919 trillion. Taxpayer-funded expenditures are projected to increase to $3.642 trillion in 2024.

Medicare accounted for 20.1% of all healthcare expenses in 2013, and is expected to rise to 22.5% in 2024. Medicaid, for its part, rose from 15.9% of overall expenditures in 2013 to 17.3% in 2015, and is expected to stay at about that level, the investigators noted.

Another large category, tax subsidies to private health spending, accounted for $294.9 billion in 2013 — or 10.1% of total health expenditures — and are expected to remain at about 10% through 2024, they wrote. “Federal income and payroll tax subsidies account for more than 80% of these tax expenditures, with state and local income tax subsidies accounting for the rest.”

When it comes to employer payments for private health insurance, government employers now account for 28%, and that number is expected to rise to 31% in 2024. “Most of these expenditures (more than four-fifths) are made by state and local governments,” the authors wrote.

Himmelstein and Woolhandler noted several limitations to their study. First, the projections could end up being inaccurate due to economic fluctuations or unanticipated changes in healthcare policy or tax policy. In addition, the analysis may slightly understate public spending since they did not include tax subsidies for nonprofit hospitals, which were estimated at $24.6 billion in 2011, or about 1% of health spending.

Overall, the trend toward an increasing percentage of total healthcare spending coming from federal, state, or local government coffers “seems likely to continue,” they wrote. “The expected uptick in government’s share is attributable both to the effects of the [Affordable Care Act] and to population aging, which will push Medicare enrollment up by 37% between 2013 and 2024.”

The Canadian government funds about 71% of healthcare spending in that country, which has a pretty comprehensive single-payer system, noted Woolhandler, who, along with Himmelstein, has long advocated for single-payer health insurance for the U.S. “We’re really paying for the price of national health insurance and just not getting it,” she said in the interview. “We’re spending this tax money wastefully.”

About 31% of each U.S. healthcare dollar is spent on administrative costs, compared with 16.5% in Canada, Woolhandler said. “We also pay for wasteful facilities, excessive facilities, and high-tech care where it’s not needed, and finally we pay much, much higher drug prices. Every other nation gets lower prices than the U.S., and certainly [a] single-payer [system] gives huge market leverage to get better prices.”

Himmelstein and Woolhandler disclosed serving as co-founders of Physicians for a National Health Program. The authors disclosed no relevant relationships with industry.

Joyce Frieden is news editor at MedPage Today.

http://www.medpagetoday.com/PublicHealthPolicy/HealthPolicy/55771

U.S. health system is already predominantly taxpayer funded

The Current and Projected Taxpayer Shares of US Health Costs

By David U. Himmelstein, MD, and Steffie Woolhandler, MD, MPH
American Journal of Public Health, Published online ahead of print January 21, 2016

Objectives:  We estimated taxpayers’ current and projected share of US health expenditures, including government payments for public employees’ health benefits as well as tax subsidies to private health spending.

Methods:  We tabulated official Centers for Medicare and Medicaid Services figures on direct government spending for health programs and public employees’ health benefits for 2013, and projected figures through 2024. We calculated the value of tax subsidies for private spending from official federal budget documents and figures for state and local tax collections.

Results:  Tax-funded health expenditures totaled $1.877 trillion in 2013 and are projected to increase to $3.642 trillion in 2024. Government’s share of overall health spending was 64.3% of national health expenditures in 2013 and will rise to 67.1% in 2024. Government health expenditures in the United States account for a larger share of gross domestic product (11.2% in 2013) than do total health expenditures in any other nation.

Conclusions:  Contrary to public perceptions and official Centers for Medicare and Medicaid Services estimates, government funds most health care in the United States. Appreciation of government’s predominant role in health funding might encourage more appropriate and equitable targeting of health expenditures.

From the Discussion

Americans pay the world’s highest health-related taxes. Yet many perceive that US health care financing system is predominantly private, in contrast to the universal tax-funded health care systems in nations such as Canada, France, or the United Kingdom. By 2024, government expenditures in the United States are expected to account for more than two thirds of national health spending. This is nearly the same proportion as in Canada, where official figures put government’s share at 70.7% (although this figure excludes modest tax subsidies for supplemental private coverage).

Public funds help the vast majority of Americans pay for care, but these funds flow through many different spigots. The funding streams for the poor, the elderly, veterans, family planning, and public sector workers are visible and hotly debated. Meanwhile, the hundreds of billions in tax subsidies that disproportionately benefit wealthier Americans have drawn far less public attention.

Although taxpayers fund the vast majority of health spending, overall priorities for this funding are rarely discussed. Appreciation of the magnitude of government funding might encourage more explicit, appropriate, and equitable targeting of these expenditures as components of a total health budget.

http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302997

***

Comment:

By Don McCanne, M.D.

We often hear that we cannot afford the taxes to pay for a single payer national health program – an improved Medicare for all. Yet we are already paying most of the taxes that would be required; it’s just that they are relatively obscure and thus not recognized by most taxpayers.

By 2024, government expenditures will pay for more than two-thirds of national health spending (up from 64.3% in 2013). “Government health expenditures in the United States account for a larger share of gross domestic product (11.2% in 2013) than do total health expenditures in any other nation,” according to this study. Our government health expenditures alone are more than both government and private health expenditures in any other nation. We are paying for a national health program, but we are not getting it.

Most people are aware of the insurance premiums and out of pocket expenses that they and their employers pay for health care, so they tend to think that most health care spending is private. They are aware of the payroll deduction for Medicare, but they do not tend to consciously connect other taxes, especially income taxes, with expenditures for Part B and Part D Medicare, Medicaid, CHIP, the VA system and other government health programs. Also, totally out of mind is the portion of personal and corporate income taxes that help pay for government health programs – taxes that are built into the pricing of consumer goods and services (not to mention that the cost of employee health benefit programs is also built into consumer prices). (This may be double counting for the tax tally, but higher health spending in the U.S. does pass on opaque employer plan health costs to the consumer.) And one of the largest silent taxes is the tax expenditure (tax subsidies) on the federal, state and local level that help pay for private, employer-sponsored health plans. Also, we are paying, through taxes, for most of the health benefits offered to federal, state and local government employees.

The roughly $300 billion we pay for tax expenditures for employer-sponsored health plans (will be over $500 billion by 2024) is a prime example of how dysfunctional our health care financing is. The subsidies are credited in direct proportion to income – the higher a person’s income, the greater the subsidy. That is really unfair to lower-income individuals and families who may be paying the same insurance premium, directly or indirectly through forgone wage increases, as the higher-income employees do, but at a greater dollar amount than those with higher incomes after the subsidy is applied, and at a much greater percentage of income. This is a highly regressive tax policy.

The point is, we are already spending our taxes on the health care system, and we can do it much more equitably through a well-designed single payer program. Not only would we increase transparency, we would also reduce inefficient spending by eliminating the private insurance industry, saving more in premiums than would be the increase in taxes. The next time someone says that we cannot afford the taxes for a single payer system – clue him or her in. Let everyone know that it is time to demand much greater value for the enormous amount of taxes that we are already paying for health care.

Government funds nearly two-thirds of U.S. health care costs: American Journal of Public Health study

Contrary to popular perceptions, taxpayers fund 64 percent of U.S. health care, more public dollars per capita than the citizens of other nations – including those with universal health programs

FOR IMMEDIATE RELEASE, January 21, 2016
Contact: Mark Almberg, PNHP communications director, (312) 782-6006, mark@pnhp.org

Tax-funded expenditures accounted for 64.3 percent of U.S. health spending – about $1.9 trillion – in 2013, according to new data published today [Thursday, Jan. 21] in the American Journal of Public Health. The Affordable Care Act will push that figure even higher by 2024, when government’s share of U.S. health spending is expected to rise to 67.3 percent.

At $5,960 per capita, government spending on health care costs in the U.S. was the highest of any nation in 2013, including countries with universal health programs such as Canada, Sweden and the United Kingdom. (Estimated total U.S. health spending for 2013 was $9,267 per capita, with government’s share being $5,960.) Indeed, government health spending in the United States exceeded total health spending (government plus private) in every other country except Switzerland.

The finding that Americans pay the world’s highest health-related taxes conflicts with popular perceptions that the U.S. health care financing system is predominantly private, write Drs. David U. Himmelstein and Steffie Woolhandler, the authors of the study. Himmelstein and Woolhandler are professors at the City University of New York School of Public Health and lecturers in medicine at Harvard Medical School.

Direct government payments for such programs as Medicare, Medicaid and the Veterans Administration accounted for 47.8 percent of overall health spending. The analysis also identified two commonly overlooked tax-funded health expenditures – government outlays for public employees’ private health insurance coverage ($188 billion, or 6.4 percent of total spending) and tax subsidies to health care ($294.9 billion, or 10.1 percent of the total). Together, these public expenditures put the U.S. in first place for health care taxes.

Using another yardstick, the researchers note that tax-funded health expenditures in the U.S. accounted for a larger share of the gross domestic product (11.2 percent in 2013) than did the total health expenditures of any other nation.

The researchers drew upon data from the Centers for Medicare and Medicaid Services, the Office of Management and Budget, the U.S. Census Bureau and the Internal Revenue Service to analyze government outlays for health care costs. They utilized data from the Organization for Economic Co-operation and Development to compare the U.S. data with that of other nations.

“We pay the world’s highest health care taxes. But patients are still saddled with unaffordable premiums and deductibles,” said Dr. Steffie Woolhandler. “Meanwhile, billions are squandered on paperwork, and insurers and drug companies pocket huge profits at taxpayer expense.”

Dr. David Himmelstein commented: “Our study shows that universal coverage is affordable – without a big tax increase. In fact, we already pay for national health insurance, but we don’t get it. It’s an outrage that the American people pay sky-high health care taxes, but 33 million are still uninsured.”

In addition to their academic posts and clinical work as internists, Himmelstein and Woolhandler are co-founders and leaders of Physicians for a National Health Program, a nonprofit organization that advocates for a single-payer health system. PNHP had no role in funding their study.

**

“The current and projected taxpayer shares of U.S. health costs.” David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H. American Journal of Public Health, online ahead of print, Jan. 21, 2016. doi: 10.2105/AJPH.2015.302997

A PDF of the article is available to media professionals upon request from Mark Almberg at mark@pnhp.org. The abstract of the article is available here: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302997

**

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 20,000 doctors who support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

U.S. health system is already predominantly taxpayer funded

The Current and Projected Taxpayer Shares of US Health Costs

By David U. Himmelstein, MD, and Steffie Woolhandler, MD, MPH
American Journal of Public Health, Published online ahead of print January 21, 2016

Objectives:  We estimated taxpayers’ current and projected share of US health expenditures, including government payments for public employees’ health benefits as well as tax subsidies to private health spending.

Methods:  We tabulated official Centers for Medicare and Medicaid Services figures on direct government spending for health programs and public employees’ health benefits for 2013, and projected figures through 2024. We calculated the value of tax subsidies for private spending from official federal budget documents and figures for state and local tax collections.

Results:  Tax-funded health expenditures totaled $1.877 trillion in 2013 and are projected to increase to $3.642 trillion in 2024. Government’s share of overall health spending was 64.3% of national health expenditures in 2013 and will rise to 67.1% in 2024. Government health expenditures in the United States account for a larger share of gross domestic product (11.2% in 2013) than do total health expenditures in any other nation.

Conclusions:  Contrary to public perceptions and official Centers for Medicare and Medicaid Services estimates, government funds most health care in the United States. Appreciation of government’s predominant role in health funding might encourage more appropriate and equitable targeting of health expenditures.

From the Discussion

Americans pay the world’s highest health-related taxes. Yet many perceive that US health care financing system is predominantly private, in contrast to the universal tax-funded health care systems in nations such as Canada, France, or the United Kingdom. By 2024, government expenditures in the United States are expected to account for more than two thirds of national health spending. This is nearly the same proportion as in Canada, where official figures put government’s share at 70.7% (although this figure excludes modest tax subsidies for supplemental private coverage).

Public funds help the vast majority of Americans pay for care, but these funds flow through many different spigots. The funding streams for the poor, the elderly, veterans, family planning, and public sector workers are visible and hotly debated. Meanwhile, the hundreds of billions in tax subsidies that disproportionately benefit wealthier Americans have drawn far less public attention.

Although taxpayers fund the vast majority of health spending, overall priorities for this funding are rarely discussed. Appreciation of the magnitude of government funding might encourage more explicit, appropriate, and equitable targeting of these expenditures as components of a total health budget.

http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302997

We often hear that we cannot afford the taxes to pay for a single payer national health program – an improved Medicare for all. Yet we are already paying most of the taxes that would be required; it’s just that they are relatively obscure and thus not recognized by most taxpayers.

By 2024, government expenditures will pay for more than two-thirds of national health spending (up from 64.3% in 2013). “Government health expenditures in the United States account for a larger share of gross domestic product (11.2% in 2013) than do total health expenditures in any other nation,” according to this study. Our government health expenditures alone are more than both government and private health expenditures in any other nation. We are paying for a national health program, but we are not getting it.

Most people are aware of the insurance premiums and out of pocket expenses that they and their employers pay for health care, so they tend to think that most health care spending is private. They are aware of the payroll deduction for Medicare, but they do not tend to consciously connect other taxes, especially income taxes, with expenditures for Part B and Part D Medicare, Medicaid, CHIP, the VA system and other government health programs. Also, totally out of mind is the portion of personal and corporate income taxes that help pay for government health programs – taxes that are built into the pricing of consumer goods and services (not to mention that the cost of employee health benefit programs is also built into consumer prices). (This may be double counting for the tax tally, but higher health spending in the U.S. does pass on opaque employer plan health costs to the consumer.) And one of the largest silent taxes is the tax expenditure (tax subsidies) on the federal, state and local level that help pay for private, employer-sponsored health plans. Also, we are paying, through taxes, for most of the health benefits offered to federal, state and local government employees.

The roughly $300 billion we pay for tax expenditures for employer-sponsored health plans (will be over $500 billion by 2024) is a prime example of how dysfunctional our health care financing is. The subsidies are credited in direct proportion to income – the higher a person’s income, the greater the subsidy. That is really unfair to lower-income individuals and families who may be paying the same insurance premium, directly or indirectly through forgone wage increases, as the higher-income employees do, but at a greater dollar amount than those with higher incomes after the subsidy is applied, and at a much greater percentage of income. This is a highly regressive tax policy.

The point is, we are already spending our taxes on the health care system, and we can do it much more equitably through a well-designed single payer program. Not only would we increase transparency, we would also reduce inefficient spending by eliminating the private insurance industry, saving more in premiums than would be the increase in taxes. The next time someone says that we cannot afford the taxes for a single payer system – clue him or her in. Let everyone know that it is time to demand much greater value for the enormous amount of taxes that we are already paying for health care.

More Hispanic children covered, but do we need a public option?

Historic Gains in Health Coverage for Hispanic Children in the Affordable Care Act’s First Year

By Sonya Schwartz, Alisa Chester, Steven Lopez, and Samantha Vargas Poppe
Georgetown University Health Policy Institute & National Council of La Raza, January 2016

Key Findings

1. Uninsurance rates for Hispanic children reached a historic low in the first year that the Affordable Care Act’s (ACA) coverage provisions took effect. The number of uninsured Hispanic children dropped by approximately 300,000 children, from about 2 million uninsured Hispanic children in 2013 to 1.7 million in 2014. The uninsurance rate for Hispanic children declined by nearly 2 percentage points from 11.5 to 9.7 percent in the same one-year time period.

2. Hispanic children were much more likely to have health coverage in states that have taken multiple steps to expand coverage for children and parents. In 2014, 20 states had uninsurance rates for Hispanic children that were significantly below the national average. Of these, 16 states covered children in Medicaid and the Children’s Health Insurance Program (CHIP) above 255 percent of the Federal Poverty Level (FPL, the median eligibility level for children), 18 states provided Medicaid and/or CHIP coverage to lawfully residing children in the five-year waiting period, and 17 states extended Medicaid to low-income parents and other adults.

3. Despite these gains, health coverage inequities for Hispanic children remained. Hispanic children accounted for a much greater share of the uninsured child population (39.5 percent) than the child population at large (24.4 percent) in 2014. These inequities existed even though the vast majority of uninsured Hispanic children were eligible for Medicaid and CHIP, but unenrolled.

http://ccf.georgetown.edu/wp-content/uploads/2016/01/CCF-NCLR-Uninsured-Hispanic-Kids-Report-Final-Jan-14-2016.pdf

***

Comment:

By Don McCanne, M.D.

They say that the historic gains in health coverage for Hispanic children is one of the many accomplishments of the Affordable Care Act (ACA) that we can celebrate. From 2013 to 2014 the number uninsured Hispanic children declined from about 2 million to 1.7 million.

Of course, under a well-designed single payer system, that number would have dropped to zero, not only for Hispanic children, but for everyone. Yet, now that single payer has been thrust back into the political debate, the sides are lining up between those who say that we should try to build on ACA and those who say that we should move to single payer, improved Medicare for all.

Now be real. With ACA, we have reduced the number of uninsured Hispanic children by about 300,000. What kind of adjustments would we have to make in ACA to insure the other 1,700,000? With greater outreach to the eligible children, we might be able knock that number down a little bit more, but there is no mechanism under ACA, even if tweaked, that we could use to come anywhere near eliminating uninsurance.

The ongoing, highly publicized debate between two potential presidential candidates has produced a surge in interest in single payer, according to several polls. There is now a spate of opinion articles being written by progressives who have previously acknowledged the straightforward benefits of single payer. Ironically, many of these articles represent a retreat, taking the position that we have gained much with ACA and we should continue to build on it, that single payer is not politically feasible. Yet none of them have even hinted at the policies they would propose that would be truly effective in achieving the same goals as single payer, except maybe for the fantasy fix of the public option.

The public option would be only one more player in our dysfunctional, administratively complex, multi-payer system, and an expensive one at that. If it were a Medicare buy-in, would new enrollees be placed in the same risk pool as the elderly and people with long-term disabilities? That would require very high premiums because of the greater needs of these patients. Also Medicare covers only about one-half of health care costs and works only because almost everyone has some additional coverage such as Medigap, employer-based retiree coverage, Medicare Advantage, or Medicaid. So would people have to buy two plans – the Medicare buy-in plus some sort of Medigap plan? Too expensive and administratively wasteful. If the buy-in were a Medicare Advantage plan insurers would be reluctant to enter that market since it is subject to adverse selection and a death spiral because of the high premiums they would have to charge. Besides, Medicare Advantage plans are private plans and could hardly be categorized as a “public” option. Instead of using Medicare, could we start with a new government-run insurance plan? We would want to have reasonably comprehensive benefits, with a higher actuarial value to avoid excessive out-of-pocket costs, and we would want free choice of our health care professionals and institutions, all with no underwriting (subjecting it to adverse selection). Since the government would require that it be budget-neutral, the premiums of such a plan would be much higher than any plan currently on the market. Forget that. Okay, so let’s offer an affordable public option that has spartan benefits, low actuarial value (high deductibles, etc.), and limited choice of narrow networks. Wait a minute. Isn’t that where ACA is taking us? Do we really want the public option to be just another player on the ACA exchanges? How could that ever be considered an incremental step that would bring us closer to single payer?

Back to those 1,700,000 uninsured Hispanic children. Do we want all of them insured, along with everyone else? It will never happen under ACA since thousands of tweaks would not be enough to make it an effective financing system that would take care of everyone. The fundamental ACA infrastructure is irreparably flawed. We have to let these sheep in progressive clothes – the aforementioned opinion writers – know that they are flat-out wrong. Instead of whining about feasibility, we need to change the politics so that single payer becomes the only feasible choice.

Or shall we simply continue on the ACA path and adopt some more tweaks so that in the next decade or so we can get maybe another 300,000 Hispanic children insured? And the other 1,400,000 Hispanic children? Under single payer, we wouldn’t have to ask that.

(Note: While we are battling for single payer, we do need to continue tweaking ACA. California’s Health for All Kids law will allow about 170,000 of the state’s 497,000 uninsured children to quality for Medi-Cal, plus many others are already qualified but do not enroll. But we cannot allow ACA tweaking to in any way diminish our drive toward national single payer.)

More Hispanic children covered, but do we need a public option?

Historic Gains in Health Coverage for Hispanic Children in the Affordable Care Act’s First Year

By Sonya Schwartz, Alisa Chester, Steven Lopez, and Samantha Vargas Poppe
Georgetown University Health Policy Institute & National Council of La Raza, January 2016

Key Findings

1. Uninsurance rates for Hispanic children reached a historic low in the first year that the Affordable Care Act’s (ACA) coverage provisions took effect. The number of uninsured Hispanic children dropped by approximately 300,000 children, from about 2 million uninsured Hispanic children in 2013 to 1.7 million in 2014. The uninsurance rate for Hispanic children declined by nearly 2 percentage points from 11.5 to 9.7 percent in the same one-year time period.

2. Hispanic children were much more likely to have health coverage in states that have taken multiple steps to expand coverage for children and parents. In 2014, 20 states had uninsurance rates for Hispanic children that were significantly below the national average. Of these, 16 states covered children in Medicaid and the Children’s Health Insurance Program (CHIP) above 255 percent of the Federal Poverty Level (FPL, the median eligibility level for children), 18 states provided Medicaid and/or CHIP coverage to lawfully residing children in the five-year waiting period, and 17 states extended Medicaid to low-income parents and other adults.

3. Despite these gains, health coverage inequities for Hispanic children remained. Hispanic children accounted for a much greater share of the uninsured child population (39.5 percent) than the child population at large (24.4 percent) in 2014. These inequities existed even though the vast majority of uninsured Hispanic children were eligible for Medicaid and CHIP, but unenrolled.

http://ccf.georgetown.edu/wp-content/uploads/2016/01/CCF-NCLR-Uninsured-Hispanic-Kids-Report-Final-Jan-14-2016.pdf

They say that the historic gains in health coverage for Hispanic children is one of the many accomplishments of the Affordable Care Act (ACA) that we can celebrate. From 2013 to 2014 the number uninsured Hispanic children declined from about 2 million to 1.7 million.

Of course, under a well-designed single payer system, that number would have dropped to zero, not only for Hispanic children, but for everyone. Yet, now that single payer has been thrust back into the political debate, the sides are lining up between those who say that we should try to build on ACA and those who say that we should move to single payer, improved Medicare for all.

Now be real. With ACA, we have reduced the number of uninsured Hispanic children by about 300,000. What kind of adjustments would we have to make in ACA to insure the other 1,700,000? With greater outreach to the eligible children, we might be able knock that number down a little bit more, but there is no mechanism under ACA, even if tweaked, that we could use to come anywhere near eliminating uninsurance.

The ongoing, highly publicized debate between two potential presidential candidates has produced a surge in interest in single payer, according to several polls. There is now a spate of opinion articles being written by progressives who have previously acknowledged the straightforward benefits of single payer. Ironically, many of these articles represent a retreat, taking the position that we have gained much with ACA and we should continue to build on it, that single payer is not politically feasible. Yet none of them have even hinted at the policies they would propose that would be truly effective in achieving the same goals as single payer, except maybe for the fantasy fix of the public option.

The public option would be only one more player in our dysfunctional, administratively complex, multi-payer system, and an expensive one at that. If it were a Medicare buy-in, would new enrollees be placed in the same risk pool as the elderly and people with long-term disabilities? That would require very high premiums because of the greater needs of these patients. Also Medicare covers only about one-half of health care costs and works only because almost everyone has some additional coverage such as Medigap, employer-based retiree coverage, Medicare Advantage, or Medicaid. So would people have to buy two plans – the Medicare buy-in plus some sort of Medigap plan? Too expensive and administratively wasteful. If the buy-in were a Medicare Advantage plan insurers would be reluctant to enter that market since it is subject to adverse selection and a death spiral because of the high premiums they would have to charge. Besides, Medicare Advantage plans are private plans and could hardly be categorized as a “public” option. Instead of using Medicare, could we start with a new government-run insurance plan? We would want to have reasonably comprehensive benefits, with a higher actuarial value to avoid excessive out-of-pocket costs, and we would want free choice of our health care professionals and institutions, all with no underwriting (subjecting it to adverse selection). Since the government would require that it be budget-neutral, the premiums of such a plan would be much higher than any plan currently on the market. Forget that. Okay, so let’s offer an affordable public option that has spartan benefits, low actuarial value (high deductibles, etc.), and limited choice of narrow networks. Wait a minute. Isn’t that where ACA is taking us? Do we really want the public option to be just another player on the ACA exchanges? How could that ever be considered an incremental step that would bring us closer to single payer?

Back to those 1,700,000 uninsured Hispanic children. Do we want all of them insured, along with everyone else? It will never happen under ACA since thousands of tweaks would not be enough to make it an effective financing system that would take care of everyone. The fundamental ACA infrastructure is irreparably flawed. We have to let these sheep in progressive clothes – the aforementioned opinion writers – know that they are flat-out wrong. Instead of whining about feasibility, we need to change the politics so that single payer becomes the only feasible choice.

Or shall we simply continue on the ACA path and adopt some more tweaks so that in the next decade or so we can get maybe another 300,000 Hispanic children insured? And the other 1,400,000 Hispanic children? Under single payer, we wouldn’t have to ask that.

(Note: While we are battling for single payer, we do need to continue tweaking ACA. California’s Health for All Kids law will allow about 170,000 of the state’s 497,000 uninsured children to quality for Medi-Cal, plus many others are already qualified but do not enroll. But we cannot allow ACA tweaking to in any way diminish our drive toward national single payer.)

High deductibles do not increase patient price shopping

Cost-Sharing Obligations, High-Deductible Health Plan Growth, and Shopping for Health Care

By Anna D. Sinaiko, PhD; Ateev Mehrotra, MD; Neeraj Sood, PhD
JAMA Internal Medicine, January 19, 2016

The rapid growth of high-deductible health plans (HDHP) has been driven in part owing to a belief that cost-sharing obligations (ie, having skin in the game) will encourage health insurance enrollees to shop for health care. The wide variation in costs across physicians and hospitals implies considerable opportunity for enrollees to save money by switching to lower-cost providers. High-deductible health plan enrollment is associated with lower health care spending. However, prior studies using health insurance claims data indicate these savings are primarily owing to decreased use of care and not because HDHP enrollees are switching to lower-cost providers. Limited prior work has assessed attitudes toward price shopping among HDHP enrollees and whether they were more likely to consider costs when seeking care.

From Methods

We surveyed a nationally representative sample of insured US adults between 18 and 64 years of age who used medical care in the last year and compared HDHP enrollees with people in traditional plans on rates of shopping for care. The definition of an HDHP was established as a health plan having an individual deductible greater than $1250 or a family deductible greater than $25006 or a health plan that included a health savings account.

From Results

During their last use of medical care, HDHP enrollees were no more likely than enrollees in traditional plans to consider going to another health care professional for their care (n = 120 [10.9%] vs n = 85 [10.0%]; P = .67), or to compare out-of-pocket cost differences across health care professionals (n = 42 [3.8%] vs n = 23 [2.7%]; P = .37).

From Discussion

Simply increasing a deductible, which gives enrollees skin in the game, appears insufficient to facilitate price shopping. Members of HDHP and traditional plans are equally likely to price shop for medical care, and they hold similar attitudes about health care prices and quality.

http://archinte.jamanetwork.com/article.aspx?articleid=2482348

Editor’s Note

High-Deductible Health Plans and Higher-Value Decisions

By Joseph S. Ross, MD, MHS

High-deductible health plans — insurance plans that have lower premiums but higher deductibles than traditional health plans — have been increasingly promoted as a means to incentivize higher-value health care decision making. However, we have little information on how individuals take accessibility, cost, and quality information into account when making health care decisions. Moreover, there remains uncertainty about whether individuals will obtain recommended health care services while at risk for greater out-of-pocket costs.

In this issue of JAMA Internal Medicine, Sinaiko and colleagues conduct an internet-based survey of enrollees in high-deductible health plans and traditional health plans to better understand how they think about health care decisions. Individuals enrolled in plans with different financial incentives actually share many of the same beliefs about health care pricing and how to obtain high-quality care. Both rarely consider obtaining care from a different health care professional and even less often compare costs among health care professionals. Despite the limitations of an internet-based sample and few questions to disentangle the nuance of decision making, an interpretation of this study could be that high-deductible health plans are rationally designed for individuals who do not yet have access to sufficient information to make higher-value decisions in today’s market, suggesting that these plans have not yet succeeded at making cost and quality information more available and more actionable for their enrollees. However, a more likely interpretation is that getting enrollees to make higher-value decisions remains a mirage. High-deductible health plans take advantage of an irrationally designed health care system. In fact, information about our health care system is asymmetric in that it is better understood by physicians and less so by patients, which means patients obtaining care are not truly informed decision makers.

It is true that high-deductible health plan enrollees have “skin in the game.” However, these enrollees are exposed to substantial out-of-pocket cost risk with little evidence that this risk exposure will incentivize higher-value health care decisions, meaning they are essentially playing the game blindfolded with one hand tied behind their back.

http://archinte.jamanetwork.com/article.aspx?articleid=2482346

***

Comment:

By Don McCanne, M.D.

This study shows that individuals with high-deductible health plans (HDHP) are no more likely to select their care based on their out-of-pocket costs than do individuals enrolled in traditional health plans without high deductibles. As the editorial states, it is likely that “getting enrollees to make higher-value decisions remains a mirage.”

So high deductibles do not cause patients to be smart shoppers, but they do cause patients to decline beneficial health care services. They also create financial hardships for some patients. Thus high deductibles have a net negative impact. We should get rid of them. A single payer system is a much more efficient and patient-friendly method of controlling health care spending.

High deductibles do not increase patient price shopping

Cost-Sharing Obligations, High-Deductible Health Plan Growth, and Shopping for Health Care

By Anna D. Sinaiko, PhD; Ateev Mehrotra, MD; Neeraj Sood, PhD
JAMA Internal Medicine, January 19, 2016

The rapid growth of high-deductible health plans (HDHP) has been driven in part owing to a belief that cost-sharing obligations (ie, having skin in the game) will encourage health insurance enrollees to shop for health care. The wide variation in costs across physicians and hospitals implies considerable opportunity for enrollees to save money by switching to lower-cost providers. High-deductible health plan enrollment is associated with lower health care spending. However, prior studies using health insurance claims data indicate these savings are primarily owing to decreased use of care and not because HDHP enrollees are switching to lower-cost providers. Limited prior work has assessed attitudes toward price shopping among HDHP enrollees and whether they were more likely to consider costs when seeking care.

From Methods

We surveyed a nationally representative sample of insured US adults between 18 and 64 years of age who used medical care in the last year and compared HDHP enrollees with people in traditional plans on rates of shopping for care. The definition of an HDHP was established as a health plan having an individual deductible greater than $1250 or a family deductible greater than $25006 or a health plan that included a health savings account.

From Results

During their last use of medical care, HDHP enrollees were no more likely than enrollees in traditional plans to consider going to another health care professional for their care (n = 120 [10.9%] vs n = 85 [10.0%]; P = .67), or to compare out-of-pocket cost differences across health care professionals (n = 42 [3.8%] vs n = 23 [2.7%]; P = .37).

From Discussion

Simply increasing a deductible, which gives enrollees skin in the game, appears insufficient to facilitate price shopping. Members of HDHP and traditional plans are equally likely to price shop for medical care, and they hold similar attitudes about health care prices and quality.

http://archinte.jamanetwork.com/article.aspx?articleid=2482348

Editor’s Note

High-Deductible Health Plans and Higher-Value Decisions

By Joseph S. Ross, MD, MHS

High-deductible health plans — insurance plans that have lower premiums but higher deductibles than traditional health plans — have been increasingly promoted as a means to incentivize higher-value health care decision making. However, we have little information on how individuals take accessibility, cost, and quality information into account when making health care decisions. Moreover, there remains uncertainty about whether individuals will obtain recommended health care services while at risk for greater out-of-pocket costs.

In this issue of JAMA Internal Medicine, Sinaiko and colleagues conduct an internet-based survey of enrollees in high-deductible health plans and traditional health plans to better understand how they think about health care decisions. Individuals enrolled in plans with different financial incentives actually share many of the same beliefs about health care pricing and how to obtain high-quality care. Both rarely consider obtaining care from a different health care professional and even less often compare costs among health care professionals. Despite the limitations of an internet-based sample and few questions to disentangle the nuance of decision making, an interpretation of this study could be that high-deductible health plans are rationally designed for individuals who do not yet have access to sufficient information to make higher-value decisions in today’s market, suggesting that these plans have not yet succeeded at making cost and quality information more available and more actionable for their enrollees. However, a more likely interpretation is that getting enrollees to make higher-value decisions remains a mirage. High-deductible health plans take advantage of an irrationally designed health care system. In fact, information about our health care system is asymmetric in that it is better understood by physicians and less so by patients, which means patients obtaining care are not truly informed decision makers.

It is true that high-deductible health plan enrollees have “skin in the game.” However, these enrollees are exposed to substantial out-of-pocket cost risk with little evidence that this risk exposure will incentivize higher-value health care decisions, meaning they are essentially playing the game blindfolded with one hand tied behind their back.

http://archinte.jamanetwork.com/article.aspx?articleid=2482346

This study shows that individuals with high-deductible health plans (HDHP) are no more likely to select their care based on their out-of-pocket costs than do individuals enrolled in traditional health plans without high deductibles. As the editorial states, it is likely that “getting enrollees to make higher-value decisions remains a mirage.”So high deductibles do not cause patients to be smart shoppers, but they do cause patients to decline beneficial health care services. They also create financial hardships for some patients. Thus high deductibles have a net negative impact. We should get rid of them. A single payer system is a much more efficient and patient-friendly method of controlling health care spending.

Forward to Single Payer Health Care

By Kay Tillow
Daily Kos, Jan. 17, 2016

A new day is breaking for single payer health care. This concept of publicly funded, universal health care, locked out of the national debate six years ago, has made it on stage in the presidential debates. Millions of people are hearing the concept of single payer (an improved Medicare for all) for the first time, and they like what they hear.

The December Kaiser tracking poll has reported that 58% of people support Medicare for All. Among Democrats the support is 81%, Independents 60%, and Republicans 30%.

Seven more Congresspersons signed on to HR 676 in December and January bringing the cosponsors on Rep. John Conyers’ HR 676, Expanded and Improved Medicare for All, to a total of 60. This is the model single payer legislation in Congress that would assure care to all with no premiums, no co-pays, no deductibles. All medically necessary care, including dental and drugs, would be covered. Everyone would choose their own physician and hospital—no more networks, preferred providers, or surprise bills from someone in the surgical suite who was not on your insurance company’s approved list.

The US is the only industrialized country that has not yet moved to a system of universal healthcare. That failure takes a toll on our health, our lives, our economy. The US pays over $9,000 per capita annually yet the median is under $4,000 in the countries that make up the Organization of Economic Cooperation and Development.

We pay more but get less. We rank 19th out of 19 countries in preventing deaths due to causes that were amenable to medical care. The US does poorly in life expectancy—51st in rank among the countries of the world. We live up to 4 years less than people in the countries that have universal health care systems. Our infant mortality rate is going up instead of down leaving us at 28th in the world. The US rate for maternal mortality is 12.7 per 100,000 live births. Canada’s is 4.8.

In terms of equality, the US has a long way to go. A study by Dr. Adewale Troutman and Surgeon General David Satcher found that there are over 83,000 excess deaths annually among African Americans. Employers whose workforce is predominately female can still charge higher prices for health coverage because of that fact. Insurers who sell on the exchanges can charge up to three times the regular premium because of age. The drugs and care crucial to those with AIDS, MS, epilepsy, leukemia, cancer, mental health and a host of other problems can be priced beyond the reach of patients. Discrimination has not ended.

In December of this year the Kaiser Tracking Poll reported that 46% of the population views the health care reform law passed in 2010 as unfavorable while 40% view it favorably. That is not all attributable to the crazed campaign of misinformation perpetrated by the far right. The very real problems that were not solved by the law plague us with differing impacts on various strata, but leaving no one truly protected. When the ACA is fully implemented, over 30 million will still be uninsured. That alone will bring us 30,000 unnecessary deaths per year.

While the uninsured numbers have diminished, the underinsured, those who nominally have insurance but cannot afford care, are increasing. Over 25% of the insured go without needed care because of the cost. That rises to 46% in low income families. Premiums rise by double digits. Deductibles are now in the thousands. Insurance is no longer a guarantee against bankruptcy. While the provisions of the ACA pour billions into subsidies to the insurance companies, care is priced beyond the means of far too many. Doctors and hospitals are off limits in the networks set up by the insurers who still control our system, and state insurance departments are unable to keep up with regulations.

We deserve better. Across the country and here in Kentucky the single payer movement is gaining support. The city of Vicco in Eastern Kentucky’s Floyd County passed a resolution endorsing HR 676. The city commissioners sent their resolution to Congressman Hal Rogers asking him to sign on. Boyle County has also passed a resolution for HR 676. So has the city of Louisville, the city of Morehead, and the Kentucky House of Representatives. This past year medical students at the University of Louisville organized a student chapter of Physicians for a National Health Program, and a group of their colleagues at the University of Kentucky are working to do the same. A campaign of outreach, education, and activism can win more hearts and minds to this real solution.

We have an immediate fight on our hands to block any backward steps in Medicaid expansion. The new governor has threatened to impose onerous conditions on this best part of the ACA, and all people of good will must demand that our Frankfort representatives stop the threat.

But the current health system will never cover us all, never end the denial of care, never stop the rationing based on the ability to pay. It’s your money or your life in this market-based system.

The costs for those who must purchase insurance will continue to increase. The deductibles and co-pays will rise. Employer-based insurance will continue to depress wages as employers shift more of the costs onto the workers. Cadillac plans are rare. We have mostly broken down junkers.

The essential difference between the US and other countries is that the insurance companies are at the center of our health care system. Their drive for profit is at the core of why health care is so expensive. Over 30% of US health costs are attributable to profits and administrative costs.

Insurance companies and their experts say the high costs are due to overuse of care. It just isn’t true. In the US we visit physicians half as much as those in other countries, and we spend fewer days in the hospital. All of the co-pays and deductibles and all of the cost control efforts written into the ACA are based on this wrong diagnosis.

Marcia Angell, MD, former editor of the New England Journal of Medicine, says that under our current market-based system, we cannot simultaneously improve care and lower costs. Improving care costs more. Cutting costs cuts care. To change those dynamics, we must cut out the cause of the problem—the profit-based insurance companies. That will allow us to remove the administrative wastes and profits and apply those funds to extending care to everyone and improving it for all. It’s the right thing to do! Let’s make it happen.

Kay Tillow is a leader of Kentuckians for Single Payer Health Care and the All Unions Committee for Single Payer Health Care–HR 676. She resides in Louisville.

http://www.dailykos.com/stories/2016/1/17/1471029/-Forward-to-Single-Payer-Health-Care?_=2016-01-17T11:07:03-08:00