By David Himmelstein and Steffie Woolhandler
The Huffington Post, January 29, 2016

Professor Kenneth Thorpe recently issued an analysis of Senator Bernie Sanders’ single-payer national health insurance proposal. Thorpe, an Emory University professor who served in the Clinton administration, claims the single-payer plan would break the bank.

Thorpe’s analysis rests on several incorrect, and occasionally outlandish, assumptions. Moreover, it is at odds with analyses of the costs of single-payer programs that he produced in the past, which projected large savings from such reform (see this study, for example, or this one).

We outline below the incorrect assumptions behind Thorpe’s current analysis:

1. He incorrectly assumes administrative savings of only 4.7 percent of expenditures, based on projections of administrative savings under Vermont’s proposed reform.

However, the Vermont reform did not contemplate a fully single-payer system. It would have allowed large employers to continue offering private coverage, and the continuation of the FEHBP and Medicare programs. Hence, hospitals, physicians’ offices, and nursing homes would still have had to contend with multiple payers, forcing them to maintain the complex cost-tracking and billing apparatus that drives up providers’ administrative costs. Vermont’s plan proposed continuing to pay hospitals and other institutional providers on a per-patient basis, rather than through global budgets, perpetuating the expensive hospital billing apparatus that siphons funds from care.

The correct way to estimate administrative savings is to use actual data from real world experience with single-payer systems such as that in Canada or Scotland, rather than using projections of costs in Vermont’s non-single-payer plan. In our study published in the New England Journal of Medicine we found that the administrative costs of insurers and providers accounted for 16.7 percent of total health care expenditures in Canada, versus. 31.0 percent in the U.S. – a difference of 14.3 percent. In subsequent studies, we have found that U.S. hospital administrative costs have continued to rise, while Canada’s have not. Moreover, hospital administrative costs in Scotland’s single-payer system were virtually identical those in Canada.

In sum, Thorpe’s assumptions understate the administrative savings of single-payer by 9.6 percent of total health spending. Hence he overestimates the program’s cost by 9.6 percent of health spending — $327 billion in 2016, and $3.742 trillion between 2016 and 2024. Notably, Thorpe’s earlier analyses projected much larger administrative savings from single-payer reform — closely in line with our estimates.

2. Thorpe assumes huge increases in the utilization of care, increases far beyond those that were seen when national health insurance was implemented in Canada, and much larger than is possible given the supply of doctors and hospital beds.

When Canada implemented universal coverage and abolished copayments and deductibles there was no change in the total number of doctor visits; doctors worked the same number of hours after the reform as before, and saw the same number of patients. However, they saw their healthy and wealthier patients slightly less often, and sicker and poorer patients somewhat more frequently. Moreover, the limited supply of hospital beds precluded the kind of big surge in hospitalizations that Thorpe predicts. In health policy parlance, “capacity constraints” precluded a big increase in system-wide utilization.

Thorpe bases his estimates on what has happened when a small percentage of people in a community have had copayments eliminated or added. But in those cases there are no capacity constraints, so it tells us little about what would happen under a system-wide reform like single-payer.

Thorpe does not give actual figures for how many additional doctor visits and hospital stays he predicts. However, his estimates that persons with private insurance would increase their utilization of care by 10 percent and that those with Medicare-only coverage would increase utilization by 10 to 25 percent suggest that he projects about 100 million additional doctor visits and several million more hospitalizations each year – something that’s impossible given real-world capacity constraints. There just aren’t enough doctors and hospital beds to deliver that much care.

Instead of a huge surge in utilization, more realistic projections would assume that doctors and hospitals would reduce the amount of unnecessary care they’re now delivering in order to deliver needed care to those who are currently not getting what they need. That’s what happened in Canada.

3. Thorpe assumes that the program would be a huge bonanza for state governments, projecting that the federal government would relieve them of 10 percent of their current spending for Medicaid and CHIP — equivalent to about $20 billion annually.

No one has suggested that a single-payer reform would or should do this.

4. Thorpe’s analysis also ignores the large savings that would accrue to state and local governments — and hence taxpayers — because they would be relieved of the costs of private coverage for public employees.

State and local government spent $177 billion last year on employee health benefits – about $120 billion more than state and local government would pay under the 6.2 percent payroll tax that Senator Sanders has proposed. The federal government could simply allow state and local governments to keep this windfall, but it seems far more likely that it would reduce other funding streams to compensate.

5. Thorpe’s analysis also apparently ignores the huge tax subsidies that currently support private insurance, which are listed as “Tax Expenditures” in the federal government’s official budget documents.

These subsidies totaled $326.2 billion last year, and are expected to increase to $538.9 billion in 2024. Shifting these current tax expenditures from subsidizing private coverage to funding for a single-payer program would greatly lessen the amount of new revenues that would be required. Thorpe’s analysis makes no mention of these current subsidies.

6. Thorpe assumes zero cost savings under single-payer on prescription drugs and devices.

Nations with single-payer systems have in every case used their clout as a huge purchaser to lower drug prices by about 50 percent. In fact, the U.S. Defense Department and VA system have also been able to realize such savings.

In summary, professor Thorpe grossly underestimates the administrative savings under single-payer; posits increases in the number of doctor visits and hospitalizations that exceed the capacity of doctors and hospitals to provide this added care; assumes that the federal government would provide state and local governments with huge windfalls rather than requiring full maintenance of effort; makes no mention of the vast current tax subsidies for private coverage whose elimination would provide hundreds of billions annually to fund a single-payer program; and ignores savings on drugs and medical equipment that every other single-payer program has reaped.

In the past, Thorpe estimated that single-payer reform would lower health spending while covering all of the uninsured and upgrading coverage for the tens of millions who are currently underinsured. The facts on which those conclusions were based have not changed.

Drs. David Himmelstein and Steffie Woolhandler are professors of health policy and management at the City University of New York School of Public Health and lecturers in medicine at Harvard Medical School. The opinions expressed here do not necessarily reflect the views of those institutions.

http://www.huffingtonpost.com/david-himmelstein/kenneth-thorpe-bernie-sanders-single-payer_b_9113192.html?1454092127

PNHP note: Physicians for a National Health Program (PNHP) is a nonprofit, nonpartisan, educational and policy research organization that neither supports nor opposes any candidate for public office nor any political party.

Airtalk with Larry Mantle
Southern California Public Radio, KPCC, Jan. 28, 2016

PNHP note: The following are excerpts from an unofficial transcript of a debate between Dr. Steffie Woolhandler of Physicians for a National Health Program, a practicing primary care physician and professor in the City University of New York School of Public Health at Hunter College, and Avik Roy, senior fellow at the Manhattan Policy Institute and current health care adviser to Marco Rubio. Only the remarks of Dr. Woolhandler, PNHP’s co-founder, have been transcribed here. A link to the full audio of the debate is provided at the end.

Host Larry Mantle (LM): So Bernie Sanders’ claim is that if you take the profit out of American health care on the insurance side that there are huge savings there. If the government can negotiate with a position of great leverage drug manufacturers, you can drive down prescription drug rates. And without Americans having to pay health premiums, that the taxes would essentially even out with the savings that would be provided. We’re going to examine that claim and talk about what impact overall Sanders’ proposal would have on the American health care system.

With us is Dr. Steffie Woolhandler with Physicians for a National Health Program, an organization that advocates universal, comprehensive, single-payer national health care. Dr. Woolhandler, thank you for being with us. We appreciate it.

Steffie Woolhandler (SW): My pleasure.

LM: So first of all, let’s talk about, just real briefly, how a system like this would work. It sounds like he’s saying this would work for everybody the way Medicare works for seniors.

SW: Yes, and actually it would work a little bit better than Medicare works. Canada does have a single-payer program. It covers 100 percent of health care costs, first dollar to last dollar, for doctors’ care, for hospital care. Some provinces have pharma care, some don’t. When you have pharma care then drugs are folded in as well. The reason Canada can do this affordably is because they get such huge administrative cost savings by eliminating private health insurance. Total administrative costs in health care are only about 16 percent of spending in Canada. You have to compare that to 31 percent of total U.S. health spending that goes for overhead and paperwork and administration. So the difference between those percentages is about 14 percent of total health spending that you can save through administrative simplification with a single payer is a huge amount of money, about $400 billion annually that would be freed up to improve care.

LM: Let’s talk about what the federal government, in expense, would have to do ramp up though, because already Medicare fraud is a huge expense to taxpayers. So presumably you’d have to bulk up the federal government’s capacity to investigate fraud considerably, you’d have to build a much larger federal infrastructure for health care. How would that cost compare to what the costs are for the private insurers.

SW: You’re absolutely wrong on that. In fact, if you have a single-payer system it’s potentially easier to identify fraud. So there was, for instance, a doctor in Canada who was billing for $125,000 worth of urinalysis tests, which is a ridiculous number of tests. That’s fraud. It was very easy to detect because all of the bills were sent to the single payer, and you could see what’s going on. So actually you’re in a much better position to identify and eliminate fraud if you have a single payer that sees all of the bills that the doctors and the hospitals send. The other thing I want to say is that we know how much a public bureaucracy costs. We can look at Canada, where the overhead on insurance is about 1 percent. We can look at our Medicare program, our traditional fee-for-service Medicare program. That overhead is about 2 percent. And you have to compare that to the overhead in private insurance firms which averages about 14 percent, but sometimes rises as high as 20 percent. So you get huge insurance overhead savings due to single payer, that’s not theoretical – we know it’s true from the data from our own Medicare program and the Canadian single payer.

LM. OK. Also, on the issue of doctor and hospital reimbursements, because the government wouldn’t employ physicians directly or hospitals, but that’s where the reimbursements would come from. How would the government keep doctors from opting out, at least some of them, in setting up boutique sorts of practices as we’re already seeing with some physicians leaving Medicare?

SW: Well Canada has a rule that if you accept any money from the public Medicare system, you have to be completely in the system, you have to take any patient in the system. There’s a handful of doctors who have opted out of Canada’s single payer, I think less than a dozen, but the overwhelming majority of doctors end up participating in the system because of the rule of 100 percent in, or 100 percent out. Now there are a couple of cosmetic surgeons who do things that aren’t covered by the single payer, but that’s a different story, but for most routine medical care the doctors are pretty much 100 percent participating in Canada.

LM: So the doctors would all – they couldn’t really set their rates. They’d all be paid the same, the great doctors, the mediocre doctors. Everybody gets paid the same under this.

SW: Well, that’s true at some level. Different specialties doing different things get paid slightly different amounts in Canada. What happens in Canada is that doctors’ fees are set by some combination of negotiation and regulation. The provincial medical society, which is like our state medical society, comes up with a fee schedule for the entire set of doctors in the province and they negotiate that with the provincial government. It’s rather contentious, but at the end of the day the Canadian doctors have done extremely well. Canadian primary care doctors are paid just as much as primary care doctors in the United States, and specialty doctors in Canada are paid somewhat more than primary care doctors in Canada, but not the huge kind of salaries that some high-paid specialists can reap in the United States. But the doctors are doing just fine financially; we know that because Canadian doctors can immigrate to the United States, and the net immigration is zero. They’re simply not crossing the border to come to the U.S. at this point.

LM: In Canada, if you’ve got a really expensive city like Vancouver to live in, do doctors there get an extra bump in their reimbursement for their overhead?

SW: The rates are set at the provincial level, and I assume there’s some bump for very high costs – when it’s expensive to run a practice. I’m not sure of that, but it does vary from province to province.

LM: We’re talking with Dr. Steffie Woolhandler of Physicians for a National Health Program. Talking about Sen. Bernie Sanders’ proposed Medicare for all, single-payer health care program. If you have questions about Bernie Sanders’ proposal, I know there’s a lot of you who are pro or con on it, and we are most interested in questions that you may have about it – the economics of it, how it would work, as opposed to just saying yea or nay. If you want to call in and take part, I welcome your questions. …

[At this point Mantle speaks with Avik Roy, who argues, inter alia, that under a single-payer program doctors and hospitals would have to take significant cuts in reimbursements, that Canadians face very long wait times to see a doctor or get treatment, can’t get the care they need and therefore travel to the U.S. to get it.]

LM: Let’s take the first point that doctors and hospitals would have to take significant cuts in reimbursements.

SW: The doctors in Canada are doing just fine. Their incomes are similar to primary care doctors in the United States. The hospitals are doing just fine. They’re not in bankruptcy, they have big modern hospitals that provide care. The insurance companies took a major hit under single payer. They were more or less put out of the health care business. The drug companies took a major hit under single payer. Their prices ended up being cut in half. And the device industry takes a bit hit – their prices are cut in half. So it’s bad for insurers, the drug industry and device manufacturers, but it is not bad for doctors and hospitals, and frankly, it is not bad for patients. I was an attending physician at the Massachusetts General Hospital at Harvard Medical School, a world leader in medical care. We had patients from all over the world come to Mass General to get our services, but we did not see patients from Canada, despite being less than a 4-hour drive from the border. Canadian patients do not come to the United States in droves and that’s not just my anecdotal impression, that’s what’s been found when people have studied it. Avik’s figures about waiting lists are wildly exaggerated. The provinces post their wait times on the Internet; you can go and look at how long it would take, for instance, a prostate surgery. In British Columbia, it’s something like days to weeks. We’re not talking about months and years the way he’s implying. The Canadian public would not tolerate this kind of wait, and it’s a rumor that has been perpetrated by The Wall Street Journal, by conservative analysts like Avik, that everybody’s waiting for care, that they’re streaming across the border to get in the U.S. – it’s simply not the reality on the ground.

LM: Why do people then come to the U.S. for health care? What’s driving them?

SW: OK. There was a giant survey of 18,000 Canadians. Fewer than 100 had received health care in the United States in the past year. And all but 18 of those had been in the United States on vacation or business when they got acutely ill and had to get emergency care. There were only 18 cases of people who come to the United States in order to get medical care, and in many of those cases their own province had given them the money and said, “You can go across the border because you live near the border and the service is available there that you need.” So we’re not talking about a massive number of not being able to get the care that they need, in fact, the overwhelming majority of Canadians do get the care that they need, which is why the overwhelming majority of Canadians support their national single-payer program.

…

[A medical student in Houston calls in to ask if single payer would reduce reimbursements to doctors, exacerbating the problem of medical student debt because of high tuition rates.]

SW: I am a medical school faculty member, I have two children in medical school and we’re paying tuition, so I’m aware of the problem. Physicians for a National Health Program, the group I work with, put out a proposal and said medical school tuition should be free, because those costs are eventually paid back by the payers, by the single payer. You can pay for the tuition up-front – make med schools free – or you can make the students go into debt and pay it off over time. One way or another it’s going to be paid by the taxpayers under single payer. And we think it’s fair and more efficient and better for everyone if you just make medical school free. I would point out that Sen. Sanders has also advocated free tuition, but I’m not speaking on behalf of Sen. Sanders, I’m speaking on behalf of single payer here today.

http://www.scpr.org/programs/airtalk/2016/01/28/46098/policy-experts-debate-viability-of-senator-bernie/

PNHP note: Physicians for a National Health Program (PNHP) is a nonprofit, nonpartisan, educational and policy research organization that neither supports nor opposes any candidate for public office nor any political party.

By Ida Hellander, M.D.
Director of Health Policy and Programs, PNHP

Misinformation about single payer is nothing new. When the U.S. was at war with Germany in WWI, national health insurance was attacked as “the Kaiser’s health plan.” President Johnson’s Medicare program – which turned 50 last year – was aggressively red-baited as “socialized medicine” by the right.

Responses to 10 recent attacks on single payer in the news are below.

1. Single payer is an expensive “tax hike on the middle class.”
   
By eliminating the waste and bureaucracy associated with the private insurance industry, single payer saves over $400 billion (yes, that’s with a “b”) a year on administrative costs that can be funneled into patient care. That’s enough money to cover all the uninsured and to eliminate co-pays and deductibles for everyone. Negotiating drug prices with pharmaceutical companies, as other nations do, will save even more. As a result, single payer is able to cover everyone with no increase in national health spending, and is the only reform that pays for itself. A recent attack by Ken Thorpe that single payer will raise costs is refuted here.

Over the long term, single payer’s ability to control health care costs will generate even more savings compared to the status quo. At the current rate of medical inflation (5.6 percent), health care is projected to consume 20 percent of GDP in 2024 year, about double the share of GDP other wealthy nations devote to health care. Single payer controls costs with proven effective strategies such as negotiated fees with doctors, global budgets for hospitals and other institutions, bulk purchasing from drug and device companies, and real health planning for capital investment. Since Canada adopted a single-payer program, their health care costs have grown more slowly than costs in the U.S. One study estimated that U.S. could have saved over $2.2 trillion between 1980 and 2009 in the Medicare program alone if costs had grown at Canadian rates.

A new study shows that taxes already fund 64.3 percent of U.S. health spending. As a result, the tax increase necessary to fund a national health program is relatively low. Americans spend more public dollars per capita ($5,960 per capita in 2013) on health care than the citizens of other nations pay – including those with universal health systems – except Switzerland. In that sense, Americans are paying for national health insurance, but not getting it.

In terms of how single payer would be financed, PNHP does not have a specific plan, but advocates replacing most private funding from households and businesses – about one-third of health spending – with progressive taxes. Taxes would replace health benefit costs by employers and the heavy burden of current health care spending by families on insurance premiums, co-pays, and deductibles for medically necessary care.

In addition to replacing premiums and other health spending with income-based taxes, single payer redistributes the current burden of health care costs from the poor and sick (who often fall into bankruptcy from medical debt and job loss) to the wealthy. Health care costs must be redistributed because they are so high that people of low and middle-incomes can no longer afford health care. This is evidenced by research showing that medical bankruptcy was unaffected by ACA-like reforms in Massachusetts. The Milliman actuarial firm estimated the cost of health care for an average family of four in a PPO to be $23,215 in 2014, while average household income was $53,657. By redistributing health care costs, single payer helps reduce income equality.

The reason health care costs are so high in the U.S. is because we have a market-driven health care system. This is especially obvious with medications, as drug companies price their products as high as the market will allow, irrespective of how much it cost to develop and produce a drug. But it’s true across the medical-industrial complex: From hospitals to hospice care, studies show that for-profit health care raises costs and lowers quality. And among insurers, overhead is sevenfold high in private insurance than in the traditional Medicare program, where it is less than 2 percent.

Two possible financing schemes have been proposed for single payer, one for H.R. 676, single-payer legislation in the House, and another by Sen. Bernie Sanders. Both plans would raise household incomes for the vast majority of families. An attack on the Sanders financing plan is refuted here.

The Sanders plan would institute a small payroll tax or “income-based health premium” that would replace current health care spending by middle-class families on insurance premiums, co-pays, and deductibles for medically necessary care. (Goods and services that would not be covered include over-the-counter medications – $44 billion in 2014, or 1.5 percent of health spending – as well as luxury eyeglasses, cosmetic surgery, and some dental. Long-term care services would require case management.) In his financing plan, this tax is 2.2 percent of income. As a result, net household incomes for the vast majority of families would rise under single payer. Employers would also pay a payroll tax of 6.2 percent for health care for their workers that would replace what they are currently spending on health benefits (private employers pay 7.7 percent of total compensation towards health benefits, while state and local government pays 11.6 percent).

The Sanders plan redistributes the burden of health care costs from low- and middle-income households to the wealthy by raising marginal tax rates on incomes above $250,000, taxing capital gains, dividends, and estates, and closing some tax loopholes. The top one-tenth of 1 percent of households (average incomes of $2 million – $10 million) and in particular, the 1,300 wealthiest households (average incomes over $10 million) would pay the highest marginal tax rates (48 percent and 52 percent, respectively). The average middle-class household would pay less in taxes than they are already paying for care.

2. Single payer would “eliminate the ACA” and its protections for people with preexisting conditions.

In fact, single payer would replace current skimpy policies that are inadequate and require very high cost sharing (e.g. a $10,545 deductible for a “bronze” family plan, a $6,010 deductible for a “silver” plan) with guaranteed lifelong coverage regardless of age, income, or health status. It would also eliminate co-payments and deductibles, which is important for people with preexisting and chronic conditions, and anyone with a serious illness. A recent article by oncologists advocated for single payer because of the burden of the high cost of cancer care on their patients.

Single payer does not “eliminate” the ACA or require that we “re-litigate” old health debates. It moves the country forward, replacing the ACA and other public and private programs with a program that works by addressing the underlying cause of the health care crisis – a market-based health care system driven by profits, not patients.

3. Single payer would require that we pay physicians and hospitals less.

No. Single payer is not financed by reducing physician incomes and hospital revenues, but by slashing administrative overhead and bureaucracy associated with the private insurance industry and funneling those resources – $400 billion annually – into patient care. Currently, one-quarter of hospital spending goes to billing and insurance related overhead, and administrative work consumes one-sixth of physicians’ time. Doctors in the U.S. spend four times as much ($82,975) as Canadian physicians on overhead due to the complexity of our payment system. Private insurance overhead is sevenfold as much as Medicare’s. By slashing administrative costs, and monopsony purchasing of drugs and devices, single payer frees up enough money to expand coverage to the uninsured and eliminate co-pays and deductibles for everyone.

While physicians on the whole won’t make less, the gap between what the various specialties earn may narrow. In Canada, physician income has increased under their single-payer plan.

Single payer is also a potent tool for improving quality and detecting fraud in health care because health care utilization and payment information is all in one database, instead of hundreds of proprietary databases run by insurance companies. This makes it easy to identify outliers (e.g. a physician billing for many more tests than their peers) and to track what’s going on (e.g. the UK was able to easily track down every patient who had received a certain type of defective hip implant, and Medicare was able to detect inappropriate anti-psychotic prescribing to seniors in nursing homes).

4. Single payer will put state governors in charge of health care.

No. The ACA did that with Medicaid, after the Supreme Court ruled that the Medicaid expansion contained in the ACA was, in effect, optional. As a result of the opposition of Republic governors and legislatures, 5 million poor Americans in 19 states remain uninsured.

Single payer would be administered at the federal level, as Medicare is today. In some single-payer proposals, starting with the late Sen. Paul Wellstone and in earlier versions of Sen. Sanders’ plan, single payer would have been administered at the state level, like Canada’s provincial health plans, but the federal government would have taken over running the health system for any state that did not do so. Sen. Sanders’ current plan is administered at the federal level.

 5. Vermont decided not to adopt single payer because it was too expensive.

The Vermont plan, known as Green Mountain Care, was not a single-payer plan. The ultimate design for GMC retained multiple payers, and would have continued to pay hospitals and other institutional providers on a per-patient basis, perpetuating the expensive billing apparatus that siphons funds from care. Hospitals would have continued to rely on surpluses from day-to-day operations as their main source of capital funds, forcing hospital administrators to identify and pursue profit opportunities. Single payer pays hospitals via lump-sum budgets with separate grants for capital costs. Even so, it was political will, not cost, that defeated the Vermont health reform. The health exchange the state set up under the ACA didn’t work (as happened in several other states as well), draining political capital, and the governor barely squeaked through his re-election. A contributing factor was that the financing plan developed by the governor’s own team was not very progressive or diversified. Finally, making formerly hidden health care costs transparent by replacing them with taxes, even if the taxes are lower, is a heavy political lift.

6. Moving to a single-payer system would be a “tumultuous” experience. Single payer would require a massive transformation of the health care system.

Transitioning to single payer would be easier than for any other health reform, or dealing with annual insurance changes at work, for that matter. Americans would only need to enroll once for life, and most people could be automatically enrolled through the Social Security System. For those that aren’t enrolled automatically, it should be noted that Medicare enrolled 19 million people in 1966 with index cards, for a cost of $867 million (in today’s dollars), including the cost of beneficiaries’ medical care. In contrast, the transition to the ACA was filled with “glitches” and cost $6 billion.

The major change in the health system would be that patients would be able to choose their doctors and hospitals, and doctors would only need to bill one source. Patients would no longer receive medical bills and doctors and hospitals would no longer have to commit so much time and money to getting paid.

No other reform will actually control costs and get us to universal coverage. What is tumultuous is the health care crisis, which will remain until we have a single-payer system. Providers are rapidly consolidating into large health and hospital systems to gain market power and assure their revenues for the future. This process is raising, not lowering, costs. Consolidation would not be necessary under a single payer. In fact, by simplifying the payment system, single payer enables providers to return to small or solo practice if they choose.

7. A simple, efficient single payer is not politically feasible in the current Congress.

That’s why we need a grassroots mobilization and campaign finance reform, so that Congress can represent the people they are supposed to serve, not the insurance and drug companies. A December 2015 poll found that 58 percent of Americans support Medicare for All, including 81 percent of Democrats, 60 percent of Independents and even 37 percent of Republicans. Women’s suffrage and abolition were once politically infeasible too.

Incidentally, in 2009 the Democrats had the White House, a large majority in the House, and 60 Senators – all the votes needed to pass single payer. What was lacking was political will.

8. Single payer would cause “debate over abortion, contraception, HIV prevention, immigration policy, and other matters.”

This is a red herring. Controversial matters are debated all the time, in the context of health reform, and outside it, as with immigration policy.

As physicians, we advocate that everyone living and working in the U.S. be covered for all medically necessary care, including immigrants. Undocumented immigrants are currently excluded from many state and federal health programs, including the ACA, even though recent research shows that unauthorized immigrants contributed a net of $35.1 billion to the Medicare Trust Fund between 2000 and 2011.

9. Single payer would cut benefits for workers with employer-sponsored coverage.

Employer-sponsored benefits have been steadily eroding for over a decade, with more employees now saddled with unaffordable co-payments and deductibles. The average deductible for a family with HMO coverage is $2,758 and for an individual is $1,318. Also, workers are increasingly limited to a narrow network of providers. In contrast, 83 percent of primary care physicians and 91 percent of specialists nationally report they are accepting new Medicare patients, giving beneficiaries a much wide choice of doctors.

The ACA’s 40 percent excise tax on high-cost workplace private health insurance, the misnamed Cadillac tax, had already begun to drive benefits down when it was postponed late last year. Although the tax wasn’t supposed to go into effect until 2018, unions negotiating multi-year contracts found that employers were using it as leverage at the bargaining table to push for wage and benefit cuts.

Single payer would improve benefits for children, working age-adults, and seniors (see note below) by eliminating out-of-pocket costs and premiums and by giving patients a free choice of providers. It would also end “job lock” whereby people have to stay in a job to keep their benefits.

Note: The current Medicare program requires co-payments and deductibles and requires beneficiaries to purchase drug coverage separately (with federal subsidies). Single payer would eliminate out-of-pocket costs and the need for separate drug coverage and supplemental plans. For that reason, national single payer legislation is called the “Expanded and Improved Medicare for all Act.” It would help seniors, who have average incomes of $23,500 and currently spend an average of $4,734 a year on out-of-pocket medical costs and premiums.

10. Single payer plans “lack details.”

Not all of them. Physicians for a National Health Program’s single-payer plan (cited in the New Yorker recently as a good model) has more details about how single payer would work in practice, and served as the model for national legislation, H.R. 676. PNHP’s proposal appeared in the Journal of the American Medical Association and may be found here.

But the length of a plan is not correlated with its effectiveness. Some single-payer plans, including plans adopted in other countries, have been succinct.

The Canada Health Act was just 8 pages long. It specified the five key principles of Canadian health insurance: Universal (“all insured residents”), Comprehensive (coverage for “all necessary health services”), Portable (from province to province), Accessible (“reasonable access to health facilities” and “reasonable compensation” for providers, and Public Administration. Every provincial health plan must meet these principles, which have stood the test of time.

Rep. John Conyers single payer plan, H.R. 676, is just 30 pages long.

Conversely, the ACA contains 906 pages of details, but it hasn’t solved the health care crisis. The ACA was drafted by a former insurance company executive, Liz Fowler, who left government to become a lobbyist for a drug company.

****

The health care crisis by the numbers – 2016

33.0 million Americans (10.4 percent) are still uninsured, including 5 million children (Census Bureau).

31 million Americans are underinsured (Commonwealth Foundation). 20 percent of insured Americans have trouble paying their medical bills. Among those who reported having problems paying their bills despite having insurance, 63 percent said they used up all or most of their savings; and 43 percent said they skipped medical care they needed in the past year due to the cost (New York Times/Kaiser poll. 1/5/16).

Health care costs are high and rising by 5.6 percent a year. In 2014, health spending was $3.0 trillion, $9,523 per capita, 17.5 percent of GDP. By 2024 health care will be 19.6 percent of GDP, nearly 20 percent of the economy. Deductibles are rising seven times faster than wages. The average employer-based family policy costs $17,545, of which employees are paying $4,955 of the premiums for a plan with a deductible $2,758 for HMO coverage.

Drug prices are skyrocketing. Pfizer raised their list prices on over 60 brand name drugs with at least $10 million in annual U.S. sales by 10.6 percent at the beginning of the year, according to the Wall Street Journal (1/10/16). At least four other large drug firms have similarly raised prices across a broad spectrum of products for no reason other than to boost profits.

Dr. Ida Hellander is director of policy and programs at Physicians for a National Health Program, a 20,000-member nonprofit, nonpartisan organization of doctors headquartered in Chicago. She co-edits PNHP’s newsletter and specializes in teaching clinicians evidence-based health policy and empowering them to become effective advocates for reform.  Dr. Hellander received her B.A. from Yale and her M.D. from the University of Minnesota Medical School.  Before joining PNHP in 1992, she was a research associate with the Public Citizen Health Research Group.  She is a member of the International Association of Health Policy, a frequent contributor to the International Journal of Health Services and co-author of the book “Bleeding the Patient: The Consequences of Corporate Health Care.”