Readers of this blog are probably aware that I am a member
of Physicians for a National Health Program (PNHP)
and, like that organization, support the creation of a single-payer health
system in the US. Sometimes referred to as a Canadian-type health system, or as
in Sen. Bernie Sanders’ presidential campaign, “Medicare for All”, it is pretty
easy to understand, and is a system that has worked not only in Canada but, in
modified forms, in most developed countries in the world. The key feature of
such a system is that it is one program that covers everyone in the country, “Everybody In, Nobody Out”
in the title of the book by the late Quentin Young, MD, a
former President and executive director of PNHP and a “tiger for social justice”
in the words of his Chicago
Sun-Times obituary.
Such a system would replace the bewildering, dazzling,
complex, confusing mess of the current US health care system, with its hundreds
of different private insurance policies with widely varying benefits, premiums,
and coverage, as well as the federal programs of Medicare, federal-state
partnerships like Medicaid and the ACA’s health insurance exchanges, and of
course that persistent, pesky mass of 30 million or so uninsured. And the underinsured,
who are effectively uninsured, because they buy the only policy that they feel
that they can afford only to find out when they need it that it, surprise,
doesn’t cover what they need!
Much of the defense of the ACA has been based on the fact that
an insurance pool must have healthy as well as sick people. This is a core
tenet of insurance, which would otherwise be unaffordable. Life insurance
cannot work if it only covers people on their deathbeds; car insurance cannot
work if it only is purchased at the time of an accident, homeowner’s insurance
cannot work if it is only bought by people in the midst of a fire. If this were
how insurance worked, there would be no need for it, for the premiums would be
basically the same as paying for the cost of the services. To have it
otherwise, as insurance, requires a pool of money contributed by folks, whether
directly or through their taxes, who are not immediately benefiting to cover
those who need it. In fact, though, understandably but impossibly, people want
coverage for when they are sick, but don’t want to pay when they are not. People
may not want to pay a lot when they are healthy (or think that they are) but
they want coverage for their sick parents, or newborn with health problems, or
when they are diagnosed with cancer, or when their adolescents are in a car
wreck. These are things that don’t happen to most of us most of the time but
happen to enough of us over our lives that we know enough to fear or expect it.
A national single-payer system gets rid of this problem, by having the largest possible
risk pool.
But the people of the US did not elect Bernie Sanders, and
he did not even get the Democratic nomination. We elected (OK, the
Constitutional unfairness of the Electoral College elected) Donald Trump, whose
positions may be erratic and change frequently, but whose appointments to
Cabinet-level posts are remarkably consistent. Most are from the most right
wing of the Republican Party, not unlike we would have expected from Ted Cruz. Despite
a campaign that attacked Wall Street and the support Hillary Clinton received
from the financial sector, he has appointed many Wall Streeters, including several
former (and current) folks from Goldman Sachs -- most recently,
their lawyer whose wife still works for them, to head the SEC. Foxes
guarding the henhouse abound; climate change deniers will head the EPA and
Department of Energy. And in the same vein, we have, for Health and Human
Services nominee, Rep. Tom Price, the orthopedic surgeon from Georgia about
whom I wrote recently (“Trump,
Price, and Verma: Bad news for the health of Americans, including Trump voters”,
December 3, 2016).
Rep. Price certainly does not stand for a single-payer national
health system. Nor does he stand for ensuring health care for the vulnerable,
whether poor, elderly, rural, or sick, as demonstrated in an excellent piece in
the New England Journal of Medicine by
Sherry A. Glied and Richard Frank, “Care for the vulnerable
vs. cash for the powerful – Trump’s pick for HHS”. It notes that he “…favors
converting Medicare to a premium-support system and changing the structure of
Medicaid to a block grant,” which would mean that not only Medicaid, and the
coverage people have received under ACA, but even Medicare which has protected
seniors for 50 years, would be under threat. The article contains information about
his positions on other issues, including favoring greater access to
armor-piercing bullets, opposing regulations on cigars and on tobacco as a
drug, opposing the reauthorization of the Violence Against Women Act and laws
prohibiting discrimination against LGBT people. In terms of ensuring health
coverage he is as mean as they come:
His
voting record shows long-standing opposition to policies aimed at improving
access to care for the most vulnerable Americans. In 2007–2008, during the
presidency of George W. Bush, he was one of only 47 representatives to vote
against the Domenici–Wellstone Mental Health Parity and Addiction Equity Act,
which improved coverage for mental health care in private insurance plans. He
also voted against funding for combating AIDS, malaria, and tuberculosis;
against expansion of the State Children’s Health Insurance Program; and in
favor of allowing hospitals to turn away Medicaid and Medicare patients seeking
nonemergency care if they could not afford copayments.
But he is the President-elect’s health guy, and we might
think that the folks who voted for Mr. Trump will get what they wanted. Except
they probably won’t, other than that small slice of voters representing the
wealthiest providers, insurers, drug manufacturers, corporate executives, and
pundits (like the Wall
St. Journal’s Kim Strassel). The health
situation in the US is bad, particularly for lower income whites, whose
mortality rate has, remarkably, as reported by the Commonwealth Fund,
been static rather than decreasing or in some cases (low income women)
increasing. These are many of the same folks who voted for Donald Trump, and
are presumably looking for a solution. The Kaiser Foundation recently conducted
focus groups among Trump voters in states have been hard hit by job losses and
were key swing states in the election – Ohio, Michigan, and Pennsylvania. The
participants either had Medicaid or were covered by ACA. The results are
summarized by an op-ed in the New York
Times by Kaiser’s CEO, Drew Altman, “The
health care plan Trump voters really want”, January 5, 2017.
If
these Trump voters could write a health plan, it would, many said, focus on
keeping their out-of-pocket costs low, control drug prices and improve access
to cheaper drugs. It would also address consumer issues many had complained
about loudly, including eliminating surprise medical bills for out-of-network
care, assuring the adequacy of provider networks and making their insurance
much more understandable.
That’s what they want. That’s what I want. It is what I
believe a single-payer system would deliver. But it sure isn’t what they are
going to get from Tom Price, or from whatever “replacement” the Republicans
come up with for ACA.
And that’s more than a shame. It’s a scandal.
…
