Ed. Note: This is a chapter in a forthcoming book Ten Excellent Reasons for National Health Insurance, eds., Mary O'Brien, M.D. and Martha Livingston, Ph.D. (New Press).

 

THE TIME HAS COME for single payer National Health Insurance in the United States. We have excellent hospitals, skilled practitioners, the technological infrastructure -- and we're already spending enough money to insure everyone and to improve access to care for many who are covered today by inadequate plans. All we need is the political will.

Yes, the barriers to single payer reform are considerable, and we ignore them at our peril. Private, for-profit insurance companies will fight tooth and nail against a system that will remove them from any significant role in the country's health care. Big Pharma too will use its clout to try to defeat single payer. The drug companies want multiple fragmented private purchasers rather than a single public payer with the power to negotiate lower prices for everyone. Moreover, right now most politicians are of little help. They often take money from and are beholden to insurance and drug companies (though with sufficient popular pressure many politicians could change their stance, and could add important strength and credibility to the fight for single payer). In addition, numerous economists and health care "experts" lend legitimacy to the current system by advocating market-oriented reforms, which fail to be truly universal and meanwhile pour more money into private insurance companies. Finally, while employers often complain about the high cost of private health insurance premiums, they have thus far chosen to deal with rising premiums by shifting costs to their employees rather than by supporting a public insurance solution.

Overcoming these obstacles will require a public that demands single payer. The movement for single payer has made great strides, drawing on the fact that most people in this country already dislike and distrust insurance companies. But many Americans have grown increasingly distrustful of government in recent years. It is not uncommon to hear "You mean you want the government that didn't rescue New Orleans after Katrina, to solve the health care crisis? Forget it!" Moreover, those with health insurance frequently fear that they will lose the benefits they have now, and that the cost of a government-financed system will mean that they will have to pay extraordinarily high taxes and will end up even worse off than they are now.

However, the arguments against single payer don't measure up to the evidence. Here are some false claims the opponents make:

• Universal coverage costs too much. No, it doesn't. Every other industrialized nation offers its people universal coverage, and at a cost much lower than we now spend in the United States, which covers only part of its population. In 2005, we spent 15.3 percent of our Gross Domestic Product on health care compared to France's 11.1 percent, Germany's 10.7 percent, and Canada's 9.8 percent.¹ Yet, in 2005 we had 45 million uninsured (it's two million more at this writing!) while other industrialized countries covered everyone's health care.

• Your taxes will go up. Perhaps, but you are still likely to come out ahead when you consider the overall expenses. Single payer will cost most people the same or less than the premiums and medical bills they are paying today, and will be secure regardless of employment or income. Both the Congressional Budget Office and the General Accounting Office have testified that the United States could insure everyone for the amount of money we're spending.²

• Americans get world-class care -- don't mess around with that. The fact is that the average American doesn't get world-class care. Sure, if you are wealthy and have the best private insurance, your chances of getting excellent care are high. But on almost all measures of health care and mortality, we lag behind Canada and Europe.³

• Other countries have much longer waiting times than we do. In actuality in other industrialized countries there are no waiting lists for emergency surgery or urgently needed procedures. It's true that the United States has shorter waits for elective surgery than Canada and England. But recent studies show that some waiting times in the U.S. are longer than in other countries. For example, in a study of seven developed countries, the Commonwealth Fund looked at how many sick adults had to wait six days or more for an appointment.⁴ By this measure, only Canada's record was worse than ours. Within our market-driven system, an appointment for cosmetic surgery may be scheduled sooner than an appointment for possible skin cancer. A recent study⁵ reported an average wait of 73 days for patients with possible skin cancer in Boston.

• People get care even if they're uninsured -- there is no problem. Don't tell that to the American Cancer Society (ACS), which in September 2007 worked with its sister advocacy organization, the ACS Cancer Action Network, to launch a major initiative to make the access to health care a state and national priority. Research shows that uninsured patients were much more likely to have their cancers diagnosed at an advanced stage, when they are less curable, than were patients with insurance.⁶ John Seffrin, the Society's chief executive, has stated that unless the health care system is fixed "lack of access will be a bigger cancer killer than tobacco."⁷ And of course the problem isn't limited to cancer: the Institute of Medicine estimates there are 18,000 deaths per year due to lack of insurance.⁸ Unnecessary suffering and disease affect millions more who have no insurance or are under-insured.

• Single payer is socialized medicine. But single payer is not socialized medicine, because for the most part government will not own the hospitals and physicians will not be on salary to government. It simply changes the financing of health care; the health care delivery system remains the same. It will operate like the Medicare program for the elderly today, in which patients are seen by private doctors in (mostly) private hospitals; this clearly isn't socialized medicine. Single payer is actually "social insurance" rather than "private insurance."

The times they are a- changing. Everyone -- most Democrats and some Republicans -- is talking about the need for universal health care coverage and cost controls. It's true that a minority of mainstream politicians endorse single payer at this time. But more and more people have jobs with no insurance, and those with insurance are seeing their employers reduce their benefits and increase their contributions for premiums, year by year. The latest General Motors-United Auto Workers agreement points toward a grim future in which employers try to shed all responsibility for insuring their employees. Meanwhile, every study that compares single payer with tax deductions or tax subsidies to buy private health insurance shows that single payer costs less and guarantees better coverage to more people than all the other approaches.

The evidence supports single payer, and increasing numbers of people in this country are seeing that we don't have to be stuck with the irrational, expensive and cruel system we have. Michael Moore's SICKO! has made an incalculable contribution to overcoming ignorance about what is possible: Moore has shown us that by cutting the wasteful and totally unnecessary private insurance industry out of our health care system we can have real universal health insurance. Of course there have been vicious attacks on Moore but the strong positive response to SICKO -- from Oprah to the New York Times to Jon Stewart -- has begun to puncture the traditional U.S. media blackout of the truth about single payer. Perhaps most important, Moore has made a convincing case that government can work for people, and has brought outrage and a passion for justice to the fight for a humane health care system in the United States. He is helping to ignite the movement we will need to make it a reality.

More and more groups are endorsing HR 676. This is the bill in the U.S. House of Representatives introduced by Michigan's John Conyers, called The United States National Health Insurance Act or Expanded and Improved Medicare for All. As of this writing HR 676 has been endorsed by the National Organization for Women, the NAACP, and a wide variety of religious and civil groups, including We Be Illin', a group of young people reaching out to their peers to show why they urgently need single payer. HR676 has also been endorsed by 389 union organizations in 48 states including 96 Central Labor Councils and Area Labor Federations and 33 state AFL-CIOs (as of October 12, 2007). For an updated list, contact Kay Tillow, All Unions Committee For Single Payer Health Care -- HR 676, c/o Nurses Professional Organization (NPO), 1169 Eastern Parkway, Suite 2218, Louisville, KY 40217, (502) 636 1551. The AFL- CIO has adopted a policy statement favoring a Medicare for All approach. The Alliance of Retired Americans, but not to date the American Association of Retired Persons (AARP), reaffirmed its earlier support for HR 676 in September 2007. It is encouraging that all these groups have indicated their support for HR 676; the next challenge is gaining endorsement from more organizations and enlisting those that have already endorsed to deploy their resources in an active fight to pass the bill and actually bring single payer to fruition.

Physicians are becoming more open to single payer. Physicians for a National Health Program has long advocated single payer national health insurance, and more doctors are coming to agree with them. In a well-designed study of Massachusetts physicians drawn from the AMA master file, 62 percent supported single payer reform.⁹ In January 2008, the American College of Physicians, the second largest physician organization in the United States after the AMA, published a position paper recommending "Single payer financing models, in which one government entity is the sole third- party payer of health care costs" as one pathway to reform.¹⁰ Recently, the New York State Academy of Family Physicians gave testimony strongly endorsing single payer.

The AMA does not have the strangle hold on physician opinion that it once had. Its membership has fallen to 27 percent of physicians. The AMA no longer represents the majority of practicing physicians in the United States. Many physicians are furious with the second-guessing and interference by the private insurance industry, which results in denial of claims and delay in treatment and in payment. Physicians become frustrated and patients suffer when each private insurance company's pharmaceutical formulary is different, so that patients can't get certain medications or have to pay higher co-pays. Private insurance company rules on prior approvals result in delay or denial of patient care. Physicians feel ethically compromised. In short, the physician is ultimately accountable to the patient, whereas the insurance company has a responsibility only to its stockholders to maximize profits.

 

A MAJORITY OF THE PUBLIC favors national health insurance. In fact, 68 percent said that "providing health care coverage for all Americans" was more important than "holding down taxes" in the September 2006 ABC/Kaiser/USA Today poll.¹¹ The more recent CNN/Opinion Research Corporation poll (May 2007) finds similar results. Asked whether the "government should provide a national health insurance program for all Americans even if this would require higher taxes," 64 percent of the sample said yes, while just 35 percent said no. When CNN asked that same question in January 1995, 55 percent answered yes and 37 percent said no. Of course, this is not an explicit endorsement of single payer, but it does suggest that more than a majority of Americans see government and higher taxes as part of the solution to the healthcare crisis, even when they have not been informed that for most people higher taxes under a single payer system would be compensated for by lower premiums, deductibles and co-pays.

Halfway solutions won't work, particularly those that put more taxpayer money into helping people buy more private health insurance. Private health insurance is not only extremely costly; it will result in more and more under-insurance and will actually move us away from achieving quality universal coverage. In order to maintain profits and control their costs, private insurers will jack up deductibles and co-pays and cut benefits. Private insurers will do all they can to recruit the healthy, and avoid the sick, who are burdened with pre-existing conditions.

Herein lies the fallacy of the "level the playing field" argument put forward by politicians and pundits who propose that we have Medicare offered to everyone and let it compete with private health insurance. The competition will not be fair, because private insurers will figure out how to attract the well by offering perks like free health-club memberships and by advertising aggressively among healthier groups, and how to skip over the less healthy by under-marketing to high-risk populations, even if they are legally required to insure all applicants. This will inevitably leave a disproportionate number of the sick to Medicare, which will in turn raise Medicare premiums, which will make it less attractive to healthy people than private insurance.

Many reformers advocate regulating private insurance to prevent these abuses, but the record of government regulation in this country is poor. The private industry being regulated uses its clout to find ways to constrain and distort government intervention. Moreover, no one has proposed comprehensive regulations to curb the worst features of the insurance industry, its built-in desire to avoid paying claims. Most regulation being proposed involves primarily selling insurance, not actually paying for health care.

We already have a clear example of how private health insurance avoids regulation when it coexists with public health insurance, when we compare traditional Medicare to Medicare Advantage in which private insurance companies provide coverage. These private plans receive 12 to 18 percent more funding than traditional Medicare, and yet have been fraught with major problems. "Tens of thousands of Medicare recipients have been victims of deceptive sales tactics and had claims improperly denied by private insurers," according to a review of 91 audit reports conducted by the New York Times.¹² The companies reviewed included three of the largest participants in the Medicare market: United Health, Humana, and Wellpoint. The problems described in the audit reports include "the improper termination of coverage for people with H.I.V. and AIDS, huge backlogs of claims and complaints, and a failure to answer telephone calls from consumers, doctors and drugstores . . . the audits document widespread violations of patients' rights and consumer protection standards. Some violations could directly affect the health of patients -- for example, by delaying access to urgently needed medications."

The danger of halfway solutions is not only that they won't work but also that their failure can discredit the whole effort on behalf of universal coverage. The public will blame the advocates for universal coverage for the lack of improvement in affordability and coverage. Moreover, the halfway measures that have been proposed lend added legitimacy and resources to the private insurance companies, who will use those assets to fight single payer every step of the way.

We must build a movement for single payer National Health Insurance in the United States from the bottom up, and by the power of our numbers bring enough politicians over to our side. No, it won't be easy, given the array of forces that will oppose it. But political outcomes are not determined simply by the wishes of powerful elites. And some of the elites (e.g., businesses outside the health insurance and pharmaceutical industries) could potentially be moved by a determined popular movement and by the unwillingness of their employees to accept the growing restrictions and cutbacks on coverage that are generally the preferred response of business.

Building a powerful movement will require a creative combination of activism and education about how a mobilized public can make government responsive to the needs of ordinary people. It will be a challenge, but the only alternative to a single payer system is to consign the people of our country to a more and more brutal health care system. The single payer movement can win not only a humane health care system, but also can contribute, in the words of Michael Moore, to making the United States more of a "we" society than a "me" society, one in which the individual and the society can truly flourish.

 

Notes

1. OECD, Health Data, Paris, France, 2007. return

2. Canadian Health Insurance: Lessons for the United States", U.S. General Accounting Office, Washington, DC, June 1991, "Estimates of Health Care Proposals from the 102nd Congress", Congressional Budget Office, Washington, DC, July 1993. return

3. C. Schoen et al, "Why Not the Best: Results from a National Scorecard on Health System Performance," Commonwealth Fund Commission on a High Performance Health System, New York, September 2006. return

4. "Toward Higher-Performance Health Systems: Adults' Health Care Experiences In Seven Countries, 2007," Health Affairs Web Exclusive Vol. 26, No. 6, p. w717, Exhibit 4. return

5. Kowalczyk L. "Dangerous Delays to see Skin Doctors." Boston Globe, January 7, 2007. return

6. Roetzheim et al, "Effects of Health Insurance and Race on Early Detection of Cancer, Journal of the National Cancer Institute, Vol. 91, No. 16, 1409- 1415, 1999. return

7. New York Times: September 7, 2007. return

8. "Care Without Coverage: Too Little, Too Late." Institute of Medicine, Washington, DC, 2002). return

9. McCormick D, Himmelstein D, Woolhandler S. Single payer National Health Insurance: Physicians' Views [in Massachusetts]), Archives of Int Med 2004;164:300-304. return

10. American College of Physicians, Position Paper: Achieving a High- Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries. Ann of Intern Med. 2008;148:55-75. return

11. See here. return

12. New York Times: September 2, 2007 return.

JOANNE LANDY is the former Executive Director of the New York Metro Chapter of Physicians for a National Health Program and a member of the New Politics editorial board. DR. OLIVER FEIN, M.D. is a practicing general internist, and Professor of Clinical Medicine and Clinical Public Health at the Weill Cornell Medical College. He is also the Chair of the NY Metro Chapter of PNHP and President-Elect of National PNHP.