Single-payer national health insurance (NHI) is one of the important differences in the current discussion between Bernie Sanders and Hillary Clinton, the presumptive Democratic presidential candidate. Hillary contends that the ACA will work, that single-payer would overwhelm the middle class with new taxes, and that national health insurance (NHI) is politically unfeasible. In 1994, after the failure of the Clinton Health Plan, she called single-payer inevitable (possibly by 2000) because of strong public support. (1) She has since backtracked from that prediction in coming to her present position--stick with the ACA--a position that appears incompatible with her claims to take on the insurance and drug industries because of their exploitive costs. As she promotes the ACA with tweaks, she continues to play into the hands of corporate stakeholders in our under-regulated, subsidized "free market" system. Meanwhile, she has taken in almost $240,000 in campaign contributions from the drug industry from the start of her campaign to the end of April, much more than all other Republican candidates had received from that source. (2)
Bernie has the leverage of more than 12 million voters, many younger with great concern over their future health care, and has won in 22 state caucuses and primaries. The GOP is in disarray, with serious divisions between Donald Trump, the Republican presumptive presidential candidate, and much of the Republican establishment. With Trump's 70 percent unfavorable rating, it appears to be an ideal time for the Democrats to capitalize on the GOP's vulnerability and include NHI in its platform, with the support of 81 percent of Democrats and about 60 percent of all Americans. As the Republicans engage in their circular firing squad, it may even be possible for the Democrats to gain the presidency and both the Senate and House in Congress. It is time to be bold in their platform, not lose opportunities by being too cautious.
Continuing the ACA will not work. Despite some improvement in access to care through subsidized coverage in exchanges and expansion of Medicaid in all but 20 states, these markers show that we have a growing crisis in health care six years after the ACA was enacted:
- There is no cost containment as prices continue to escalate far above the cost of living; as one example, the average family of four with an employer-sponsored PPO plan now pays25,000 a year for insurance and out-of-pocket expenses for health care (3); that's untenable with the current median average U. S. household income of about53,000).
- There are still about 30 million uninsured and tens of millions underinsured, with continued degradation of the value of insurance.
- Insurance premiums for 2017 are going up big time (e.g. by 29.6 percent for the Providence Health plan in Oregon, and by 32.3 percent for the Moda Health Plan Inc., a competitor, after a 25 percent increase last year). (5)
- Patients' choices of physician and hospital have been greatly restricted by narrow and changing networks that disrupt continuity of care.
- Co-ops are failing, accountable care organizations are not saving money, and quality outcomes are not improving.
- The ACA has accelerated corporatization and consolidation, with less competition as a result (e.g. just three health insurance giants have a combined membership of more than 135 million enrollees).
- Some insurers are exiting markets (e.g. the giant UnitedHealth Group leaving California's health insurance exchange) (7) as others prosper with tax subsidies (e.g. The Florida Blues, which collected472 million in profits in 2015 by marketing narrow network plans with high deductibles). (8)
As described earlier, the private health insurance industry is obsolete and is living on borrowed time through various government subsidies. We can't afford its excesses and volatility. (9) In sharp contrast, NHI can directly address the urgent need for cost containment and making health care affordable for all Americans as it provides universal coverage for the first time without cost-sharing at the point of service. According to the landmark 2013 study by Gerald Friedman, professor of economics at the University of Massachusetts, it will save about $592 billion a year ($476 billion by eliminating profits and administrative waste of the insurance industry and another $116 billion by negotiating prices of prescription drugs down to European levels). It will be paid for through progressive taxation whereby 95 percent of Americans will pay less than they do now for health insurance and health care. (10)
With NHI, employers will be relieved of the burden of providing employer-sponsored insurance and will become more competitive in a global economy. With the administrative efficiency of a single-payer public financing system, costs can be controlled through negotiated annual budgets with hospitals and other facilities, negotiated fees with physicians and other health professionals, and negotiated prices for drugs and medical devices. Coupled with a private delivery system, patients will have full choice of physician and hospital anywhere in the country.
According to a national study of more than 2,200 physicians, single-payer NHI enjoys the support of three of five U. S. physicians (11), who would be relieved of the hassle factor in today's medical practice dealing with some 1,300 private insurers. The National Nurses Union strongly supports NHI, as do such labor organizations as the AFL-CIO. (12)
2017 could well be the year for H.R. 676, the Expanded and Improved Medicare for All bill in the House. Now is a moment calling for political courage and will. The Democrats could govern for many years to come if they can mobilize existing public support, step up to the plate and add NHI to their platform. In their 2014 book, Social Insurance: America's Neglected Heritage and Contested Future, Theodore Marmor, Jerry Mashaw and John Pakutka bring us this timely insight:
In health care, the "invisible hand" [of the free market] fails to drive down costs, improve quality, or ensure distributional outcomes that are regarded as fair. We can tinker with the rules, regulations and payment schemes that govern medical care, but the forces that increase the demands for and supply of more care are relentless. Only powerful countervailing institutions can keep them under control. Only governments have the necessary authority, assuming they have the political will to use it. (13)
John Geyman, M.D. is the author of The Human Face of ObamaCare: Promises vs. Reality and What Comes Next and How Obamacare is Unsustainable: Why We Need a Single-Payer Solution For All Americans
- Gibson, G, Smith, G. Clinton outpaces rivals in drug company donations. Reuters, June 16, 2016.
- Clinton, H. speaking to a group at Lehman Brothers Health Corporation, June 15, 1994, as reported by Health Care for All-WA Newsletter, Winter 2015, p. 9.
- Milliman Medical Index, May 2015.
- Geyman, JP. The continued degradation of health insurance under the ACA. The Huffington Post, December 3, 2015.
- Radnovsky, L, Mathews, AW. Health insurers struggle to offset new costs. Wall Street Journal, May 5, 2016: A1.
- Mattioli, D, Hoffman, L, Mathews, AW. Anthem nears48 billion Cigna deal. Wall Street Journal, July 23, 2015: A1.
- Terhune, C. UnitedHealth to exit California's Obamacare market. Kaiser Health News, May 31, 2016.
- Herman, B. Florida Blues collected471 million profit on ACA plans in 2015. Modern Healthcare, June 15, 2016.
- Geyman, JP. Why the private health insurance industry has to go. The Huffington Post, June 9, 2015.
- Friedman, G. Funding H. R. 676. The Expanded and Improved Medicare for All Act. How We Can Afford a National Single Payer Health Plan. Physicians for a National Health Program. Chicago, IL, July 31, 2013.
- Carroll, AE, Ackermann, RT. Support for national health insurance among U. S physicians: five years later. Ann Intern Med 1481 566-567. 2008.88
- Legislative Action Center. Petition calling on national Democratic party to include "Medicare for All" in 2016 DNC platform. National Nurses United. June 16, 2016.
- Marmor, TR, Mashaw, JL, Pakutka, J. Social Insurance: America's Neglected Heritage and Contested Future. Los Angeles, CA. Sage Copress, 2014, p. 128.