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Subject: qotd: Michael Hiltzik: To fix health law, go single-payer
Date: Wed, 11 Sep 2013 10:27:00 -0700
From: Don McCanne <email@example.com>
To: Quote-of-the-Day <firstname.lastname@example.org>
Los Angeles Times
September 10, 2013
Health law's ailments can be cured by single-payer system
All the shortcomings of the healthcare restructuring result from the
decision to leave it in the hands of private insurers.
By Michael Hiltzik
With the Oct. 1 rollout of a major facet of the Affordable Care Act on
the horizon, you'll be hearing a lot about the glitches, loopholes and
shortcomings of this most important restructuring of America's
healthcare system in our lifetimes. Here are a couple of things to keep
First, the vast majority of these issues result from one crucial
compromise made in the drafting of the 2010 law, ostensibly to ease its
passage through Congress. That was to leave the system in the hands of
private health insurance companies.
Second, there's an obvious way to correct this flaw: The country should
progress on to a single-payer system.
The idea that the ACA is a logical precursor to single-payer, in which
the government would be the source of all medical reimbursement, has
been gaining traction as key thresholds for healthcare reform approach.
The biggest milestone is the Oct. 1 launch of open enrollment for the
health insurance exchanges that will offer individual insurance starting
Last month, Senate Majority Leader Harry Reid made that point in a
Nevada news broadcast, calling the ACA "a step in the right direction"
but adding that the U.S. would have to "work our way past" private
insurance-based healthcare. "We're far from having something that's
going to work forever," he said.
"There isn't a popular groundswell yet" for a single-payer plan "because
most people haven't seen the ACA at work in detail yet," says David
Himmelstein, a professor of public health at the City University of New
York and co-founder of Physicians for a National Health Program, the
leading advocacy group for single-payer healthcare. But he anticipates
that discontent will start in October "and accelerate through the winter."
Among the law's shortcomings, he says, are the lack of effective
provisions to control healthcare costs and insurance premiums. Premium
regulation remains in the hands of the states, and many don't have
strong regulatory oversight of health insurance. In California, health
insurance premiums are exempt from prior approval by the insurance
commissioner, unlike home and auto insurance. (An initiative to remove
the exemption will appear on the November 2014 ballot.)
That's not to say that the ACA won't make health insurance more
affordable and accessible to millions of Americans now excluded from the
market. Published exchange premiums in 18 states have generally come in
below expectations, and the federal subsidies available to most buyers
will make them cheaper still.
In some cases the premiums may be higher than those of plans on the
market now. But because of exclusions for preexisting conditions — which
will no longer be legal — they're actually unavailable at any price to
people who will have no trouble qualifying for the exchange plans.
The ACA's critics observe that a plurality of Americans still view the
ACA unfavorably (43%, according to an opinion poll released in June by
the Kaiser Family Foundation). They rarely acknowledge, however, that
nearly 1 in 5 of those critics think the law doesn't go far enough —
that is, further toward single-payer.
In its earliest incarnation, the Affordable Care Act included a
prototype government single-payer provision — the "public option," a
government-sponsored plan to compete with commercial insurers in the
exchanges. The public option was deleted at the insurance industry's
But the U.S. does offer a healthcare program that resembles
single-payer. It's Medicare, the broadly popular health plan that covers
all Americans over 65. Medicare's administrative costs are only about
2%, and its size gives it the clout to extract large discounts from
doctors and hospitals. That's why one oft-proposed version of
single-payer is "Medicare for all" — simply expand its coverage beyond
Canada's single-payer system is another model. It's popular and
efficient and costs about one-third of America's system to administer.
Don't believe the myths purveyed about Canada's healthcare by the U.S.
insurance industry's minions.
As health economist Aaron Carroll has documented, Canadian patients and
doctors are satisfied with the program. As for the contention that it
"rations" care, he points out that care in the U.S. is rationed by cost:
one-third of adult Americans surveyed by the Commonwealth Fund in 2010
said they had put off important treatment because of the cost. In
Canada, the figure was 15%.
There's little question that taking private insurers out of the American
healthcare system would save hundreds of billions of dollars a year.
Dozens of studies of federal and state single-payer proposals have found
that single-payer plans could provide universal coverage — not even the
ACA does that — and still save money.
Estimates of the administrative costs of commercial health insurers
exceed 10%. That doesn't include the costs to doctors and hospitals of
maintaining billing staffs to deal with insurers and keep all their
rules and peculiarities straight, or the time lost to individuals and
their employers of navigating this unnecessarily byzantine system.
Add those, and the overall administrative costs embedded in the U.S.
healthcare system come to 31% of all spending, according to a 2003
article co-written by Himmelstein for the New England Journal of
Medicine. Administrative and clerical workers accounted for nearly 44%
of all employees in doctors' offices, they calculated.
What do Americans receive in return for all this overhead? Practically
nothing. The insurance industry says its role is to hold down costs by
negotiating for preferential fees from doctors and hospitals and
trolling for abuses, but the truth is they're totally ineffective at
Just last year I reported on an admission by Aetna and United
Healthcare, two of our biggest insurers, that they had been snookered to
the tune of $60 million by one chain of small surgical clinics in
Northern California. That happened because the insurers didn't hire
enough staff to give the claims from those clinics decent scrutiny — in
other words, their administrative costs, high as they were, didn't buy
The result, to cite just one example, was that United paid the chain
more than $97,000 for a kidney stone operation that it usually covers
"Private insurance is a parasite in the system," says Arnold S. Relman,
the former editor of the New England Journal of Medicine and an advocate
of healthcare reform. "It adds nothing of value commensurate with its cost."
Relman believes that fixing the healthcare system will require more than
single-payer. The delivery of care needs to be reorganized by promoting
the formation of more "accountable care organizations" — medium- and
large-scale group practices with hospital affiliates whose physicians
would be salaried to discourage the overuse fostered by the
What's really needed is political will. It would help if big companies,
which grouse incessantly about the rising costs of covering their
employees, would throw their weight behind a system that would relieve
them of that burden.
The forces of opposition won't lie down; the insurance industry won't
give up its central role in the healthcare system without a costly and
bruising fight, as it showed in Congress and in numerous states,
including California, where single-payer plans were on the table.
"It's going to be a slow and painful process," Relman says. "But sooner
or later we'll have to turn to single-payer. It's the only logical
Comment: This is an article that you should share with your friends and
others who may not have an adequate understanding of single payer. If
this kindles an interest in them, which it certainly should, then let
them know that they can learn more by accessing the website of
Physicians for a National Health Program at www.pnhp.org.
My gosh, who wouldn't want a lifetime of guaranteed, affordable health
care, free of the intrusions and inherent waste of the private insurance