Order 1227662: Compare and Contrast Essay over health care
tutorthammy
hs.45.1.l.pdf
Pros and Cons of Obamacare: Is It What the United States Needs?
WHY DO AMERICANS STILL NEED SINGLE-PAYER
HEALTH CARE AFTER MAJOR HEALTH REFORM?
Claudia Chaufan
Many observers have considered the Affordable Care Act (ACA) the most
significant health care overhaul since Medicare, in the tradition of Great
Society programs. And yet, in opinion polls, Americans across the political
spectrum repeatedly express their strong support for Medicare, alongside
their disapproval of the ACA. This feature of American public opinion is
often seen as a contradiction and often explained as “incoherence,” a mere
feature of Americans’ “muddled mind.” In this article I argue that what
explains this seeming contradiction is not any peculiarity of Americans’
psychology but rather the grip of the corporate class on the political process
and on key social institutions (e.g., mass media, judiciary), no less
extraordinary today than in the past. I also argue that ordinary Americans,
like millions of their counterparts in the world, would eagerly support a
single-payer national health program that speaks to their interests rather
than to those of the 1 percent. I will describe the ACA, compare it to
Medicare, explain the concept of single payer, and conclude that the task is
not to persuade presumably recalcitrant Americans to support the ACA
but rather to organize a mass movement to struggle for what is right and
join the rest of the world in the road toward health justice.
The American health care system is the most expensive in the world, even as
it consistently ranks last in international comparisons with wealthy economies
on most measures of performance, including access, quality, and equity (1–3).
Improving it was the motivation behind the Affordable Care Act (ACA), signed
into law by President Obama on March 24, 2010 (4).
International Journal of Health Services, Volume 45, Number 1, Pages 149–160, 2015
doi: http://dx.doi.org/10.2190/HS.45.1.l
149
© 2015, The Author(s)
joh.sagepub.com
Many have considered the ACA the most significant health care overhaul
since Medicare, in the tradition of Great Society programs (5). And yet, in opinion
polls, Americans across the political spectrum repeatedly express their strong
support for Medicare (6) alongside their disapproval of the ACA (7). This
feature of American public opinion is often seen as a contradiction and explained
(away) as “incoherence” on the part of Americans—a mere feature of Americans’
“muddled mind” (8). If only Americans chose the right presidential candidate,
ponder some international observers, health reform would be at their reach (9).
In this article, I argue that what explains this seeming contradiction in U.S.
opinion polls about health reform is not, nor has it ever been, any peculiar feature
of Americans’ psychology, but rather the grip of the corporate class on the
political process and on key social institutions (e.g., mass media, judiciary), as
extraordinary today as it was in the past (10). I also argue that ordinary Americans,
like millions of their counterparts throughout the planet, would eagerly support
a single-payer national health program—Improved and Expanded Medicare for
All—that speaks to their interests rather than to the interests of the 1 percent. I will
describe the ACA, compare it to Medicare, explain the concept of single payer,
and conclude that the task is not to persuade presumably recalcitrant Americans
to embrace the ACA but rather to organize a mass movement to struggle for what
is right and join the rest of the world in the road toward health justice.
IS THE AFFORDABLE CARE ACT IN THE TRADITION OF
GREAT SOCIETY PROGRAMS LIKE MEDICARE?
Since its inception, the ACA has been plagued by intractable problems. First, it
has not resolved, and is unlikely to resolve, the problem of access. Even after
expanding coverage to millions of Americans, as many as 31 million—most of
them citizens and legal residents (11)—will remain uninsured by 2024 (12).
Second, the ACA is unlikely to significantly reduce financial barriers to
care. Indeed, the United States is unique in that medical bankruptcy, a leading
cause of personal bankruptcy in the country, affects largely individuals who have
insurance. Many Americans insured after the ACA have already expressed that
the cost of care remains a significant barrier, because they cannot afford to
actually use the policies they may afford to purchase (13). In 2012, 80 million
people reported that, during the past year, they did not go to the doctor when
sick or did not fill a prescription because of cost, 75 million reported problems
paying their medical bills or were paying off medical bills over time, about
28 million adults reported using all their savings to pay off bills, and 4 million
had to declare bankruptcy in the previous two years (14).
Third, it is even more unlikely that the ACA will guarantee continuity of care.
Like pre-ACA health care, the ACA relies on multiple insurers and plans com-
peting for customers (even if competition is virtually nonexistent in many markets
dominated by insurance monopolies). As coverage and eligibility depend on
150 / Chaufan
market considerations (e.g., price, profitability), so does access to a given source
of care. The ACA also ties coverage to income and jobs. Thus Medicaid enrollees
often “churn” in and out of the program and are forced to change coverage, hence
providers, as their income, and subsequently their eligibility, change over time
(15). For those with employer-sponsored coverage, coverage and source of care
change with changes in job situation, not unusual in times of precarious, scarce,
and “flexible” employment. In fact, coverage often does change even without
changes in job situation, as employers try to cut their health costs and stressed-out
employees struggle to understand yet another set of (forced) “choices,” which
typically consist of higher payments for increasingly restricted services. The
University of California San Francisco, for example, announced its annual “health
benefits open enrollment” period with the slogan of “Big Changes, New Choices.”
Finally, the ACA will not address spiraling costs (health care costs have
increased worldwide, yet nowhere at U.S. rates), not explained by inflation,
age structure, health status, above-average utilization, or medical technologies
(although segments of the population may use more health care and advanced
technologies, for millions of Americans the real problem is too little, not too much,
care) (16). Even if the “tinkering-around-the-edges” cost-cutting approaches
encouraged by the ACA—electronic health records, pay-for-performance, greater
price transparency, or “cost consciousness”—were successful (and the empirical
evidence supporting the cost-cutting abilities of these approaches ranges from
dubious to nonexistent) (17, 18), none of them utilizes the power of economies of
scale. For this reason, they cannot yield lower prices nor reduce administrative
overhead—savings that would amount to around $600 billion (all dollar amounts
in U.S. dollars) annually (19, 20). Nor can they yield the savings that would
ensue from ending overpayments to private (“Advantage”) Medicare plans—
$282.6 billion, or 24.4 percent, of total Medicare spending on private plans
between 1985 and 2012 (21). Altogether, these savings would be more than
enough to provide first-dollar coverage for every U.S. resident. Nor can any of
these measures deal with inscrutable “benefit packages,” skimpy coverage, ever-
narrowing provider networks, or changes in coverage with changes in jobs or
income level, among so many other problems built into the very design of the ACA.
In stark contrast, less than a year into becoming the law of the land in 1965 as
a national social insurance program administered by the U.S. federal government,
Medicare had already enrolled, and was paying the bills on behalf of, more than
19 million seniors (99% of those eligible for coverage)—with no websites,
navigators, or the threat of penalties. How? Very simple. Most seniors were
already known to the Social Security Administration, which used Social Security
numbers for Part A (hospital services) and index cards for Part B (doctors’
services) enrollment, while creating jobs for 5,000 low-income seniors who went
door to door to help contact those among the aged who were difficult to reach (22).
As a government program that granted seniors full rights to the same com-
prehensive package of services and free choice of any participating provider,
Single-Payer Health Care after Reform / 151
Medicare dispensed with the pursuit of profit that is the lifeblood of commer-
cial insurance, so the costs of marketing or of helping users navigate “coverage
options”—substantial with the ACA (23–25)—were zero.
Providers gained independence in medical decision making and the guarantee
that their bills would get paid. There was, and there remains, much room for
improvement—in access, coverage, quality, and cost control. But the relevant
feature of Medicare was, and remains, its financial structure: the program is
organized as a social insurance system that spreads the financial risk asso-
ciated with illness across society to protect everyone. Enrollees pay into the
system according to their ability and are entitled to the same broad package
of services according to their medical needs. Medicare, unlike the ACA, is a
single-payer-like system.
WHAT IS SINGLE PAYER?
Single-payer national health insurance is a system in which a single public or
quasi-public agency (or strictly regulated subsidiaries) organizes health care
financing, that is, collects the money from users, purchases services in bulk, and
negotiates rates and payment schemes with, and pays, providers. The delivery
of care may remain or not in private hands (26). Nations that have adopted
single-payer systems cut across cultures, political ideologies, and levels of devel-
opment. They include countries as different as the United Kingdom, Iceland,
Taiwan, Spain, and Cuba. In fact, all wealthy nations with the exception of the
United States, and many poor nations, have organized their health care systems
as variants of single payer (27).
The Expanded and Improved Medicare for All Act, HR 676, based on a
physicians’ proposal crafted by members of Physicians for a National Health
Program and published in the Journal of the American Medical Association,
would establish an American single-payer health insurance system (28).
Under this system, all residents, documented or not, would be covered for all
medically necessary services, including doctor, hospital, preventive, long-term,
mental health, reproductive health, dental, and vision care; prescription drugs; and
medical supplies. Dramatic overall savings would ensue from the system’s power
to purchase goods and services in large amounts, thus negotiate prices with
providers’ associations, pharmaceutical companies, and medical device suppliers.
Importantly, paperwork that does not contribute to more or better care would
be eliminated (19).
Wasteful paper pushing comes from essentially three sources: (a) the need
of multiple insurers to market plans to profitable customers, authorize or deny
services, pay handsome CEO salaries, and make a profit; (b) providers’ need
to screen patients’ coverage and file claims to multiple insurers to get paid
(or fight back when services are not “approved”) (29); and (c) users’ need to
juggle with an extraordinarily cumbersome system that requires thousands of
152 / Chaufan
“navigators” to help them figure out which plans meet their needs (and fit
their pockets), what services they are entitled to, and how to handle denied
services (Table 1).
A U.S. single-payer plan as proposed by HR 676 would do away with this
waste: it would dramatically reduce prices, slash overhead, and utilize col-
lective savings to purchase health care for all (20). Even as taxes might slightly
increase, most Americans would save money, time, and distress, as they would
no longer be compelled to comparison-shop for increasingly pricier and
inscrutable plans, juggle with unpredictable (and unaffordable) out-of-pocket
costs (premiums and out-of-pocket costs would disappear), or struggle to figure
out which providers are “in network,” as most providers in the country would
find it convenient to join the system.
DO WE NEED TO PERSUADE AMERICANS TO
SUPPORT THE AFFORDABLE CARE ACT?
Why have the crafters of the ACA been unable to sell the legislation to the
American public? Is it a matter of “messaging” (30)? Don’t Americans understand
the purpose or value of health insurance? Do they indeed have “muddled minds”?
Or is it the substance of the ACA that makes it a hard sale? If we are to go by
then-House Majority Leader Nancy Pelosi’s statement before the passage of the
2,400-plus pages of regulations in the ACA—“we have to pass the bill so that you
can find out what is in it” (31)—there is reason to believe that Americans have
turned against it not because they shun socialism, lack solidarity, are incoherent, or
fail to grasp the value of insurance, but because they know better.
Indeed, most insured Americans are realizing that even after major “reform,”
their health benefits are eroding—their out-of-pocket costs are increasing,
“preferred” providers’ networks are becoming narrower, and benefits remain
as uncertain as pre-ACA at the moment of use. The manifest function of the
ACA was to achieve initially universal (and later “near-universal”) health care—
by expanding coverage through Medicaid, (selectively) subsidizing commer-
cial insurance in the individual market, or allowing insured Americans to
“keep their coverage if they liked it.” Yet the latent function appears quite
different: the law has done much to yield extraordinary profits for a few and
even more to rescue the health insurance industry from the weight of its own
incompetence—incompetence, that is, to secure health care to Americans.
OPEN SECRETS
As President Obama pointed out early in his political career, you can have
universal coverage, and you can have lower costs, but you need single payer
to have both. Regrettably, as Democrats gained both houses of Congress and
the White House, the party and their leader concluded that single payer was
Single-Payer Health Care after Reform / 153
154 / Chaufan
Table 1
Comparing gains under ACA and single payer
ACA Single payer
Universal
coverage
Full range of
benefits
Choice of
doctors and
hospitals
Out-of-pocket
Savings
Cost control/
sustainability
Progressive
financing
NO. More than 30 million remain
uninsured (mostly citizens and
documented residents) by 2024
and tens of millions underinsured.
NO. HHS provides “guidance” on
“essential health benefits.” What
counts as benefits decided on the
basis of existing plans, i.e., by
insurers themselves.
NO. Insurance companies continue
to restrict access through
increasingly narrower networks
of “preferred” (by them!) providers.
YES. Varying degrees of co-pays
and deductibles. Trade-offs between
lower premiums (even if ever
increasing) and higher out-of-pocket
expenses, via “consumer-directed”
plans.
NO. Increases health spending by
about $1.1 trillion.
NO. Preserves a fragmented system
incapable of controlling costs.
Gains in coverage erased by rising
out-of-pocket expenses, bureaucratic
waste, and profiteering by private
insurers and Big Pharma.
NO. Costs are disproportionately
paid by middle- and lower-income
Americans and families facing
acute or chronic illness.
YES. Everybody is covered
automatically at birth.
YES. Covered for all
medically necessary care.
YES. Patients can choose among
any participating provider. Most
providers in the country would
find it convenient to participate.
NO. Co-pays and deductibles
eliminated.
YES. Redirects $600 billion
in administrative waste and
inflated drug prices toward
care; no net increase in health
spending.
YES. Large-scale cost controls
through economies of scale to
ensure that benefits are sus-
tainable over the long term.
YES. Premiums and out-of-
pocket costs are replaced with
progressive income and
wealth taxes. 95 percent of
Americans pay less.
“too disruptive” (32)—and at any rate, not “politically feasible” (33). They opted
for ignoring single payer, dismissing it as “too much socialism,” or, when they
could no longer ignore it, excluding single-payer advocates from the debate, if
necessary by force (34). It may have helped that, as talk about health care gained
traction in the run-up to the presidential elections, insurance and pharmaceutical
corporations rushed to increase their political donations (33). The drug and
health products sector alone gave Barack Obama $2,436,836 for his campaign,
more than twice the amount given to his nearest rival (35).
This surge in political spending may have led Congress and the president
to conclude that single payer was “unfeasible,” and to opt instead for a plan
that relied on “market forces” and was modeled after a proposal of the Heritage
Foundation. The legislation was in large part written by a former insurance
company executive from WellPoint, Liz Fowler, who went on to be hired by the
U.S. Department of Health and Human Services to implement the law (36)
and now works for a pharmaceutical giant (37).
As the icing on the cake, leading academic journals, such as Health Affairs
or the New England Journal of Medicine, dismissed single payer as little more
than a fringe view—at the (left) extreme of a continuum in which vouchers were
at the other (right) extreme and the ACA at the center (38). They co-opted the
concept of reform so that it would only mean what corporate interests considered
permissible reforms (39), framed the debate so that the “public option” became
the leftmost “progressive” alternative (40), and showcased corporate actors
such as Karen Ignani, CEO of America’s Health Insurance Plans, as merely one
disinterested (i.e., declaring “no relevant conflict of interests”) expert informant
in the “debate” (41). Giving a token nod to the “extraordinary complexity of
the U.S. health insurance marketplace” and faithfully toeing the official—and
corporate—line, academics concluded that the failure of ordinary, usually low-
income, persons to grasp this complexity—“low health literacy” (42)—was a
critical “problem” with health reform, whose “solution” was to use health care
professionals as “navigators” to guide people through the insurance maze (43).
“Clarifying, simplifying, and standardizing” the given marketplace set the boun-
daries of imaginable change (43).
The judiciary gave the “coup de grâce” by limiting the federal government’s
ability to enforce the ACA’s planned Medicaid expansion while upholding the
individual mandate, that is, the individual obligation to carry a policy (44). The
corporate media happily obliged and dutifully continues to convey expert (and
corporate) opinion (45), carefully limiting improvements to more wellness
programs (46), tradeoffs between affordability and coverage (47), or savvier
experts to help users lobby the billing departments of insurance companies (48).
And yet, polls show strong support for government-guaranteed health insurance
when the questions are adequately asked (“Would you support or oppose a
universal coverage program in which everyone is covered by a program like
Medicare that is government-run and financed by taxpayers?”) (49) and most of
Single-Payer Health Care after Reform / 155
those who disapprove of the ACA still do not want to see it repealed but improved
(7). Only a tiny fraction rejects it because they view it as “socialized medicine”
(50)—remarkably, given the strong establishment opposition to socialized modes
of health care financing, manufactured confusion about “lack of choice” and
“competition” under single payer (27), and outright falsifications about other
countries’ publicly financed health systems (51). Polls also show that a majority
of physicians, especially in primary and family care, support government legis-
lation to establish national health insurance (52).
The belief that only conservatives in government oppose single-payer national
health insurance is untrue. The fact is, both major parties respond to their real
“constituents”—the medical-industrial complex that handsomely finances their
campaigns and privileges (33). Finally, the argument that “we” the people cannot
afford a single-payer system is simply false—we are already paying for universal
and comprehensive health care coverage, yet not getting it (53).
THE WAY FORWARD
None of the problems of the ACA should come as a surprise. After all, the law
has implemented a system organized around profit-seeking insurers who manage
their risk portfolio by adjusting their pricing to the estimated health care usage
of their customers—usage that they label “medical loss.” This market-based
system treats health care as a profit source for Wall Street, like driver’s insurance,
one analogy that President Obama used to persuade Americans to embrace the
individual mandate.
Yet, as Dr. Margaret Flowers and Kevin Zeese, policy experts, corporate
watchdogs, and political activists, persuasively argue, this “uniquely American
solution” will allow the big drivers of the rising cost of health care—insurance
conglomerates, Big Pharma, for-profit hospitals—to become only stronger, at the
same time that it will institutionalize the wealth divide (36). They point out that
while the privileged few, such as Senator Ted Cruz and his wife, will receive the
best health care from their employer—in their case, from Ms. Cruz’s employer,
Goldman Sachs—many will be pushed into the so-called marketplace and divided
into four classes of people based on their wealth. Many more will receive poor
health care for poor people (Medicaid), and millions will remain in the cold. A few
“fortunate” among these will be spared from paying a fine for not complying
with the mandate, as they are found eligible for “hardship exemptions” (e.g., due
to being homeless, a victim of domestic violence, or bankrupt) and granted the
“right” to remain uninsured (54)—provided they can make their case in court.
As Flowers and Zeese assert—and I agree: “There was an easier, more polit-
ically popular route. All that President Obama had to do was to push for what
he said he once believed in, Medicare for All. By dropping two words, ‘over 65,’
the country could have gradually improved Medicare [and moved the country]
toward the best health care in the world, rather than being mired at the bottom.
156 / Chaufan
To replace [the ACA] with a single-payer system, we need to [oppose treating]
health care as a commodity like a cell phone—or, as President Obama suggested,
like auto insurance—[and] recognize that ending the corporate domination of
health care is part of breaking the domination of big business over the U.S.
government. Health care is at the center of the conflict of our times, the battle
between the people and corporate interests, the battle to put people and planet
before profits.” In short, the battle for democracy and humanity.
Acknowledgment — The author wishes to acknowledge the invaluable feedback
of Mark Almberg, Don McCanne, and Julian Field. She also acknowledges the
continuing inspiration of all members of Physicians for a National Health Program
in their unflinching determination to achieve health care justice.
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Claudia Chaufan, MD, PhD
Associate Professor
University of California, San Francisco
3333 California St., Suite 340
San Francisco, CA 94118
160 / Chaufan
Corresponding Author:
