In 2013, Drs. Ubel, Abernethy, and Zafar published “Full Disclosure — Out-of-Pocket Costs as Side Effects” in the New England Journal of Medicine. In this essay, the authors grapple with the ethical responsibilities of physicians when it comes to the enormous cost of modern medicine. If a surgery or a course of chemotherapy is likely to bankrupt a patient, what is our duty to warn them, to ensure that they have considered both benefits and harms? A larger question, however, was left unasked: “How do we as physicians ethically operate within a medical system that forces people on a regular basis to choose between health and financial stability”
To grasp the extent of the issue, consider that even after the passage and defense of the Affordable Care Act, 27 million American remain uninsured. An additional 41 million Americans are underinsured which is to say that their out-of-pocket expenses (such as deductibles and copays) are enough to cause financial duress, despite having health insurance. And as health insurance deductibles increases faster than wages, the proportion of Americans who are underinsured continues to grow.
The consequences of this are grave. Three out of ten American adults report forgoing needed medical care due to cost concerns. One in four were unable to pay for basic necessities like food, heat, or rent because of medical bills. One third spent down all of their savings.
When health economists have looked to explain why it is that health care is so enormously expensive in America, time and time again they have found (in the words of the late, great Uwe Reinhardt) that “it’s the prices, stupid.”
That is to say that hospitals, doctors, pharmaceutical companies, and medical device manufacturers charge Americans prices far in excess of what people are charged in other high-income countries. Joseph Dieleman and his colleagues at Harvard reassessed this question for the Journal of the American Medical Association just last year and came to the same conclusion (though with a less blunt title).
One key distinction between America and its peer nations is that other nations have centralized institutions to determine fair pricing for medical goods and services. In Germany, this is the Institute for Quality and Efficiency in Health Care (IQWiG). In the U.K., it is the National Institute for Health and Clinical Excellence (NICE). In France, it is the National Union of Health Insurance Funds (UNCAM). Each of these countries takes advantage of a strong price negotiating position through centralization.
The other crucial distinction between America and its peer nations is that these other nations recognize that some minimum level of health is a necessary precondition to social, civic, and economic participation and as such is worth the investment of public funds. In other words, by treating health care as a human right, they protect their citizens’ capacity to exercise their other rights in good health. This framework justifies distributing the costs of health care equitably, and in turn preventing financial penalty from compounding the injury of illness.
These two features of an improved health care system – 1) centralized purchasing and 2) equitable funding – are achievable in the United States with a transition to a Single Payer system. In such a system, a single publicly funded entity (e.g. Medicare) would pay for all medical goods and services on behalf of Americans. Medical care will still be delivered by private doctors and hospitals, and medical goods will still be produced by private companies. The only difference for most people is that the money that you had been paying to a private insurance company will instead be going to a public insurance entity (e.g. Medicare).
Many proposals for different Single Payer systems are currently being considered by both national and state legislative bodies in the United States. Perhaps the most famous at this time is Bernie Sanders’ Medicare For All Act (S. 1804 with 16 co-sponsors) and its accompanying house legislation (H.R. 676 with 120 co-sponsors) introduced by Representative John Conyers. Senator Chris Murphy has been working on his own Single Payer strategy which is qualitatively similar to Representative Pete Stark’s AmeriCare Single Payer plan. There are also numerous state-level Single Payer plans including The Washington Health Security Trust (HB 1026, SB 5701), The Healthy California Act (SB 562), and the New York Health Act (A. 4738 and S. 4840).
These legislative pushes take place in the context of the rising popularity of Single Payer, which has now achieved majority support in public opinion polling. As the popularity of Single Payer legislation grows, Democrats positioning themselves for 2020 presidential bids like Kamala Harris, Cory Booker, and Kirsten Gillibrand have already declared their support, recognizing that Single Payer is a necessary part of a popular Democratic platform.
This momentum should not inspire complacency, however. There is a great deal of organizing, consensus building, and legislative refinement needed in the months ahead. For my part, I plan on working with Health Care For All Washington on their push for state-level single payer and Democratic Socialists of America on their push for federal-level Medicare For All. Others are doing great work through Physicians for a National Health Program and National Nurses United.
If this has piqued your interest, I encourage you to continue read up on Single Payer and find the right level of involvement for yourself. Whether that’s calling your elected officials, talking with your friends and co-workers, writing an op-ed for your local newspaper, or knocking on doors, it’s all important work.
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