Functioning Democracy: A Prerequisite for Single Payer

Comment by: Jim Kahn

On Tuesday, a Washington DC grand jury handed down four indictments of former President Donald J. Trump for his efforts to overturn the results of the 2020 election. This reflects the investigation led by special prosecutor Jack Smith, guided by the Congressional Jan. 6 hearings. It is a historic moment – holding to account a US president whose conspiratorial actions threatened a pillar of democracy: that the vote should determine the election outcome.

In my view, it is far more than symbolic. Many voters in the general presidential election will be swayed by the evidence of Trump’s malfeasance presented at trial, and by convictions. This will shift votes to the Democratic candidate, likely Joe Biden. Thus, the pursuit of justice may be a deciding factor for who is the next president, and by extension the country’s future.

The implications for single payer are also vast. A Trump presidency would be a large step toward fascism, with dire consequences for progressive political action. Our political challenges in achieving single payer are well-acknowledged. Indeed, many Democratic leaders oppose single payer. But at least in a functioning democracy we have the freedom to work toward change, to translate broad popular support for public funding of universal insurance into legislative action. And thus to transform our health system.

As discussed previously in HJM, I believe that single payer is fundamentally democracy-enhancing. It fosters our highest democratic values– e.g., health, freedom, equality, and community. Our fragmented and profit-oriented system, on the other hand, deepens inequality, causes countless unnecessary deaths, constrains our choice, and divides us.

What a great day indeed when the tenets of democracy are enhanced, increasing the likelihood that the single payer movement can in the future return the favor. It’s the perfect healthy feedback loop.


Round-up, Pause for Reflection, & Makeover

Greetings HJM readers –

I’m using a different format today.

#1 – Round-up. Plenty of recent news items exemplify the usual rocky functioning of US health care. Here’s a sampling:

Medicaid: Eligibility assessment post-COVID proceeds apace, with 4 million disenrolled so far, widely variable by state (Texas is highest). CMS has asked some states to pause due to problems with the eligibility redetermination. One company is profits very well with this process. Meantime, the DHHS Inspector General found that prior authorization denial rates are especially high in Medicaid, which is 70% under managed care. So, in summary, it’s harder to stay on Medicaid and on Medicaid harder to get care, and private companies profit in the process.

Medicare: Risk selection of healthier individuals (within diagnosis) by Medicare Advantage plans yields 11% lower medical costs than enrollees in traditional fee-for-service Medicare. Higher diagnostic coding intensity adds 6%. The total cost difference of 17% represents $70 billion per year, or $1500 per MA enrollee. Another estimate comes in at 20%. And artificial intelligence (AI) is being misused to arbitrarily limit care. Meantime, drug companies are suing to stop price negotiations in the Inflation Reduction act. Who profits? MA plans and Pharma, of course.

Patients: Administrative barriers to getting care can be very dangerous and extraordinarily expensive. This brings to life the stats — individuals spend 8 hours per month coordinating health care, and one in four insured patients delay or forego care due to administrative hurdles. Medical debt and bankruptcy are pervasive.

Insurers: Profits galore, billions and billions. Definitively covered in Wendell Potter’s HEALTH CARE un-covered. Largely due to Medicare Advantage and Medicaid managed care (see above).

Hospitals: Dubious hospital billing practices are being challenged, as hospital profits grow. Meantime, many rural hospitals suffer existential threats from low private insurer payment rates.

There’s more … there’s always more; our fragmented and dysfunctional insurance approach can be counted on to generate stories of care denied coupled with profits maximized. But enough for today.

#2 – Pause for Reflection

Reading a terrific book, The Persuaders: At the Front Lines of the Fight for Hearts, Minds, and Democracy by Anand Giridharadas. For those committed to progressive policy change, it’s revelatory – laying out vividly what persuasive strategies work. I’m contemplating how the insights can bolster single payer advocacy.

I’m also busy this summer with family travel and cataract / glaucoma surgery (luckily, I have very good insurance, and terrific ophthalmologists).

So, HJM posts will slow.

#3 – Makeover

The HJM website will be reborn later this year in much grander fashion. It will still have all the blog posts, plus some from Don’s prior “quote of the day”, with an advanced search capacity. Plus a glossary and FAQs, as well as visuals and resources for activism. Some short videos too. Stay tuned. If you want to be a “beta tester”, let me know.

Hope you’re having a great summer. – JGK


NY Times Tantalizingly Close On Health Care Financing Issues

Summary: This week, a profile of challenges facing the UK NHS and an op-ed proposing universal coverage in the US got so many issues right. But they critically missed on pivotal pillars of successful health care financing: adequate funding and comprehensiveness of coverage.

A National Treasure, Tarnished: Can Britain Fix Its Health Service?
New York Times
July 16, 2023
By Mark Landler

As it turns 75 this month, the N.H.S., a proud symbol of Britain’s welfare state, is in the deepest crisis of its history: flooded by aging, enfeebled patients; starved of investment in equipment and facilities; and understaffed by doctors and nurses, many of whom are so burned out that they are either joining strikes or leaving for jobs abroad.

Health care spending rose by an average of less than 2 percent a year from 2010 to 2019, compared with 5.1 percent from 1998 to 2008. Britain spent less a year per person on health care than the wealthiest European Union countries during the decade of austerity, and now has fewer doctors and hospital beds per capita than its European neighbors. Its capital investment lagged the bloc’s average by $41 billion, according to the Health Foundation, which tracks the industry.

We’re Already Paying for Universal Health Care. Why Don’t We Have It?
New York Times
July 18, 2023
By Liran Einav and Amy Finkelstein

There is no shortage of proposals for health insurance reform, and they all miss the point. They invariably focus on the nearly 30 million Americans who lack insurance at any given time. But the coverage for the many more Americans who are fortunate enough to have insurance is deeply flawed.

Health insurance is supposed to provide financial protection against the medical costs of poor health. Yet many insured people still face the risk of enormous medical bills for their “covered” care. A team of researchers estimated that as of mid-2020, collections agencies held $140 billion in unpaid medical bills, reflecting care delivered before the Covid-19 pandemic. To put that number in perspective, that’s more than the amount held by collection agencies for all other consumer debt from nonmedical sources combined. As economists who study health insurance, what we found really shocking was our calculation that three-fifths of that debt was incurred by households with health insurance.

What’s more, in any given month, about 11 percent of Americans younger than 65 are uninsured. But more than twice that number — one in four — will be uninsured for at least some time over a two-year period. Many more face the constant danger of losing their coverage. Perversely, health insurance — the very purpose of which is to provide a measure of stability in an uncertain world — is itself highly uncertain. And while the Affordable Care Act substantially reduced the share of Americans who are uninsured at a given time, we found that it did little to reduce the risk of insurance loss among the currently insured.

It’s tempting to think that incremental reforms could address these problems. For example, extend coverage to those who lack formal insurance. Make sure all insurance plans meet some minimum standards. Change the laws so that people don’t face the risk of losing their health insurance coverage when they get sick, when they get well (yes, that can happen) or when they change jobs, give birth or move.

But those incremental reforms won’t work. Over a half-century of such well-intentioned, piecemeal policies has made clear that continuing this approach represents the triumph of hope over experience, to borrow a description of second marriages commonly attributed to Oscar Wilde.

Coverage needs to be free at the point of care — no co-pays or deductibles — because leaving patients on the hook for large medical costs is contrary to the purpose of insurance. A natural rejoinder is to go for small co-pays — a $5 co-pay for prescription drugs or $20 for a doctor visit — so that patients make more judicious choices about when to see a health care professional. Economists have preached the virtues of this approach for generations.

But it turns out there’s an important practical wrinkle with asking patients to pay even a very small amount for some of their universally covered care: There will always be people who can’t manage even modest co-pays. …

Finally, coverage must be basic because we are bound by the social contract to provide essential medical care, not a high-end experience. Those who can afford and want to can purchase supplemental coverage in a well-functioning market.

Keeping universal coverage basic will keep the cost to the taxpayer down as well. It’s true that as a share of its economy, the United States spends about twice as much on health care as other high-income countries. But in most other wealthy countries, this care is primarily financed by taxes, whereas only about half of U.S. health care spending is financed by taxes. For those of you following the math, half of twice as much is … well, the same amount of taxpayer-financed spending on health care as a share of the economy. In other words, U.S. taxes are already paying for the cost of universal basic coverage. Americans are just not getting it. They could be.

We … were struck — and humbled — to realize that at a high level, the key elements of our proposal are ones that every high-income country (and all but a few Canadian provinces) has embraced: guaranteed basic coverage and the option for people to purchase upgrades.

Comment by: Jim Kahn & Don McCanne

The profile of UK NHS challenges is vivid and compelling in portraying the financial and associated operational and clinical problems plaguing that system. And, buried deep into the article, they do mention, in passing, the reason: “Health care spending rose by an average of less than 2 percent a year from 2010 to 2019, compared with 5.1 percent from 1998 to 2008.”

Let’s be appropriately blunt about this: The Conservative Party (the Tories) are intentionally bleeding the system, since 2010 putting the NHS on austerity footing. See HJM discussion here. Privatization is driving up family financial burdens and increasing mortality.

Thus, the crisis is intentional, policy- and politics-driven. The good news is that there is a good chance that the Tories will pay a steep political price for this evisceration of the popular NHS.

Turning to the US: Wow, Einav and Finkelstein got so much right. The health insurance system is fundamentally broken, unfixable. We need free, universal coverage. Just what we in the single payer movement have been saying for decades. Just what all other wealthy nations do.

But wait, “basic”? What does that mean? The article doesn’t elaborate (their book, to be released later this month, lays out some principles if not a definitive definition …).

We don’t like the sound of it. If “basic” means “access to under-funded and over-stretched providers,” that’s a recipe for a two-tiered system with divergent political interests, like we have for schools. If basic means excluding a subset of medical services, what would we comfortably omit? Not a good solution.

On the other hand, if “basic” means “everything necessary for quality medical care, and no fluff” that could be fine. As long as “medical care” includes inpatient, outpatient, drugs, mental health, dental, vision, medical equipment … everything medically indicated. That’s what other countries do: supplemental insurance is typically just a few percent of total health spending, for example providing access to private hospitals or specialists in a system with excellent public care. Long-term care should be in the “basic” category too.

We think it will be impossible to define “basic” narrowly in a way that is medically sound and doesn’t lead to operational and political fractures. The good news is, we don’t need to be stingy. Analyses of single payer demonstrate that we can provide standardized, comprehensive coverage and still save money for the system and for households.

Our colleague Ed Weisbart put it very well: “Two-tiered systems become as underfunded as the UK’s National Health Service, and outcomes degrade. We’re either all in this together, as a society that looks out for each other, or it’s Game of Thrones for us all.”


Fee-for-Time Payment for Physicians

Summary: Current physician payment rules are complex, time-consuming, and unfair to primary care providers. Success of universal coverage with single payer will require a simpler and fairer approach. Fee-for-Time is such a proposal.

Optimizing physician payment for a single-payer healthcare system
International Journal of Social Determinants of Health and Health Services
May 24, 2023
By Stephen B. Kemble and James G. Kahn

For independent physicians, we recommend that a U.S. single-payer system return to fee-for-service payment, replacing RBRVS [Resource-Based Relative Value Scale] with a time- and training-based system designed to be as administratively simple, objective, fair, and incentive-neutral as possible.

This approach would improve on RBRVS in multiple ways. It would base the value of physician services on two straightforward factors: time to complete the procedure (i.e., effort) and years of training (i.e., investment for needed expertise). Physician cognitive and procedural activity would be valued equally, given equal training duration. Practice expenses would be measured and fully covered. Payment would be delinked from extensive documentation, easing EHR demands and ending gaming to maximize income. Physicians would be paid for all time spent on patient care, including documentation, coordination, alternative care delivery modes such as telephonic and telehealth care, and administration. Total physician work and training would determine physician personal income. The physician’s interest in a clinical focus and the system’s interest in efficiency would align to minimize administrative burdens.

A simple example illustrates how this system might work. Assume 2,400 work hours in a year. A doctor who works more hours would earn more, and part-time practitioners would earn less. Practice expenses would be reimbursed at cost, so the work component determines physician personal income. Assume collective negotiations arrive at a base rate for medical school plus internship of $80/hour, plus $25/hour per added year of required training for the next 2 years and $15/hour for subsequent years. That would yield the following personal annual incomes by specialty:

Example Scenario of Fee-for-Time Physician Payment

  SpecialtyYears of Post-grad TrainingHourly RateIncome for One Year
GP just internship1$80$192,000
Internist, Family Physician, Pediatrician3130312,000
Internal medicine specialist5160384,000
General cardiologist6175420,000
Surgical specialist7190456,000
Interventional cardiologist8205492,000

The complications and gaming now seen with RBRVS-based fee-for-service for providers paired with data demands of capitated fiscal intermediaries, or with capitation of providers, would disappear with the FFT proposal. There would be no disincentive to treat sicker people (no risk pool to game), no risk adjustment of capitation rates and therefore no up-coding, no incentive to deny care inappropriately, no complicated problems with attribution, and no problematic benchmarking methods. In other words, the gaming of payment now seen with all forms of capitation would no longer be motivated or possible.


We believe fee-for-service payment of independent physicians using the Fee-for-Time proposal would be substantially simpler, more objective, fairer, and less costly to administer than fee-for-service based on RBRVS and Evaluation/Management coding or “value-based” payment (notably capitation) with pay-for-performance and risk adjustment. A universal single-payer system that paid hospitals with global budgeting and physicians based on time and expertise, with standardized salaries for employed physicians and time-based payment for independent physicians, would likely achieve greater administrative savings and lower total cost than any proposal based on existing Medicare fee-setting policies or shifting insurance risk onto doctors and hospitals. U.S. healthcare might then achieve cost-effectiveness comparable to all other advanced countries.

Comment by: Steve Kemble & Jim Kahn

Moral injury and burnout are now pervasive among U.S. physicians. Doctors are disenchanted with private practice due to the complexities and frustrations of medical billing and collections, compounded by the distractions and documentation demands of “value-based payment.” These administrative tasks frustrate a focus on clinical care. Further, inappropriate interference in physician-patient decision-making by insurance plans is now widespread, via care denials and unreasonable formulary restrictions and prior authorization policies. Physicians are rapidly losing professional autonomy and control over their time.

When private practice becomes untenable, physicians are driven to sell their practices to large corporations, often for-profit and investor-owned, or private equity. They stay on as clinicians, soon discovering that accountability is to shareholders and investors who expect return on investment, even at the expense of the best interests of patients and providers.

For all these reasons a single-payer healthcare system is increasingly attractive to physicians.

However, many remain skeptical because they fear that a publicly funded system would mean “Medicare-as-we-know-it for all,” with complex billing rules including value-based payment. RBRVS has been complex and subject to gaming, detracting from clinical focus. They need assurances about the implications of single payer for medical practice – confidence of adequate income and a focus on clinical care.

Fee-for-Time payment (disclosure: we’re the authors) is a proposed answer to these questions. It greatly simplifies billing, fairly compensates physicians across specialty (notably, including primary care), and leaves providers the latitude to spend adequate time on patient care.

We encourage exploration of FFT, salary, and other simple, fair compensations systems under Medicare for All.


The Hazards of Private Equity

Summary: Dr. Glaucomflecken efficiently & amusingly skewers private equity. Plus a technical report …

How to Ace Your Private Equity Interview
(2-minute YouTube video)
Dr. Glaucomflecken

“rapid maximal extraction of wealth by any means necessary”

Comment by: Jim Kahn

Dr. Glaucomflecken, in his usual concise, elegant, and entertaining style, precisely captures how private equity ownership of provider practices threatens physician autonomy, evidence-based medicine, and patient welfare.

For those craving a more technical read today on the rapid expansion of private equity, market distortions, and higher costs, see a detailed report here.


Federal Actions Leave in Place a Flawed Health Insurance System

Summary: The White House announced several actions to improve health care financial protections for consumers. Left in place is a fragmented and dysfunctional health insurance system which imposes massive burdens on consumers. Time for single payer!

President Biden Announces New Actions to Lower Health Care Costs and Protect Consumers from Scam Insurance Plans and Junk Fees
The White House
July 7, 2023

  • The Biden-Harris Administration is cracking down on junk insurance. New proposed rules would close loopholes that the previous administration took advantage of that allow companies to offer misleading insurance products that can discriminate based on pre-existing conditions and trick consumers into buying products that provide little or no coverage when they need it most. These plans leave families surprised by thousands of dollars in medical expenses when they actually use health care services like a surgery. If finalized, the rule would limit so-called “short-term” plans to truly short time periods, close loopholes made worse by the previous administration, and establish a clear disclosure for consumers of the limits of these plans.
  • The Administration is releasing important guidance on rules against surprise medical billing. Biden-Harris Administration rules are already preventing as many as 1 million surprise medical bills every month. New guidance will help stop providers from gaming the system by evading the surprise billing rules with creative contractual loopholes that still leave consumers with unexpected costs.
  • The Administration is announcing new steps to protect consumers from unfair medical debt. For the first time in history, the Consumer Financial Protection Bureau, HHS, and Treasury are collaborating to explore whether health care provider and third-party efforts to encourage consumers to sign up for medical credit cards and loans are operating outside of existing consumer protections and breaking the law. Medical credit cards and loans often lead to higher costs without consumers fully understanding the risks.
  • The Department of Health and Human Services is releasing a new report showing that nearly 19 million seniors and other Part D beneficiaries are projected to save $400 per year on prescription drugs when President Biden’s $2,000 out-of-pocket cap goes into effect. It’s also releasing state by state data that demonstrates how seniors across the country are helped by just one element of the President’s robust agenda to lower prescription drug prices.

Comment by: Don McCanne & Jim Kahn

Everyone knows that we have very serious problems with our health care system. We spend the most per capita of any nation, yet leave millions without adequate health care coverage or with any health care coverage at all, resulting in rampant financial hardship and even personal bankruptcy. We know that we can readily fix this by enacting and implementing Medicare for All – a single payer, publicly financed and publicly administered health care financing system.

Yet what reform does the current administration in Washington offer us? They would “crack down” on short-term junk insurance, but nevertheless leave it in place. They would reduce gaming of surprise out-of-network billing, while leaving in place restrictive provider networks and uncovered services. They would rein in abusive medical credit practices, while leaving in place the massive deductibles and cost-sharing (and uninsurance) that result in nearly half of adults having medical debt and hundreds of thousands of bankruptcies annually. They would save Medicare beneficiaries a few hundred dollars in drug costs, while leaving in place lack of and incomplete drug coverage for tens of millions.

It’s time to stop “leaving in place” our fundamental health insurance problems. Medicare for All legislation is sitting in the House and the Senate waiting for action.

My gosh. Talk about insensitivity. Those horrible problems are staring us in the face, and they are merely going to spin their wheels in minor rule-making.

Let’s get real. Single payer! Now!


Ah the Price of Dealing with Medical Insurance!

Summary: We all spend too much time as patients wrangling medical billing. Here’s one creative approach to accounting for that. Disappears with single payer, of course.

Billing the Hospital Billing Department
The New Yorker
July 3, 2023
By Kendra Allenby

Late-stage capitalism getting you down? Try this fun, D.I.Y. fix—sending your own personalized bill to the hospital billing department:

Dear billing department,

Below are the fees that you’ve incurred. Please pay the balance at your earliest convenience.

Phone calls pre-procedure: To make double, extra sure that the procedure is going to be fully covered by insurance. (Am assured that it will be.) An hour and a half at $300 per hour: $450

Initial phone call post-procedure: Asking why this huge bill showed up after I made double, extra sure that the entire procedure would be covered by insurance. Forty-five minutes at $400 per hour: $300

Follow-up phone call: To find out that the incorrect code was used in billing the procedure. Forty-five minutes at $400 per hour: $300

Misc. phone calls (three): To get the code changed to the correct code. Two hours and fifteen minutes at $400 per hour: $900

One more phone call: To get assurance and e-mail confirmation that the code has been changed and that I will not receive additional bills in the mail. Thirty minutes at $400 per hour: $200

Mug: Smashed when the third bill arrived in the mail. One mug at $47 per mug: $47

Fee for sterile disposal: Of mug. One mug at $347 per mug: $347

Fee for lost sleep: Over the huge bill that should have been entirely covered by insurance. A hundred and thirty-two hours over six months at $300 per hour: $39,600

Therapy to treat anxiety: Resulting from a six-month protracted follow-up on a bill that I never should have received in the first place, plus anxiety spikes upon repeatedly seeing additional bills in the mailbox. Twenty-four sessions at $200 per session: $4800

Tylenol. Couldn’t hurt: One pill at $300 per pill: $300

TOTAL COST: $47,244

My dog has negotiated your rate so that you are only responsible for a percentage of the total cost. If you choose not to go with my dog’s negotiated rate, you may be responsible for the total cost of the fees.

ADJUSTMENTS (as negotiated by dog): -$10,014


Congratulations, you saved $10,014!

Comment by: Jim Kahn

Exactly right, sadly. Excellent dose of humor for a vexing situation.

We’ve all experienced this (I know I have … e.g., hours of calls regarding vaccination for foreign travel, and many letters and calls and emails to get reimbursed for an urgent care visit, and … and …).

HJM discussed research on this issue in late 2021.


Linking Democracy & Health Care for All

Summary: Democracy and health intersect and interact. Threats to one are threats to both. On this July 4th, let’s recognize these links, and redouble efforts to strengthen democracy by strengthening our health system … with single payer. Health care for all, not for the few who stand to profit the most.

Threats to Democracy Are Threats to Health
MedPage Today
by Lawrence O. Gostin & Sarah Wetter
June 29, 2023

The U.S. is facing dual crises: a crisis of health and a crisis of democracy. Our nation has been getting sicker. We’re facing the greatest decreases in life expectancy in over a century — with causes extending beyond COVID-19 to include rising drug overdoses, injuries, heart and liver diseases, and suicide. Maternal mortality, often considered a test of a society’s commitment to health and equality, has risen sharply. On all of these measures of health and equity, we are falling behind most all of our peer nations.

Our democracy, too, is unwell, with few guardrails on campaign financing, allowing wealthy individual and corporate donors to have outsized influence on policy and gerrymandering, making political representation simply unrepresentative of the populace.

The health of our nation is inextricably linked to the health of our democracy. Our laws directly affect whether someone has access to health services (e.g., abortion or transgender care) and safe environments (e.g., workplace safety or gun control). In theory, democracy is all about the public’s health, safety, and welfare. Political leaders should have no greater calling. Free and fair elections enable voters to elect leaders who fight to fulfill their health needs; political leaders are incentivized to pay attention to voters’ wellbeing, and are held accountable.

Yet, unlimited and dark money has shifted politicians’ attention away from constituents’ health and toward the interests of big donors. Gerrymandering pushes representation toward the extremes, enabling super-majorities in state legislatures that can pass measures harmful to health (e.g., targeting transgender individuals, forgoing Medicaid expansion, banning abortion, encouraging fossil fuels). And voting rights restrictions often fall on the most vulnerable: the poor and racial minorities. When the voting rights of society’s most vulnerable citizens are curtailed, it makes it all too easy for politicians to ignore them.

The Constitution’s Preamble expresses public wellbeing as the quintessential aim of American governance: “We the People, in Order to form a more perfect Union” and to promote the “general Welfare” do “ordain and establish this Constitution.” The “General Welfare” clause expresses a constitutional value of health, peace, and safety. The Supreme Court was supposed to be the guardian of the common welfare. Yet, it has done the opposite. The justices have given rich donors a virtual free hand to give huge sums of money (often dark money); loosened anti-corruptions restrictions; and allowed extreme gerrymandering and voting rights restrictions.

Medical organizations call voting rights a social determinant of health. The reasons abound: access to voting is consistently associated with better health. Women’s suffrage is associated with decreases in child mortality rates as high as 15%; the Voting Rights Act has been tied to reductions in economic inequality and increased health spending. Voting is linked to reduced risks of cancer death and improved mental health, while voting restrictions correlate with higher likelihood of lacking health insurance.

Comment by: Jim Kahn

On July 4th, we celebrate the founding of US democracy. The revolutionary events of nearly 250 years ago prompted the rise of democracy around the world. This celebration is appropriate, despite – and indeed because of — today’s challenges to democracy at home and abroad. Democracy is under assault, and needs defending.

As Gostin and Wetter persuasively note, the crisis in democracy is echoed by, and intertwined with, a crisis in health. The role of government in advancing the public welfare is undercut by increasing deference to the preferences of corporations and the wealthy. The examples they provide are apt.

But they don’t go far enough. The entire US health system is the antithesis of democracy. A few wealthy individuals and corporations rule the many, by imposing a fragmented insurance system and consolidating the ownership of services. Compromised access to medical care and elevated mortality are accepted as collateral damage from an illusory “free market” in health (which brings no efficiency or welfare maximization) and all-too-real immense financial gains for executives and shareholders. Other wealthy countries democratize health care – everyone has identical coverage, with excellent access to care, and the freedom to choose a provider. Money is saved in the process, and directed to other social needs.

Single payer would foster democracy, freedom, and the general welfare. Let’s issue a “Declaration of Health Care for All”, and revamp our health care into a democracy-conforming and democracy-fostering approach. We will celebrate this revolution for at least the next 250 years.


Physicians as a Leading Force for Progressive Change

Summary: Eric Reinhart brilliantly issues a call for physicians – long a conservative force in health care – to expand their political horizon from their own recent labor awakening to join the progressive movement to transform our desperately ailing health system.

The Political Education of US Physicians
JAMA Network Open
June 27, 2023
By Eric Reinhart

Since the beginning of Ronald Reagan’s presidency, the proportion of workers in the United States who belong to a union has declined by approximately 50%, while income inequality has increased by approximately 20%. Today, just 10% of all US workers are employed in unionized positions. But following the recession that started in 2007 and 2008 and then the temporary resurgence of a social democracy during a pandemic that exposed neoliberal policy as a public health disaster, labor organizing against exploitation and public abandonment has been increasing. Amid growing concern about workforce attrition associated with the demoralization of nurses and physicians in a flailing medical industry shaped by profit rather than ethics, health care workers have become increasingly involved in this revival of labor politics.

A wave of nurses’ strikes and house staff unionization has put this ideological shift front and center in contemporary health care politics. There are now approximately 70 000 physician union members in the US, representing 7% of physicians—a nearly 30% increase relative to a decade ago. …

It is into this context that the analysis of housing affordability and housing-related benefits for house staff by Brewster et al interjects. Using data from the 2022 to 2023 academic year, Brewster et al found that compensation levels at 60% of 855 institutions administering residency programs imposed rent-burdened status on their resident physicians (ie, they required residents to devote >30% of monthly income to rent). Brewster et al also found that while inflation-adjusted rental prices increased by 18% between 2000 and 2022, inflation-adjusted first-year resident salaries decreased by 0.2% during that same period. Concluding with a call for more equitable compensation, Brewster et al note that resident labor unions have been associated with improved access to housing stipends.

This adds to what should be already clear rationale for physicians, nurses, and other health care workers to unionize to protect their own interests and to protect patient safety by improving working conditions. But there is another intertwined and more fundamental issue at stake: the political education of the most influential workers in what may be the most powerful industry in the US.

Worst-among-peer-nations life expectancy, alongside globally unparalleled health care spending and rapidly declining trust in medicine, public health, and government, make undeniable that the US is in need of a basic reorganization of its health systems. After allowing health care over the last half century to be dominated by private entities motivated by profit and enabled by depoliticized concepts of charity as substitutes for rights guaranteed by public systems, to achieve meaningful change will require a repoliticization of care. This must be linked with mass movements to demand public investment in universal health care and, even more importantly for public health, infrastructures for everyday nonmedical care that are essential for preventing disease and shrinking the currently elephantine footprint of reactive US medicine.

Comment by: Ana Malinow

In a fiery “Invited Commentary”, Eric Reinhart responded to a concurrent article on lopsided housing affordability and resident salaries in JAMA Network Open. Reinhart blasts medical training exploitation for its “high medical-education costs, undercompensation, excessive work hours, and an infantilizing hierarchical culture characterized by intensive personality policing under the veneer of racist, misogynistic, and classist professionalism norms and their self-defensive moralisms.”


The effort Reinhart believes would best achieve the “political education of US physicians” is the unionization movement currently taking hold in many institutions training residents today. He rightly maintains that by unionizing, residents have a chance to better their own working conditions, with spillover effects into better patient care.

But the goal of unionizing residents goes further to open the eyes of future doctors, who for too long have been blind to the paradox that is their training and the health care system in which they work.

For the last 100 years, Reinhart rightly asserts, the medical education of doctors has been political, but not in the way that raises awareness, but one that is “overwhelmingly conservative, profoundly uncritical, and reflexively protective of an ethically bankrupt field that has spent a century building up a capitalist health care industry.” It has been an anti-solidarity education that lulls doctors with the expectation of lucrative salaries and social position into complicity, working silently and thus propping up a health care system that immorally puts profits over patients. US physicians “have been professionalized into a convenient political nihilism” instead of questioning the paradox under which they labor. They accept, buttress, and uplift the for-profit, market-driven, repulsive health capitalism we call the U.S. health care system.

“Medical trainees deserve an explicitly political education,” Reinhart concludes, that “must be linked with mass movements.” This call must be heeded now more than ever, as for-profit insurance companies, private equity, venture capitalists, and corporations such as Amazon and Best Buy devour what is left of our public programs (Medicare and Medicaid especially), hospice, emergency departments, independent physician practices, and community and rural hospitals. An Obama-era scheme called “value-based payment” (VBP) is spreading across our health care system like wildfire, buttressing the profit-takers and, like wildfires, leaving widespread destruction behind. With the collusion of the Centers for Medicare and Medicaid Services, VBP and its corporations will soon take over the last bastions of non-corporate care provision and truly public financing, traditional Medicare and the Veterans Health Administration.

Through unionization, physicians begin to understand that extending care beyond the clinic into the community “hinges on power and policy” and beyond that, leads to “political organizing and struggle.” As physicians, we must join and amplify grassroots organizations that are fighting to end privatization of our public programs through local organizing, mobilization, and direct action. This grows the mass movement we need to achieve national single payer and end the paradox we serve. It would be a profoundly valuable use of physicians’ high incomes and social standing.

Reinhart’s is an incisive, impressive, and important essay, which I implore every physician to read. It’s a critical piece of our medical education.


Subpar Consumer Experiences with Health Insurance

Summary: Surprise, surprise – our fragmented, profit-driven, gap-permeated health insurance “system” leads to terrible consumer experiences accessing health care. It’s time, finally, to adopt a simple, efficient and generous solution – single payer.

Survey of Consumer Experiences with Health Insurance
June 15, 2023
By Karen Pollitz, et al.

Key Findings

*  Most insured adults give their health insurance positive ratings, though people in poorer health tend to give lower ratings. … 84% of people who describe their physical health status as at least “good” rate insurance positively, compared to 68% of people in “fair” or “poor” health.

*  Despite rating their insurance positively, most insured adults report experiencing problems using their health coverage; people in poorer health are more likely to report problems. A majority of insured adults (58%) say they have experienced a problem using their health insurance in the past 12 months – such as denied claims, provider network problems, and pre-authorization problems.

*  Nearly half of insured adults who had insurance problems were unable to satisfactorily resolve them, with some reporting serious consequences.

*  Among those with the greatest mental health needs, many adults across insurance types find their coverage lacking and report forgoing needed care. Among insured adults who report being in “fair” or “poor” mental health, four in ten (43%) say there was a time in the past year when they did not get mental health services or medication they thought they needed …

*  Affordability of premiums and out-of-pocket costs are a concern, particularly for those with private health coverage, and for some, contributed to not getting care.

*  Insured adults overwhelmingly support public policies to make insurance simpler to understand and to help them avoid or resolve insurance problems.

Adults with Medicare are the most positive in their overall ratings with nine in ten (91%) rating their coverage positively, including half who say it is “excellent.”

Marketplace enrollees, regardless of health status, are the most likely to rate their insurance negatively.

Over the years, Congress has enacted a number of measures to make health insurance more understandable and easier to navigate, and to hold health insurers and public programs accountable for the coverage they promise. Alone, these measures are unlikely to eliminate all the problems people encounter with health insurance, especially those related to affordability, but they may help to reduce somewhat the dizzying complexity of health insurance in the U.S. And they may inform oversight so that regulators can better monitor how well insurance works when people need to use it. At the same time, stronger oversight and accountability could entail more administrative costs – a trade-off we did not probe in this survey.

Comment by: Don McCanne & Jim Kahn

This comprehensive survey should be read in its entirety to understand the startling inadequacy of US health insurance under our complex combination of public and private plans and no insurance at all. Despite its failings, it is the most expensive health system of all nations.

One of the major deficiencies in our system is the very high administrative costs which waste funds that could be filling the voids in care, so it is ironic that Congress responds to the recognized problems with even more administrative burdens. Which “may help to reduce somewhat the dizzying complexity of health insurance in the US” … wow, how low can we set expectations?

Viewing the report, much of the problem lies with the tools used by the private insurance industry, but when you think about that, it is not too difficult to understand why. Private insurance is designed primarily to make generous profit for the owners – the billionaire shareholders whose goal is further wealth accumulation. On the other hand, truly public insurance is owned by the people of the nation and is designed specifically to deliver health care to those who need it.

When you read the findings, it’s obvious that all we would have to do to correct the deficiencies is to make the entire insurance program public. The simplest, most efficient, most effective, and most equitable way would be to enact and implement a single payer (an improved Medicare for All) that includes everyone, a single payer that we, the people, own. The problems listed in the Key Findings above would melt away.

But this does mean that elected leaders would have to put in place policies that serve the people rather than the private insurers and their investors. This last point we must tackle seriously now. Really! Access to health care is at stake, as the report vividly describes.