High Uninsurance post-ACA for Low-Income, Black, Hispanic

Summary: This study used a national survey to document high levels of uninsurance among vulnerable populations after ACA implementation, especially in states not choosing to expand Medicaid – up to 40-60% for some groups in some states. Sadly, but unsurprisingly, the ACA falls far short.

States’ Performance in Reducing Uninsurance Among Black, Hispanic, and Low-Income Americans Following Implementation of the Affordable Care Act
Health Equity
July 21, 2021
By G. Lines et al.

From the abstract:

Purpose: To assess state-level variation in changes in uninsurance among Black, Hispanic, and low-income Americans after implementation of the Affordable Care Act (ACA) [in 2014].

Methods: We analyzed data from the Behavioral Risk Factor Surveillance System from 2012 to 2016 …

Results: The range in the percentage point reduction in uninsurance varied substantially across states: 19-fold for Black (0.9–17.4), 18-fold for Hispanic (1.2–21.5), and 23-fold for low-income (1.0–27.8) adults. … In some states, more than one quarter of Black, one half of Hispanic, and approaching one half of low-income adults remained uninsured after full implementation of the ACA. Compared with states in the lowest quintile of change in coverage, states in the highest quintile experienced greater improvements in ability to see a physician.

From Fig 3, for Low Income individuals. Dark bars are states that expanded Medicaid.

Comment by: Jim Kahn

National averages for uninsurance don’t do justice to the dismal post-ACA shortfalls for vulnerable groups – Blacks, Hispanics, and low-income. Especially in states that failed to expand Medicaid, but also in states that did expand. As this study demonstrates, these shortfalls impair ability to see a physician, and that, we know, worsens health outcomes.

How long will our country continue its commitment to highly inefficient convoluted health insurance schemes when there is a simple, efficient, equitable solution waiting for us to pluck it off the shelf and put it in place?

Single payer would not need studies or graphics like this. We’d just cover everyone.



Californians Crave Single Payer!

Summary: Three diverse California groups – doctors in training, low income populations, and leaders of community-based organizations — recently showed high support for single payer. Very encouraging trend, invigorating! Let’s harness that energy.

Health reform debate
USC Keck School of Medicine
September 21, 2021
Single Payer presenter Paul Song MD

See Paul’s ppt deck here.

Community Voices Priorities and Preferences of Californians with Low Incomes for Health Care Reform
September 2021
By The Healthy California for All Commission

From the Executive Summary:

Both the public opinion poll and the CBO leader interviews and surveys conducted show strong support for a single, statewide, government-run health care program that covers all people who live in California. The poll suggests that 65% of Californians with low incomes support the concept, with people of color showing greater support: 76% of African Americans, 71% of Latinos, 73% of Asian/Pacific Islanders, 65% of Native Americans and 54% of whites. Similarly, a majority of CBO leaders indicated support for the concept of a single statewide government-run health care program.

Comment by: Jim Kahn

Look what’s happening in California: So much support for single payer, from different corners … two diverse examples arrived in the last couple of days.

All of us who educate and advocate for single payer have been in debates, arguing the merits of single payer versus strategies that are pure market (“skin in the game”) and blended (like the ACA). Usually we’re quite pleased to swing opinion 10-20%. Look what happened when Paul Song spoke at USC Keck School of Medicine – a 41-point swing! To 89% support! Paul is a brilliant presenter. But, also, the times are changing … more and more people in health care and out recognize the gaping flaws in the current health care non-system, and the excellent performance of single payer.

Who recognizes it especially well? The population that is most vulnerable and in need. In statewide polling of low income populations and of community-based organization leaders, the Health California for All Commission found a clear consensus: “strong support for a single, statewide, government-run health care program that covers all people who live in California”. That sounds like … single payer.

There’s lots of work left to do. Lots more people to convince, including importantly our legislators. Bills to write, battles to wage. But I think we’ve turned a corner … to widespread recognition of what is known so well outside our country’s borders: single payer is a stunningly efficient and effective solution.


If USC is ready for single payer, it’s time!

Summary: The University of Southern California medical school is often regarded as high class. But at least two of its current top leaders share health justice goals, and endorse single payer. The tide of support is turning!

Steve Shapiro brings a big-picture approach to medicine at USC
USC News
September 14, 2021
By Leigh Hopper

Steve Shapiro takes the macro view of medicine. This spring, he became the first senior vice president for health affairs at USC, where he will oversee — and build bridges between — clinical operations at Keck Medicine of USC and research and medical training at the Keck School of Medicine of USC.

Question: You’ve said that L.A. traffic will give you more time for audiobooks. Any recommendations, audio or otherwise?

S. Shapiro: I’ve just finished a couple of books. One was called Broken, Bankrupt and Dying by our chief medical officer at LAC+USC, Brad Spellberg. It’s the best argument I’ve heard for a single-payer system, as well as explaining the nuances of what single-payer means. It’s really impressive.

Broken, Bankrupt, and Dying
By Brad Spellberg (chief medical officer at LAC+USC)

I believe we should move forward with a universal, single-payer, national insurance plan, with no deductible or coinsurance, but with copays for speciality care and prescription drugs, funded by central collected taxes that everyone pays, but while still giving the individual a choice about whether they want to use the public insurance or buy their own private insurance. The resolution to the seeming paradox between a single-payer plan and offering choices is to give government-sponsored insurance to all residents, but also allow and encourage a thriving private insurance market that people can choose to purchase into if they would like. Let the public plan and private markets compete. Give people options.

I think this collective ideal makes the most sense. I think it will offer the best coverage at the best price, and will help reform healthcare delivery to eliminate waste and improve outcomes. I also think it is the most politically palatable, minimizing triggering opposition by including aspects that should appeal to people on both sides of the aisle.

But you know what? At this point, I’ll accept almost any universal system that can muster the political and social support behind it to get it done. I have no use for a philosophically optimal system that can never be implemented. I want something that can get done. So I’m keeping an open mind while advocating for what I think is best, and I’d encourage you to do that too.

Comment by: Don McCanne

For those of us on the West Coast, USC School of Medicine has the reputation, perhaps unfairly, of being the medical school with Rolls Royces in the doctors’ parking lot. For those who might doubt the social mission of USC medical school, these leaders at USC have provided very reassuring comments that show that they share health justice goals with the rest of us.

This book by Brad Spellberg describes many of the intolerable deficiencies and injustices of the current US healthcare system while proposing many corrections that must take place. Though there will be some debate over the specifics, the general approach of establishing a national health insurance program seems to have reached the point where there should be broad public acceptance. At least we now have reassurance that the institutions of the health professions are moving into alignment on the issues. Let’s all move in together and get it done.


Allowing For-Profit Hospice: The Worst Health Policy Idea Ever?

Summary: For-profit ownership has reached two-thirds of hospice agencies. Yet for-profit status is associated with fewer services, less clinically skilled staff, more formal complaints, more discharges of sicker patients, and more hospital and emergency department use. Removing for-profit ownership is part of health reform.

Hospice Tax Status and Ownership Matters for Patients and Families
(behind a paywall)
JAMA Internal Medicine
August 1, 2021
By Melissa D. Aldridge.

From the article: 

The increase in ownership of hospices by private equity (PE) firms and publicly traded companies . . . follows almost 2 decades of steady growth of for-profit ownership of hospice agencies, from one-third of hospices in 2000 to almost two-thirds by 2017. Why is this noteworthy? It is difficult to identify a health care sector more detrimentally affected by the mismatch between profit maximization incentives and quality of care than hospice. Whereas some have argued that tax status (ie, whether a hospice is for profit or nonprofit) is unrelated to hospice quality, an increasing body of evidence suggests otherwise. The requirement for for-profit organizations to distribute net income to shareholders provides strong incentives to generate consistent profits over short time periods. . . .

For-profit compared with nonprofit hospices provide narrower ranges of services to patients, use less skilled clinical staff, care for patients with lower-skilled needs over longer enrollment periods, have higher rates of complaint allegations and deficiencies, and provide fewer community benefits, including training, research, and charity care. For-profit hospices are more likely than nonprofit hospices to discharge patients prior to death, to discharge patients with dementia, and to have higher rates of hospital and emergency department use. In one analysis of 355 hospices, 90% of those with the lowest spending on direct patient care (eg, patient home visits) and the highest rates of hospital use were for-profit hospices.

Comment by: David Himmelstein and Steffie Woolhandler

Allowing for-profit hospices is crazy. The deranged care documented in the commentary above (each statement is referenced in the original article) is the predictable result of reimagining dying patients as prudent shoppers in a commercial transaction. Medicare pays for the overwhelming majority of hospice care and could proscribe the participation of for-profits – it excluded for-profit home care agencies until 1980.

With more and more health care providers being snapped up by for-profit firms, and evidence of their misbehaviors mounting, proscribing for-profit ownership has become an essential element of health care reform.    


Crowdsource ideas on government role in single payer

Summary: Today is an experiment: crowdsource day at Health Justice Monitor! We know that HJM readers think about healthcare reform and discuss it with family and friends, and we’d like to learn from that – garner the most persuasive arguments. Please share your ideas. If this works well, we’ll incorporate it regularly.

Comment by: Jim Kahn

What do you find to be the most persuasive arguments to counter the concern, “Our government can be counted on to get it wrong! Inefficient and ineffective! Look at the post office, the public schools, and Medicaid.”

My usual response is, “Our government gets it right when people in all social strata need the service (e.g., the fire department and Medicare among the elderly) and is especially good at disbursing funds (e.g., social security). Where government services fall short is when the beneficiaries are those without political power, e.g., Medicaid for the poor.”

A possible rejoinder is, “Yeah, but what if enough rich people buy out of the single payer system to support a parallel private healthcare system. They pay their taxes and also for their own upscale medical care. Like they do for private schools.”

To that I say, the “There aren’t enough people able and willing to pay twice for health care. Sure, a few super rich will buy out, but the vast majority – including large segments of society with powerful political voice – will stay in, as will almost all doctors. Just like Medicare today.”

What would you say in this discussion? What has actually worked well in conversations with skeptics?

Send your thoughts to, subject line including “Crowdsource ideas on government role in single payer”. Brief please – 25-50 words. And, let us know if / how you want to be identified.

We’ll curate (edit, trim, organize) and compile in a Google document which we’ll share. (To assure a focus on content and civility, we’re not currently planning to make this site interactive.)

Many thanks. Looking forward to your ideas.


Am I a Single Payer Zealot?

Summary: Yes, proudly.

Health Care Unions Defending Newsom From Recall Will Want Single-Payer Payback
KHN (Kaiser Health News)
September 13, 2021
By Angela Hart

Bob Ross, president and CEO of the California Endowment, a nonprofit that works to expand health care access, is on Newsom’s single-payer commission. He said it will work through “tension” in the coming months before issuing a recommendation to the governor on the feasibility of single-payer.

“We have a camp of single-payer zealots who want the bold stroke of getting to single-payer tomorrow, and the other approach that I call bold incrementalism,” Ross said. “I’m not ruling out any bold stroke on single-payer; I would just want to know how we get it done.”

Comment by: Jim Kahn

If believing that we should jettison $800 billion in administrative bloat and transfer the savings to health care makes me a zealot, I accept the label.

If favoring full health care equity is zealotry, I’m on board.

If removing financial barriers to care and thereby avoiding 80,000 deaths per year is zealous, that’s me.

If patient choice of doctor is a zealot’s errand, where do I sign up?

If reducing physicians’ billing burden so they can focus on clinical care is zealotry untrammeled, count me in.

If rejecting “incremental approaches” that end with tens of millions uninsured or underinsured, and trillions of healthcare dollars diverted to profits for shareholders brand me a zealot, I’ll wear that insignia with pride.

If saying, “enough already, it’s time for the US to join the global consensus on health care as a human right” leads to whispers of out-of-control zeal, I’ll shout it from the mountain tops.

Am I a single payer zealot? Guilty as charged.

(p.s., the KHN article mistakenly asserts that creating single payer in California will cost $400 billion / year. Instead, it will *reduce* spending from the current level of about $400 billion …)


A public option would perpetuate our highly dysfunctional financing system

Summary: Jacob Hacker proposes Public Option 2.0 as part of Medicare and integrated into ACA marketplaces. He says it would pave the way for Medicare for All. But would it? History teaches us that it might well derail the drive for Medicare for All.

Medicare for More — Why We Still Need a Public Option and How to Get There
The New England Journal of Medicine
September 11, 2021
By Jacob S. Hacker

When I first argued for the public option two decades ago, it was seen as a huge reach. Today, it is a mainstream Democratic idea. Indeed, the version that Biden supported during his campaign is more robust than anything considered during the debate over the ACA — so much so that I believe it should be called the “Public Option 2.0.” The public option that Biden embraced would explicitly be part of Medicare, using Medicare’s provider network and basing its reimbursements on Medicare payment rates. It would also be available through the ACA marketplaces to all legal U.S. residents who are not eligible for other public coverage, including workers with employer-sponsored insurance (who today are essentially barred from obtaining ACA coverage), and tax credits would be provided on the same terms as they are with private plans. In addition, the Public Option 2.0 envisions a system in which employers could eventually pay the federal government to enroll their workers in the Medicare-based plan.

The Public Option 2.0 would not be Medicare for All. But it could evolve into something similar.

Progressive critics of the public option argue that it would end up at a competitive disadvantage relative to private plans. They note that in Medicare Advantage, commercial insurers siphon off an increasing share of healthier-than-average beneficiaries who would otherwise enroll in the traditional public plan. On a level playing field, the public option’s ability to negotiate lower prices would give it an important advantage over private plans, as would Medicare’s popularity and the broad choice of providers it offers.

Voters not only support a generous public option by overwhelming bipartisan margins, but they also support automatically enrolling every uninsured person in it. Nor do they seem too worried about its evolving into Medicare for All. Indeed, the largest plurality of voters think it should be a stepping stone to universal Medicare.

Medicare has substantial gaps — most notably, no cap on out-of-pocket costs and no drug benefit integrated into the traditional public program. Expanding Medicare benefits will help beneficiaries now, and it will help the cause of expanding Medicare later. By the same token, Medicare Advantage plans should be stripped of their current unjustified advantages.

Advocates of the Public Option 2.0… can build power to finally make Medicare an option for all Americans who need it.

Comment by: Don McCanne (adapted from NEJM posting)

Jacob Hacker has long been a leader in designing and advocating for a Medicare-like public option, and his current version 2.0 would benefit many. It would be a great addition to the current insurance options, but it would leave in place the rest of our fragmented, dysfunctional, inefficient, inequitable, and overpriced financing system.

Although it has been suggested that it would serve well as a transition to an improved Medicare for All, it is likely that the breadth of coverage, as dysfunctional as it would be, would reduce further the political drive to complete the transition, as we’ve seen in the past. Possibly forever.

It would be far better to take a single leap to a well-designed, less expensive, more equitable, single payer Medicare for All. Jacob Hacker has a standing invitation to join us in the single payer camp where his system design expertise and advocacy for health justice would be most welcome.


American College of Physicians on For-Profit Medicine; Mortality from For-Profit Dialysis

Summary: Investor-owned care, with a focus on profit, has permeated U.S. health care. The American College of Physicians critiques this trend, but avoids a clear opposing position. Meantime, evidence accumulates of its deleterious effects on health. 

Financial Profit in Medicine: Position Paper from American College of Physicians
Annals of Internal Medicine
Sep 7, 2021
By R Crowley et al

From the Abstract:

The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics.

From the Recommendations:

ACP affirms support for . . . providing all Americans with access to comprehensive health care coverage, either through a public choice model or single payer model.

Mortality at For-Profit Versus Not-For-Profit Hemodialysis Centers: A Systematic Review and Meta-analysis
International Journal of Health Services
Dec 15, 2020
By S Dickman et al.

From the Abstract:

We conducted a systematic review and meta-analysis to assess differences in risk-adjusted mortality rates between for-profit (FP) and not-for-profit (NFP) hemodialysis facilities.. . . We included nine observational studies of hemodialysis facilities representing 1,163,144 patient-years. In pooled random-effects meta-analysis, the odds ratio of mortality in FP relative to NFP facilities was 1.07 (95% CI 1.04–1.11). … Approximately 3,800 excess deaths might be averted annually if U.S. FP hemodialysis operators matched NFP mortality rates.

Comment by: David Himmelstein and Steffie Woolhandler

For a generation or more doctors mostly remained silent as care was commercialized; the frogs sat still as the water heated up. The ACP’s statement continues the “let’s wait and see approach”, even as it cites the mounting evidence that allowing investor-owned (a clearer term than “for-profit”) health care delivery distorts care and raises costs. The confusion arising from the term “for-profit” is evident in the ACP’s position paper, which conflates investors’ gains from ownership of facilities (and the labor of others) with income derived from the work you do yourself, i.e. physicians’ incomes for the care of patients.

While the ACP studiously avoids taking a position on investor-owned care, many of the position paper’s 193 references attest to the harmful effects of such ownership, and the two principal profit-boosting strategies employed by investor-owned providers: (1) raising costs; and (2) skimping on care. Where payments can be inflated by raising prices (e.g. by taking ED docs out-of-network), or financial gaming (e.g. upcoding) they do that.  When payments are mostly fixed (e.g. for nursing home care or dialysis) they skimp on care, sometimes with fatal consequences (as the Dickman/Mirza study demonstrates).

While the position paper happily reaffirms the ACP’s support for single payer reform, it otherwise remains silent on the market-oriented health policies that have opened the door for investor ownership and also force non-profits to prioritize generating surpluses or risk a downward spiral toward closure.

Doctors and other health care workers should receive reasonable incomes. Health care institutions should devote all of their revenues to patient care, not to rewarding investors or accumulating funds for expansion or investment. Instead, funding for new or upgraded facilities should be allocated based on objective assessment of communities’ needs.  


Remembering 9/11 and Social Cohesion

Comment by: Jim Kahn

Today is the 20th anniversary of the airborne terrorist attacks on the NYC Twin Towers and other US targets. The terrible events of that day brought our country together in sympathy and support for the hurt and the families of the deceased. A new era of American solidarity seemed to be born. But this sentiment was squandered with an ill-conceived pair of wars, one of them duplicitously justified and both of them ineptly managed. The spirit of vicious partisanship accelerated by Newt Gingrich during the Clinton years regained traction. Unity devolved into division, and today we struggle to hold together our democracy.

In 2021, single payer offers hope of enduring cohesion. Individuals across the political spectrum greatly value social security and Medicare, and would greatly value government financing of comprehensive medical care. Social solidarity would jump. Single payer represents a return to the liberal consensus on the role of government forged under FDR and vigorously accepted by Republicans through Eisenhower and substantially into the 1970s. I have no illusions about the political barriers to enacting single payer, with moneyed interests aligned to oppose the shift to a non-profit oriented equitable health insurance system. Health care justice in the form of single payer is aspirational, for the moment. But what better aspiration could there be?

(Thanks to John Roark for US history discussion)


“But can the government afford it?”: The wrong question for Medicare for All

Summary: Modern Monetary Theory establishes the principles that can — indeed must — guide the federal government’s spending on essential population needs, like universal health care. The government’s fiscal tools enable these commitments, even beyond what taxes can cover.

The Deficit Myth: Modern Monetary Theory and the Birth of the People’s Economy
By Stephanie Kelton
Professor of Economics and Public Policy, Stony Brook University

To begin, I tackle the idea that the federal government should budget like a household. Perhaps no myth is more pernicious. The truth is, the federal government is nothing like a household or a private business. That’s because Uncle Sam has something the rest of us don’t – the power to issue the US dollar. Uncle Sam doesn’t need to come up with dollars before he can spend. The rest of us do. Uncle Sam will never go broke. The rest of us could. When governments try to manage their budgets like households, they miss out on the opportunity to harness the power of their sovereign currencies to substantially improve life for their people. We will show how MMT (Modern Monetary Theory) demonstrates that the federal government is not dependent on revenue from taxes or borrowing to finance its spending.

The sixth myth that we’ll consider is that entitlements are propelling us toward a long-term fiscal crisis. Social Security, Medicare, and Medicaid are the supposed culprits. I will show you why this way of thinking is wrong. Our government will always be able to meet future obligations because it can never run out of money. Instead of arguing over the monetary cost of these programs, lawmakers should be fighting about whose policies stand the best chance of meeting the needs of our entire population. The money can always be there. The question is, What will that money buy?

The Health-Care Deficit

At the very least, we know from MMT that our failure to provide proper insurance and care for every American isn’t because the government can’t “afford” to cover the cost. By settling for a system that provides coverage through a fractured web of private insurers, employer plans, and patchwork government programs, we’ve created a system of bottlenecks in which hospitals, providers, drug companies, and the private insurance companies can squeeze us for every last dollar – and in which bigger profits lie in making it harder for people to access care. If we’re going to set up a system where everyone has a right to the health care they need, we’ll have to make sure we’ll have the real resources to do it.

Building an Economy for the People

In the United States, where we have an abundance of resources and labor, there is no reason we cannot embark on a policy agenda that results in provisioning our entire population with quality health services, providing each worker with adequate and appropriate advanced education and job training, upgrading our infrastructure to meet the demands of a low-carbon world, and ensuring adequate housing for everyone while redesigning our cities to be clean, beautiful, and nurturing of community spirit.

With the knowledge of how we can pay for it, it’s now in your hands to imagine and to help build the people’s economy.

Comment by: Don McCanne

This book was released last year to widespread critical acclaim. But listening to members of Congress and others in the policy arena it is clear that the message has not adequately penetrated our dialogue on the essential government spending that must now take place. If you read the entire book, which you should, you will be able to dismiss the budget hawks who oppose the spending that is needed to make our society the greatest in history.

Modern Monetary Theory reminds us how government spending is fundamentally different from household or business budgets. Sovereign currency governments, such as ours, have economic tools to expand resources to provide all essential needs for everyone. For those of us at Health Justice Monitor, that means that we can provide comprehensive, equitable, affordable, high quality health care services for absolutely everyone … even if higher taxes don’t fully cover the added government costs.

But that also means that those who establish our public policies, such as the members of Congress, must understand Modern Monetary Theory and how it can help us achieve our goals of health care justice for all.