An "Exciting But Dangerous Moment" for Medicare for All

Dr. Adam Gaffney is the brand new president of Physicians for a National Health Program (PNHP), the national, Medicare for All advocacy group of medical professionals and others committed to single-payer--universal healthcare "provided equitably as a public service rather than bought and sold as a commodity."

In the announcement of his election, Dr. Gaffney said, "We've been so successful in popularizing the idea of 'Medicare for all' that everybody wants in on the slogan--even if they have something completely different in mind, like a public option. But tweaks won't solve the fundamental problems of American health care: persistently high uninsurance, rising underinsurance, unaffordable drugs, narrow provider networks, and the growing corporate domination of health care that prioritizes profits over patients."

Adam Gaffney is a pulmonary specialist at Cambridge Health Alliance in Massachusetts who earned his bachelor's and medical degrees from New York University and a master's in public health from Harvard. He's been active in the single-payer movement for several years, writing numerous articles and research papers and co-chairing a working group that developed PNHP's "Physicians' Proposal for Single-Payer Health Care Reform."

We spoke recently while he was in New York for a meeting of the commission on public policy and health in the Trump era, a group brought together by the medical journal The Lancet. Our conversation has been edited for length and clarity.

Talk a bit about your medical background and how it has made you such a strong Medicare for All advocate.

I think that my politics preceded my medical career. In college I was very progressive. In 2000, when I was a freshman in college, I supported Ralph Nader in that election. I think that's when I first heard the term "single payer," although I certainly supported universal healthcare as a concept earlier than that, back to my years in high school.

But I would say that everything I've seen since embarking on my medical career has reinforced my feelings about why we need single-payer and universal healthcare: all the patients I've seen who have gone without care because they couldn't afford it, who have skipped inhalers for their emphysema because they couldn't afford the copay, have shown up in the ICU because of complications of illness that didn't get treated because they had gone without insurance or because their insurance had lapsed. Everything I've seen since embarking on a medical career has definitely reinforced what I had thought before I started it.

People often say why do we need one public payer? Why can't we have a number of different insurance companies? There are many downsides to that. It's not just that fragmentation produces waste, which it does, it's not just the enormous burden of billing and administration that imposes on hospitals and doctors and that generates as much as $500 billion a year in wasted spending on administration. It's also the fact that often people don't even know what's covered. Physicians won't even know what's covered. People show up at the pharmacy and it turns out the drug they need isn't covered.

Literally the last thing I would want a patient or family to have to think about are the financial consequences of their healthcare. And they don't have to.

So you are completely convinced that single-payer is the best way to go?

Yes. I am also completely convinced that imposing costs on patients at the time of healthcare use has no useful purpose. That seems like a radical idea, and even people on the liberal-left side of the spectrum sometimes say, well, having a reasonable copay is not such a bad idea to ensure that healthcare is not used sort of frivolously. I think some people think a system where you don't impose costs is pie-in-the-sky and unrealistic. It's of course not unrealistic, considering that in the UK this already exists. In the UK, there are no copays for doctor's visits, no deductibles, no payments to hospitals. In Scotland, you don't even pay for parking at the hospital if you're visiting a loved one. It's clearly doable and I think it's a better system.

At the end of the day, maybe people paying for healthcare only really affects working class and poor people because well-off people are always going to be willing to pay a forty-dollar copay, right?It really is just a way of punishing the sick and the poor.

When your presidency was announced, you described it as an exciting but also dangerous moment in the history of single-payer. Why?

Exciting in that we're farther along than we ever have been. Single-payer has made incredible strides in just the last few years, from a position that was mostly on kind of the fringe of respectable politics to a position that's now very close to center that's being embraced by politicians running for president. That was not the case in 2008.In 2008, basically all the major candidates had no interest in single-payer, they already had their minds made up that healthcare reform was going to be a sort of Obamacare-like proposal, which it was. That's not the case anymore.

I think it's part of a larger, progressive swing. In many ways our politics have become more regressive with the election of Trump, with the domination of Congress by Republicans. But there has been a progressive swing with exciting, new left-wing candidates in the House of Representatives. The move of single-payer to the center of the conversation is part of that.

But it's a dangerous moment as well. Think about this: Even while we get excited about the prospects of single-payer, Republicans in Congress are now pushing dangerous new programs. States like Arkansas are imposing work requirements on a Medicaid program that's squeezing out of the program, I think the latest figure was 18,000 people, by creating bureaucratic barriers and paperwork.

There's obviously going to be an ongoing effort by the right to dismantle existing, public healthcare systems - whether that takes the form of another attempted repeal of the Affordable Care Act seems unlikely given the change in Congress in November.

In December, the Trump administration released a white paper that was mostly not noticed in the news, but it was a wish list or manifesto for a conservative healthcare future. It gives you a sense of what corporate opposition would do if it could: Further privatize the system or further privatize Medicare, it would increase high deductible health plans; it would just take an overall, laissez-faire, deregulatory approach to the health care system. So there are both promises and dangers on the horizon.

Let's talk about the 2020 elections. In the PNHP announcement of your presidency it's said that Medicare for All has become such a catchphrase that some candidates may be misusing it.

We've had the idea for a long time. But what happened was that the idea has become very popular, something that everyone is rallying behind. So I do think there's an effort to steal some of that thunder and use the branding on other types of healthcare proposals that fall well short of what we're talking about.

We're talking about a national health insurance program that covers everyone in the country. These other proposals are not that. Some of them still might help many people but they're not what the country needs. They wouldn't fix the fundamental problems of the US healthcare system.

There has been a long-standing debate over whether calling this Medicare for All is the right approach. On the pro side, Medicare is a familiar system, something that people understand, a term people are familiar with. Historically, the people who designed Medicare first envisioned it as a national health care system. It was the progeny of a national health insurance model. The architects of national health insurance under the Truman administration, when that fell through, they basically said, all right, let's at least make this into a program for seniors. So in terms of the historical, ideological lineage, there is something to be said for calling single-payer Medicare for All.

The cons are that it can be confusing, because we're not talking about replicating Medicare in its current form, we're talking about going beyond it. Medicare has copays, this system will not. Medicare doesn't cover dental, this system would. Medicare has somewhat privatized; there's Medicare Advantage, and Medicare part D, the drug benefit. In contrast, this would be a single, solitary public plan, so there are significant differences between Medicare and what we're talking about.

Would you say that Bernie Sanders' Medicare for All legislation in the Senate or the House bill comes closest to your organization's position?

The House bill comes closest. The Sanders bill has a couple of areas for improvement that we'd like to see. They're mostly sort of wonky design issues that most people don't get too excited about but that we think are very important.

Overall, the Sanders bill is a single-payer bill; it gets most of it right. We would like to see a change in the way hospitals are financed so that they get global budgets that cover all their operating expenditures rather than replicating the current Medicare payment system which incentivizes profit-oriented activities. We'd like to see no copays on drugs. The Sanders bill has almost no copays but it has small residual copays for some drugs. It's pretty minor but we'd like to see that out. We'd like to see the inclusion of long-term care, which the Sanders bill does not have. It is a lot of money but we need to deal with long-term care and make sure that's covered.

Ryan Grim had a piece in The Intercept recently reporting that Nancy Pelosi's top healthcare aide had met with representatives of Blue Cross Blue Shield and told them that the House would move on drug prices over single payer or changing the ACA.

I think there's some truth that we're not going to pass single-payer under the Trump administration. It isn't realistic to think that it's going to happen with this current government. But it is disturbing that those assurances are being given to the industry. It suggests that not all Democrats are on the same page.

There's longstanding resistance among some in the establishment to sweeping ideas like Medicare for All. I talk about all the huge strides that have been made but there are still many obstacles ahead. As you're probably aware, there's a new corporate group funded by Big Pharma and the insurances companies that is spoiling for a fight, sharpening its swords, gearing up to tackle single-payer. The industry is not going to go down without a fight. Obviously, they're going to pour money into Washington, they're going to pour money into lobbying, they're going to pour money into candidates, they're going to take out ads, they're going to smear it left and right, so our work is cut out for us.

Senator Sherrod Brown, a progressive on most things, has said that he's for Medicare for All, but thinks it should be incremental, starting by lowering the Medicare age to 55.

I understand those arguments but I think what's often not understood is that many of the savings that a single-payer system would achieve really come from a systemic shift and not from the incremental. Let's say you create a public option that's one more option people can buy into as a choice of healthcare insurance. That may achieve somewhat lower premiums, by virtue of paying Medicare rates instead of private insurance rates, but it's actually not going to take the profit orientation out of the system. It's not going to achieve the administrative savings that you get from a single payer system, it's not going to allow us to reduce the armies of billers and coders that are employed by hospitals. So I think that some of those arguments fail to realize the real policy issues.

You just mentioned this new corporate group that wants to come down hard on single-payer because you're advocating for the complete elimination of private insurance.

There may be some small residual role for private coverage of cosmetic surgery or things like that. That's basically how it is in Canada. In Canada, the system doesn't cover drugs or vision, there are supplementary plans for those things, but that's a weakness of their system, not something we should emulate. So there's really no need to have a private health insurance industry in this country. You'd have one public payer that covers everybody.

You're going up against a behemoth.

Yes. They'll need to find a new line of work (laughs). I don't know what to say. The workers in those industries definitely need to be taken care of. The Sanders bill and the House bill both have provisions to take care of displaced workers. It's not their fault that these industries don't really have value. [What happens to] the CEO's, I really don't care too much about.

But how do you go about buying out for-profit hospitals and nursing homes? How do you keep owners from simply converting hospitals and nursing facilities into apartments or hotels?

There's an ongoing debate about this among supporters of single payer. PNHP's position is that we should have a plan for how to buy out for-profit healthcare providers as we transition into single-payer. We think that you could take out a large bond, use it to buy out for-profit providers, convert them to not-for-profit and that would be a way to ensure that for-profit owners don't say to heck with this, I'm selling off all my dialysis machines to Europe.

Unions are a bulwark of the Democratic Party and I know that a lot of union members are going to say that my union healthcare plan is really good, why would I give it up for single-payer?

My response would be that you're never going to give it up for something that's not better. We and our allies would never support a plan that replaced people's existing plans with something inferior. If you look at the bills, they have comprehensive benefits and no cost sharing. That essentially beats every private plan out there and goes beyond them.

For at least the next two years, the Republicans will keep trying to destroy the Affordable Care Act. As you see it, is there value in continuing to work to shore up Obamacare until changes can be made?

I think we should join forces with everyone who's fighting to defend existing programs that help people. I think you saw that during the 2017 repeal effort when single-payer supporters linked arms with people who supported ACA or supported other forms of universal coverage and we fought together to push back against the repeal of the Affordable Care Act. I don't think that doing that retards the advance of single-payer and I don't think that fighting for single-payer gives an opening for those who want to attack the ACA.

So how do you pay for single payer?

There was a 200-page report on the economics of single payer that came out of the University of Massachusetts, Amherst, led by economist Robert Pollin. They suggested a mix of taxes that would cover its costs. It's by no means definitive, there are other approaches to the problem, [but] their proposal includes redirecting all existing public health monies into the new system. Roughly two thirds of current public health dollars are already taxpayer-financed. So you divert those funds into the new system and for the remaining, yes, you need a mix of taxes. They propose a modest sales tax on non-essentials, an employer-side payroll tax and some new taxes on the very wealthy.

What you call "truly progressive taxation."

Which has the added benefit of doing something about soaring economic inequality, which in itself is a cause of bad health. So actually, publicly financing our healthcare system has benefits by helping to confront the problem of inequality.

The other side screams "socialized medicine," just as they did when Medicare and Medicaid and Obamacare began.

Call it what you will (laughs). Medicare and Medicaid were historic advances as was the Affordable Care Act, improving people's lives. But they have left big holes, and for some people, things actually are getting worse. There just was a report from the Commonwealth Fund in which they looked at the inadequacy of insurance and they found that 45 percent of non-elderly American adults are inadequately insured or underinsured. People with insurance from their employers have seen their deductibles triple over the last decade, and the portion of people who are underinsured continues to rise. The Affordable Care Act helped to reduce the uninsured by 20 million people but it obviously left huge holes.

You alluded to "global budgets," also known as global operating plans. Explain.

There are different ways to pay a hospital. The existing way is per patient billing. Sometimes that means having to add up every single service they used or every single Tylenol and so on, which obviously is a huge waste.

So what are the downsides of that? For one, you need an enormous infrastructure of people adding up the costs on a per patient basis. US hospitals spend a quarter of their revenue on administration and billing. That is double the proportion that Canada and Scotland spend.

The other problem with existing hospital payment methods is that they incentivize a profit-oriented approach focusing on the kinds of patients or the kinds of care. I'm not saying every hospital does this; my hospital, Cambridge Health Alliance, certainly does not.

Overall, it creates an incentive for hospitals writ large to engage in some profit-oriented activities - supplying services that generate the highest revenue, neglecting those that do not. This is something that PNHP co-founders David Himmelstein and Steffie Woolhandler have written a lot about. Even non-profits are sort of beholden to this sort of system. Not only that, but for hospitals to expand, to build new infrastructure, to get new machines, new equipment, they need to generate profits because the way that new healthcare infrastructure is funded in America is from profits for hospitals.

So the whole system is designed to encourage even non-profits to engage in profitable activities because if they don't they'll go under. They won't be able to buy the new equipment, they won't be able to build the new wing, they won't be able to attract patients and the patients will go elsewhere. This is why we need to get away from a discussion that focuses on bad actors and start thinking about the way the system is designed, the defects in the system.

What do we need to do to change that? First, we need global operating budgets. Himmselstein and Woolhandler have rightly emphasized this. It's a lump sum that a hospital gets to cover all its operating expenses. This is how it works with the VA, this is how it works in Europe, in Canada, for the most part. You get a lump sum and you can use it to take care of all your patients and then you're not trying to say, well, I'll do more invasive surgery that makes a lot more money. Instead, I'll spend it where it's needed, take care of patients in response to community needs.

At the same time, what we propose and what is in the House bill is a system where the capital expenditures I mentioned are separately funded, where hospitals don't have to try to seek a profit on their operating revenues in order to have money left over to build stuff. Capital expenditures are determined based on medical need when and where the structure is needed.

So you move away from this whole profit ethos toward one that's focused on community needs. In the current system, new hospitals get built where revenues are highest, new wings get built where revenues exceed costs. Hospitals in rural areas are going under because it's hard to turn a profit in a rural

What we call single-payer incorporates things beyond just where the money comes from. It envisions a reconfiguration, a reformulation of the healthcare system away from profit-oriented activities towards one that is oriented toward community and patient needs.

People ask questions like, when do you see this happening, how do you see this happening - frankly, I have no idea. No one knows. The reality is that when we achieve single-payer there still are going to be areas for improvement. We're not going to get it perfect the first time, and there are always going to be efforts to dismantle it. But I think the single-payer system is particularly resilient against that.

You see that in Europe - even when there have been right wing governments, try as they may, they often stumble in their efforts to dismantle public systems of healthcare. Margaret Thatcher, her people certainly would have loved to have dismantled NHS but they knew they couldn't. They tinkered with it, they made it worse, they added some market elements to it...

And then the conservative Brexiteers lied and used as an argument that all the money saved from leaving the EU would be put into the NHS.

It does show how achieving real solid victories that help people on an everyday basis create the constituencies that support it. That doesn't make it invincible, I understand that. But the NHS is socialism! (laughs)

Talk a bit about PNHP's education efforts.

We have a sort of split focus, both on the medical profession and on the general public. Our members do grand rounds at hospitals, we speak to colleagues, we give talks, we disseminate materials, we produce research.We are one part of the single payer movement that does focus on the medical profession. But the reality is that we don't just want doctors to be on board, we need doctors to be on board.

There are some polls that show majority support for single payer among physicians. A lot has changed from the late 1940's when the American Medical Association was the main force that defeated Truman's national health insurance plan.

For one thing, there are more voices, it's a more pluralistic profession than it was, it's certainly a far more diverse profession than it was. There are still elements in the medical profession that are opposed to single-payer but there are elements like ours that powerfully support it. There also have been changes in the political economy of healthcare. Relatively recently, it was reported that a majority of physicians are now employees, which is a tremendous shift in the political economy of healthcare. Traditionally, physicians were essentially archetypal small business people, typically businessmen.

There have been real downsides for physicians, in terms of the quality of their work. They spend more time on clerical activities, on fighting with insurance companies, on checking boxes - interacting with the computer instead of interacting with the patients. I think it has resulted in a lot of burnout with physicians and it has resulted in job dissatisfaction, so I think there is a real desire among physicians to imagine a better world for their patients and for themselves. I think that has created an opening within the medical profession to support single-payer.

And about educating the general public?

Our members do media, write op-eds, give talks, engage in debates and also some of our members engage in policy research that our organization helps to get out there.

Drs. Himmelstein and Woolhandler were the lead authors of single-payer proposals that were published in the New England Journal of Medicine and JAMA [the Journal of the American Medical Association] that actually became the foundation for the House single-payer bills. They have done a lot of studies - the statistic that the majority of bankruptcies are medical bankruptcies was their work, just to give one example.

I'm doing healthcare research. For one project, we're focusing on patients with lung disease, at how deductibles affect people with COPD. We're also looking at how one of the big concerns with single-payer is that it would create an enormous explosion in expense because people would use more healthcare because it was free. We're not sure, so we have done some research on the effects of the Affordable Care Act an Medicare in the 1960's. Stay tuned on that.

I'm going to continue the work that previous presidents have done. If you look at some of these polls that sort of get cited where the bottom line is yes, single-payer polls really well, but when you start asking people this or that, the support is malleable. It's true that many people don't understand all of the design aspects, that it will be one public plan that covers everybody instead of an option, so there is an enormous amount of education of the public that has to take place to make single-payer a reality.

Finally, I wanted to ask you about immigration. PNHP is calling for coverage of all undocumented and documented immigrants.

We are calling for coverage of all US residents. I think that's important. Look, everyone needs healthcare. You're not going to deny people healthcare simply by virtue of the country they were born in, nor should we. Healthcare is a human right. That's imperative. At the end of the day, the reality is that unless you're willing to push people away from the doors of hospitals and call in the goons to throw them into the streets, you need to take care of people, right? It's just common decency.

The irony is there's also some research that immigrants actually pay more into the healthcare system. If that wasn't the case it wouldn't change my opinion but it is a funny irony. The reason is pretty simple - immigrants in general are younger and healthier, they use less healthcare and they pay more into the system.

But that's not the motivation. The motivation is to envision healthcare as a human right that everyone deserves by virtue of belonging to the human race.