560+ Physicians and Medical Students Agree: Time to Move on Medicare-for-All

More than 560 doctors and med students have signed onto an open letter organized by the Ad Hoc Committee on Medicare-for-All, now published at The Huffington Post:  

The renewed debate over the merits of single-payer health reform has been marred by misleading claims that such reform is unnecessary and unaffordable. We write to set the record straight…

It’s not too late to join us: follow this link to add your signature and help turn the tide.

Time to Set the Record Straight on Single Payer

Recent weeks have seen a slew of misleading attacks on the affordability and merit of single payer health care.  It’s time to set the record straight.

Please see “Setting the Record Straight on Medicare-for-All: An Open Letter From Physicians and Medical Students.”  The letter went up today.  You can endorse the letter on the webpage.  A list of endorsers will be published in the near future.  Please also circulate to colleagues.  This is a crucial moment in the national debate over health care reform and single payer.

Blog: Contraception Coverage and the ACA

A “viewpoint” article published in JAMA this week (authored by March C. Politi, Adam Sonfield, and Tessa Madden) briefly summarizes how the Affordable Act Act (ACA) expands access to contraception, but also describes the various “challenges” that thus far have prevented the full implementation of this provision.

To my mind, the points they make demonstrate how the underlying, structural flaws of our health care system make even relatively straightforward and useful reforms like the ACA’s contraception mandate enormously difficult and complex to realize in practice.

As they briefly summarize in the article (“Addressing Challenges to Implementation of the Contraceptive Coverage Guarantee of the Affordable Care Act”), the ACA includes a provision that mandated that contraception-related health care – including medications, devices, services (including sterilization), office visits, and education – be covered by privates insurers without “cost sharing” (i.e. copayments or deductibles).

This is unquestionably a good and useful measure: contraception-related care is a fundamental component of comprehensive reproductive health care. There is no plausible reason to punish women who use contraception by imposing out-of-pocket payments at the time of use (the same could be said of all medically-necessary health care, in my opinion, but that’s a story for another time).

The article then briefly summarizes the various games insurers have played in preventing the implementation of this rather straightforward provision.  For instance, they note that some insurers have left out coverage for certain modes of contraception (though they assert that this should be addressed by new federal rules), and also that insurers have not been reliably covering contraception-related clinical care.  “Inappropriate insurance practices,” they write, “may therefore lead to patients being erroneously charged for services that should be covered with no out-of-pocket costs, potentially interfering with patients’ ability to practice contraception consistently and effectively.”

But it is when they turn to the issue of billing and coding that the ridiculous complexity of our health care system – and the harm that this complexity causes – becomes most evident.  As a result of the vagaries of billing codes, what is theoretically fully covered may not be in practice.  As they write:

Physicians, other clinicians, and health care organizations may find it difficult to appropriately bill for contraceptive services in a way that ensures that patients are properly exempt from cost sharing. If a patient receives contraceptive counseling as part of a well-woman examination, the situation is straightforward because the well-woman examination has a specific Current Procedural Terminology code and is considered a covered preventive service. However, if a patient has an office visit solely for contraceptive counseling (which does not have a specific billing code), the clinician or health care center must bill an appropriate evaluation and management code (which can be used for many purposes) and billing modifier (ie, 33) to specify that the visit was for the preventive service, contraceptive counseling. Many clinicians and health organizations are unaware of this modifier, and some insurers have been slow to program their billing systems so that this modifier automatically triggers the patient’s exemption from cost sharing when the included diagnosis codes (formerly International Classification of Diseases, Ninth Revision [ICD-9], now ICD-10) indicate that primarily preventive services were provided.

Of course, it is ultimately women who are penalized by this byzantine structure of coding.

But the complexities don’t end there.  As they describe:

An additional challenge arises if care that involves diagnostic testing is provided during a visit, even when the initial visit was scheduled for contraceptive counseling or maintenance. Under the ACA provision, a visit should be considered preventive—and therefore exempt from cost sharing—if the primary purpose of the visit is for preventive care. However, the primary purpose may not always be clear to patients, clinicians, and payers when additional care is provided. Clinicians can use 2 separate billing codes, one for the preventive care and an additional code for the diagnostic care, but this could lead to confusion and disagreement about when patients will be charged. Greater transparency could help clinicians and health care centers communicate with patients about these potential fees.

This is of course ridiculous.  In reality, office visits can be a combination of things, and attempts to classify them as purely “preventive” or not is a fiction.  It’s also entirely unnecessary: if office visits for both “preventive” care and “non-preventive” both didn’t have cost sharing, none of this would matter (at least from the patient’s perspective).

They finally note that none of these protections are available for women who obtain contraception-related services “out-of-network.”  Yet this may happen unwillingly: as they describe, a women may undergo a sterilization procedure at a facility that’s inside of the insurance network, but the anesthesiologist involved in the case may be out-of-network.

The story of the contraception coverage mandate of the ACA thereby speaks to the enormous difficulty of effectively – much less efficiently! – moving towards universal health care within a structure dominated by private insurers.




Blog: What Does the Medicare Rollout Say About Single Payer?

Blog: What Does the Medicare Rollout Say About Single Payer?

An interesting article today in Huffington Post by Steffie Woolhandler and David Himmelstein – both health policy scholars and co-founders of Physicians for a National Program – looks back at the history of Medicare for lessons about single payer today.

They make a few notable points in the piece, which is headlined “Medicare’s History Belies Claim That Medicare-for-All Would Disrupt Care.”  First, they note that the implementation of Medicare was actually quite smooth.  As they describe, cards were sent to the homes of all the elderly, and those who lived in more remote locations were contacted through various outreach programs; predicted doctors’ strikes never happened, and the health system wasn’t overloaded by the demands of new beneficiaries.  Moreover, the process was relatively efficient: by their calculations, the rollout of the Obamacare “marketplaces” cost some seven times as much as the (inflation-adjusted)  rollout of Medicare.

Second, they note that Medicare was “disruptive” in a good way: it helped undo the reign of Jim Crow medicine. As they note, the implementation of Medicare forced the segregation of Southern hospitals.  At the same time, however, they rightly emphasize that de facto segregation continues today when patients with different insurance plans are treated separately. In contrast, “Medicare-for-All,” they write, “would give all Americans complete and equal coverage, completing the disruption of hospital segregation that Medicare began a half century ago.”

There is a broader point here, about the role of a true universal health care – without tiers and without financial barriers to care – in the fight against racial health inequalities.  Despite all the research and discussion around the issue of “health disparities,” this issue gets insufficient attention.  I discuss it in a lengthy review/essay about racial health inequality which will be published in the Los Angeles Review of Books sometime in the coming weeks.

Blog: Latest Results from the National Health Interview Survey

Uninsurance remains a problem in America, even in the age of the Affordable Care Act (ACA). That’s one conclusion that can be drawn from the latest survey results released two weeks ago by the National Center for Health Statistics.

The report (“Early Release of Estimates From the National Health Interview Survey, January–September 2015”) compares survey data on health insurance coverage gathered over the first nine months of 2015 with that of previous years, extending back to 2010. The estimates rely on a civilian, non-institutionalized sample, which for 2015 consisted of some 79,847 individuals in 37 states.   I’ll briefly summarize some of the key results in this post.1

The survey demonstrates a substantial reduction in the uninsured population in the years following the implementation of the ACA. In 2010, 22.3% of non-elderly adults were uninsured at the time at which they were interviewed. In contrast, for the first 9 months of 2015, this had fallen to 12.9%. This comes after about a decade of rising uninsurance, beginning in the late 1990s:

Screenshot 2016-02-16 11.24.46

The time trends by age groups are as one might expect. For younger adults (ages 18-24), the reduction in uninsurance occurred over 2010 and 2011. This makes sense, as the dependent coverage provision of the ACA was implemented in September 2010 (the law required coverage of children below age 26 under family health insurance plans). For other age groups, in contrast, uninsurance fell between the years 2013 and 2015. This squares with the fact that the main coverage expansion provisions of the ACA – i.e. the individual mandate and the Medicaid expansion – went into effect in 2014.

Inequalities in insurance status by class persist. In 2015, among non-elderly adults, 26.1% of the poor and 24.1% of the near-poor were uninsured at the time the interview was conducted, as compared to 7.7% of those who weren’t poor. However, there were notable reductions in uninsurance among the former two groups between 2013 and 2015:

Screenshot 2016-02-16 11.25.32

Coverage inequalities by race – despite improvements – also persist. In 2015, among non-elderly adults, 27.9% of Hispanics and 14.6% of non-Hispanic blacks were uninsured, as compared with 8.8% of non-Hispanic whites and 7.3% of Asians:

Screenshot 2016-02-16 11.25.49

Addressing racial health inequalities, clearly, requires addressing these inequities in coverage (among many other things).

There were also inequalities by geography. Unsurprisingly, uninsurance among non-elderly adults was higher in states that have not yet expanded Medicaid under the ACA as compared to those that have (see this analysis for estimates of the number of deaths that have needlessly resulted from this “opt out”).

Finally, the survey reveals the evolving character of insurance: high-deductible heath insurance plans are on the rise. The percentage of the privately insured non-elderly with high-deductible health care plans (whether or not they are associated with a health savings account) rose from 25.3% in 2010 to 36.2% in 2015:

Screenshot 2016-02-16 11.26.08

This is but one glimpse at a much larger story of rising deductibles and copayments – of underinurance more broadly – in the United States.

In sum, the ACA has clearly expanded coverage in the United States. In 2010, among those of all ages, 48.6 million were uninsured (determined based on the time they were interviewed) according to the estimates of this survey. For the first nine months of 2015, this had fallen to 28.8 million. This is no doubt a meaningfully and important change for the many millions who are now newly insured. Yet, the law is now in full effect, and millions are still excluded from coverage. Moreover, inequalities in coverage – along the lines of both race and class – persist. High-deductible health plans are on the rise. Universal health care has not yet been achieved.



1 Note that all the figures reproduced here from the report are in the public domain. All numbers cited in this post are from this survey. When I say “2015,” I am referring to the first nine months of 2015. “Non-elderly adults” describes those aged 18-64.

Newsletter #2: The Single Payer Debate Continues

For now, I’ll keep posting my (brief) newsletters here.  Apologies for those who come across it twice!  You can signup for the newsletter here if interested: http://tinyletter.com/awgaffney


Dear PP Subscribers,

The Democratic primary race has intensified.  Contests in Nevada and South Carolina are looming.  The debate over single payer remains fierce.

The last few weeks have seen continued arguments from a spectrum of commentators as to why a Medicare-for-all program – like that proposed by the Sanders campaign – is untenable.

A number of overlapping lines of argument can be distinguished.  First, it is frequently argued that the Sanders plan is poorly formulated and/or unrealistic given political conditions in Washington.  Recently, for instance, Paul Starr in the American Prospect (headlined “The False Lure of the Sanders Single-Payer Plan”) argues that the Sanders proposal is “not a practical or carefully thought-out proposal.”  Indeed, he sees the plan as an indictment of his overall campaign: it’s “a symbolic gesture, representative of the kind of socialism he supports.”

I addressed some of the earlier (and similar) liberal criticisms in an article published January 21 in US News & World Report, “Single Payer is Worth Fighting For.”  I conclude:

The expansion of coverage achieved by the Affordable Care Act does not constitute a system of universal health care. Too many are uninsured and underinsured. Too many are squeezed by high deductibles, contend with “narrow networks” of doctors and hospitals, or face crushing medical bills and even bankruptcy. Single-payer is the best way to remedy these injustices while simultaneously controlling overall health spending.


I also chatted about some of these issues on the radio with Arnie Arnesan on WNHN 94.7, available here.

A second line is that single payer is simply not affordable – that the number don’t add up.  For instance, in casting doubt on the seriousness of the Sanders’ single payer proposal, Starr relies on the widely-covered estimates of Kenneth Thorpe, an economist at Emory University. Vox covered Thorpe’s new estimates, which put the price of Sanders’ single payer proposal at nearly twice what his campaign has contended.

However, David Himmelstein and Steffie Woolhandler have clearly demonstrated the flawed assumptions behind these numbers in this detailed post at the Huffington Post, which is well worth reading.  As they put it:

Thorpe’s analysis rests on several incorrect, and occasionally outlandish, assumptions. Moreover, it is at odds with analyses of the costs of single-payer programs that he produced in the past, which projected large savings from such reform […] In the past, Thorpe estimated that single-payer reform would lower health spending while covering all of the uninsured and upgrading coverage for the tens of millions who are currently underinsured. The facts on which those conclusions were based have not changed.


A third line admits the shortcomings of the current state of affairs in American health care, but suggests that the right way forward would be to expand towards universal coverage under the ACA – instead of pursuing the more fundamental change of single payer.  I address this argument in an article published online Thursday in Jacobin, headlined “What Obamacare Can’t Do.” I turn to a country that has attempted to work towards “universal” coverage through a system of competing private insurers – the Netherlands – to demonstrate why this approach falls short, both from the perspective of cost and efficiency as well as that of equity.Regardless of the outcome of the primary, the campaign for single payer debate is far from over.  The incremental reforms have already been accomplished – we now either move backwards or we move ahead.

Until the next sporadically timed newsletter,


Post lightly edited. 

Blog: Implications of a Tight Race

The Democratic primary race has grown tighter and spicier than virtually anyone had predicted.  A quick glance at February:

Looking back:

February 1: Hillary Clinton bests Bernie Sanders in the Iowa caucus, but only by the narrowest of victories.

February 5: A national poll puts Clinton and Sanders in a dead heat: as Politico reported, Sanders is at 42% compared with Clinton at 44%. These percentages fall within the margin of error.

February 9: Sanders dominates the New Hampshire primary by a margin of more than 20 points. But perhaps just as important, as David R. Jones noted in a post in The New York Times, Sanders won in essentially all categories of voters:

He carried majorities of both men and women. He won among those with and without college degrees. He won among gun owners and non-gun owners. He beat Mrs. Clinton among previous primary voters and those participating for the first time. And he ran ahead among both moderates and liberals.

February 12: As the Hill reports, another poll demonstrates a tight race, with Clinton having only a 7-point lead over Sanders nationwide.


Looking forward:

February 20: The next Democratic contest, the Nevada caucus. Recent reliable polls seem to be in short supply. For what it’s worth, FiveThirtyEight’s “polls-plus” analysis gives the two candidates an equal chance of winning. On Friday, Slate’s Jim Newell described Clinton’s numerous advantages in the state – her so-called “Western firewall” – but also notes that “it wouldn’t be surprising if this firewall is crumbling, or whatever it is that firewalls do when they stop being firewalls.” Do they smolder, or are they quenched?

February 27: The South Carolina primary. This is seen as Clinton’s real “firewall,” as the odd saying goes. According to FiveThirtyEight, she is set to dominate the state. However, a long report, well worth reading, by Joyn-Ann Reid at MSNBC headlined “Warning signs for Hillary Clinton in South Carolina” argues that the situation in that state may be less settled than polls may suggest.


Time will tell. In the meanwhile, the tightening of the race has meant that single payer health care has remained front and center of the national political discussion. For single payer advocates it is a crucial time to continue pressing the cause.