Myth Busters: Answering Difficult Questions about Single Payer Healthcare SNaHP Annual Summit February 2015 Xin Guan Albany Medical College, M3 Danny Ash Ohio State U. College of Medicine, M4

“The most important thing is to show people that change is possible.” Gerald Friedman Professor of Economics University of Massachusetts, Amherst

MYTH… “The uninsured get free health care. They can just go to the emergency room.”

MYTH… REALITY Among families with at least one uninsured member, less than ¼ report getting free or discounted care in any given year. Financial pressures to provide charity care are reducing the ability of private physicians to provide charity care. Emergency department care is not free! Hospitals bill the uninsured at higher prices than insurance companies pay EDs are ill-suited to provide primary care

MYTH… “Single payer is fundamentally anti- American because America is a capitalist and individualistic society.”

MYTH… REALITY Anti‐American: our current system that discourages entrepreneurship because health insurance is tied to employment Anti-American: our current system that leaves Americans vulnerable to skyrocketing healthcare costs, so that 78% of all bankruptcies are related to medical bills Single payer will boost our economy, reduce healthcare expenditures in the long run and help us remain a strong nation.

MYTH… “Single payer is socialized medicine.”

MYTH… REALITY A single payer national health program is NOT socialized medicine Socialized medicine: a system in which doctors and hospitals work for and draw salaries from the government. – American examples: VA, Armed Services. – Other examples: Great Britain and Spain Single payer: the government pays for most healthcare (hence single payer) but does not own or manage medical practices or hospitals – American examples: Medicare – Other examples: Canada, Australia, Japan This is why our motto for single payer is “improved Medicare for all”

MYTH… “We have the best health care system in the world! Why change it?”

MYTH… REALITY Our life expectancy and infant mortality rates are worse than that of many countries International rankings: – 19th out of 19 nations in deaths from medically-treatable causes – WHO: 37th on overall performance and 24th on health attainment We spend more than any other nation in the world per capita on health care Only a select few who can afford it get some of the best care in the world. Americans get less of most kinds of care (doctor, hospital, surgery, etc.) than the citizens of other industrialized nations.

Our current system: worse outcomes… Female life expectancy at birth Figure: Gerald Friedman from data at

… for a LOT more money! Per capita healthcare spending (2011 USD, PPP) Figure: Gerald Friedman from data at

Paying more… for less! Annual per Capita Doctor Visits Figure: Gerald Friedman from data at

MYTH… “We already have healthcare reform. The ACA will cover everybody who is uninsured.”

MYTH… REALITY The ACA will cover some uninsured Americans… but the job’s not finished! CBO projections for 2019: 23 million Americans still without coverage CBO estimates do not include the underinsured, who are still vulnerable to financial ruin due to growing out-of-pocket costs Underinsurance will worsen under ACA

MYTH… “Single payer will restrict provider choice.”

MYTH… REALITY Provider choice is already restricted under current system! Many private insurers severely limit patients’ ability to choose their health care provider Single payer would promote increased patient autonomy and choice of providers by removing all “network” restrictions

MYTH… “Quality of care will suffer under single payer.”

MYTH… REALITY Single payer provides the most effective financial structure for increasing the quality and efficiency of care Facilitates large-scale adoption of quality improvement initiatives such as surgical checklists Makes it possible to identify "outliers" who are practicing outside community norms

Perverse incentives and fragmented payment system: a recipe for trouble

MYTH… “Doctors will never buy into single payer because it will interfere with their autonomy and decrease their salaries.”

MYTH… REALITY More than 60% of physicians already support a single payer system Canada is experiencing a net influx of physicians – both Canadian and American Private companies currently restrict physicians’ ability to practice medicine (network restrictions, precert, etc) Under single payer, decision making will be returned to healthcare providers and their patients Based on Canadian experience, average physician incomes should change little, though income disparity between specialties is likely to shrink

Healthcare job growth since PhysiciansAdministrators 3000% 2500% 2000% 1500% 1000% 500% Figure: Gerald Friedman from data provided by Bureau of Labor Statistics, Occupational Employment Statistics, at bls.org.

… a uniquely American phenomenon! Per capita administrative spending (2014 USD) Figure: Gerald Friedman from Woolhandler/Himmelstein/Campbell NEJM 2003;349:769 (updated 2013)

MYTH… “Single payer is politically unfeasible – look what happened in Vermont!”

MYTH… REALITY There are still single payer bills in many state legislatures and a national bill, HR 676 Single payer has growing support from health professional, labor, business, and faith-based groups Vermont’s plan had veered away from a true single payer model, so is not representative of single payer’s political prospects Effective grassroots organizing got real healthcare reform on the political radar screen in Vermont, and can get it back on the radar elsewhere!

MYTH… “Health care is not a right.”

MYTH… REALITY Even if healthcare is not a right, single payer might still be the wisest public policy because of its moral and economic benefits. Moral benefits - tens of thousands of Americans die each year because they do not have adequate access to healthcare Economic benefits - The United States spends 50% more as a percentage of its GDP than most other developed countries, but we insure a lower percentage of our population. Under single payer, the average taxpayer would have thousands of dollars more in discretionary income.

We die young because we lack access to care And it is getting worse! Slide by Gerald Friedman Source: Commonwealth Fund survey reported in Cathy Schoen, et al., "Access, Affordability, and Insurance Complexity" Health Affairs, Nov. 18, 2013

Cost of health insurance, Ohio private- sector workers with health insurance and single payer savings Average premium worker with health insurance $ 9,584 Average deductible $ 1,777 Total: $ 11,361 Average wages $ 43,170 ratio26.3% Savings under single-payer $ 7,044 Slide by Gerald Friedman

MYTH… “Single payer will create waiting lists.” “Single payer would result in rationing of care.”

MYTH… REALITY We are already rationing healthcare in the United States. All scarce goods are rationed. The only choice we have is how. – Rationing in single payer system: according to need – Rationing in the current system: according to income This is an inefficient allocation of healthcare resources. In European-style single-payer systems, some elective procedures have waiting lists, but there are rarely, if ever waiting lists for medically necessary or emergent procedures

MYTH… “How can we possibly transition from our current system to single payer? It seems impossible!”

MYTH… REALITY The payment and provider structures already exist within the Medicare program to permit a relatively smooth transition to a single payer health care system in this country Many people now working in the insurance industry are, in fact, already health professionals (e.g. nurses) who will be able to find work in the healthcare field again Many insurance and health administrative workers will need a job retraining and placement program. Cost: ~$20B/yr during transition (a small fraction of the administrative savings from transition)

THANK YOU! Photos © Ian Hayhurst, Bob Estremera, and Joe Newman