From Reproductive Rights to the Opioid Crisis and More, the Promise of Single Payer
With an authoritarian, right-wing President in office who disdains everything from women’s reproductive rights to basic climate science, who touts military coups in Venezuela and genocide in Iran and yucks it up with crowds of racist louts who want to shoot migrants, our future as a society looks more than a little bleak.
This bleak outlook is only underscored by the entrenched nature of class inequality in the United States. This pervasive fact of life impacts everything, from unaffordable cities afflicted with homelessness to the petty avarice that marks elite culture to the myriad ways corporate money corrupts politics. And then there is the broken nature of the health care system.
Regarding the latter, U.S. health care continues to be defined by multiple system failures, despite the promised improvements of the Affordable Care Act. Driven by corporate profiteering at the expense of the sick and suffering, the system despite its vast resources just doesn’t work very well. This isn’t just hyperbole. As a 2018 Harvard study concluded, the U.S. health system spends almost twice as much on medical care than other high-income nations, but offers less access to care and poorer outcomes.
Then again, if you’re a privileged health industry “leader,” everything is just fine. According to Business Insider, the nation’s largest U.S. health insurer, UnitedHealthGroup, which also runs clinics and other health programs, paid its CEO $18,107,356 last year. The CEO of Molina Healthcare received compensation worth $15,219,770. Anthem, seller of Blue Cross Blue Shield insurance, paid its CEO $14,184,276 in compensation. And so it goes.
If any wealthy health care CEO actually had a conscience, they might forgo their bloated salaries to make a statement on behalf of health care equity and justice for the millions who can’t afford the costs of care. Or maybe they could pour millions of their dollars into the GoFundMe accounts of America’s most desperate families, raising funds for their ill or injured relatives?
A demonstrative statement along these lines might at least show they believe their own corporate marketing hype about serving the needs of their “customers.” Could they get by on a more modest low six-figure salary? Unfortunately, under the present system it’s unlikely we’ll ever know. The outsized wealth of health industry executives is made possible by the costly premiums, copays, co-insurance, and high deductibles Americans are forced to pay for their overly complex, inferior insurance products.
Challenge to Industry Status Quo. If there is a counterweight to this dismal reality, it’s to be found in the widespread public support for a single-payer, or Medicare for All, health system. In fact, a 2018 Reuters poll found 70 percent of Americans support a government-sponsored Medicare for All system. According to the Kaiser Family Foundation (KFF), support for single-payer has been slowly growing for nearly two decades. While poll results will vary—KFF reports a majority 56 percent of the public now in support of such proposals—single-payer has remained consistently popular with most Americans.
There’s also traction for Medicare for All in Congress. With several public health plan reform bills now before Congress, the most far-reaching are the comprehensive single-payer bills sponsored by Sen. Bernie Sanders (I- VT) and Rep. Pramila Jayapal (D-WA). The latter’s House bill now has 108 co-sponsors. It’s testament to single-payer’s gathering momentum that the vested profiteers of the health care status quo are now organizing to discredit Medicare for All. As the New York Times and other media reported earlier this year, industry groups such as the Federation of American Hospitals, America’s Health Insurance Plans, Pharmaceutical Research and Manufacturers of America and other lobbyists are partnering to wage a public campaign against any single-payer legislative initiatives.
Enter the Partnership for America’s Health Care Future. Under the leadership of executive director, Lauren Crawford Shaver, a former advisor to Hillary Clinton’s 2016 presidential campaign, the group’s disinformation campaign seeks to frighten the public that they’ll be paying more under Medicare for All than they already are. In return they offer bland reassurances that most Americans already have affordable health care, and that whatever problems exist are nothing a few tweaks to the existing for-profit system can’t fix.
It’s hard to take such propaganda seriously. As groups like Physicians for a National Health Program (PNHP) have long argued, eliminating all individual premiums, copays, and coinsurance under a single-payer system will drastically improve access and affordability for the overwhelming majority of Americans. Indeed, a recent RAND study in New York state found single-payer legislation would dramatically lower health costs for most people, with only individuals earning above $134,000 (or a family of four earning $276,000) paying more than current costs.
Even if higher income taxes were associated with Medicare for All, Americans would be still be getting more for their health care dollar. But the assumption that tax increases on working-class Americans would be necessary can be challenged. After all, this is the country with the richest rich people and the richest corporations in the world. Certainly new taxes on the 1 percent and corporate wealth alone could ensure ordinary Americans don’t pay more for better health care. If not, there’s always the $718 billion in Pentagon military budget waiting to fund something actually useful like health care.
More Services, Better Healthcare. It is also important not to forget a key word in the Medicare for All proposals—Improved. The campaign for single-payer is an opportunity not only to improve access to affordable care, but also enhance the quality of care available to every person.
This is recognized in the Sanders and Jayapal bills, which promote extending coverage for a full range of reproductive care services, including abortion services, as well as vision, dental, and prescription drug benefits. With the renewed assault on women’s reproductive rights in Alabama and other states, imposing de facto bans on abortion under so-called “heartbeat” laws, it’s especially vital now that the Medicare for All movement clearly stand in defense of abortion as a legitimate medical procedure.
As a May 16 PNHP twitter statement declared, “We need to urgently reverse course and expand access to reproductive health care, including abortion. That means guaranteed coverage, access to providers in all communities, and zero cost sharing.”
Likewise, to safeguard quality and patient safety, the Sanders bill would also mandate limits on nurse-patient ratios and staffing levels for physicians and other providers, based on input from the National Nurses United union and others. Notably, the Sanders bill also designates the Department of Health and Human Services (HHS) to determine which “complementary and integrative” medical services are included in the new public system.
This is important. Nearly 40 percent of U.S. adults use some form of complementary or integrative care. While some of what falls under this category includes products or services better categorized as self-care outside of a professional health care setting, medical treatment by licensed professionals for acupuncture, chiropractic, naturopathic care, and related services deserve to be included in the single-payer roster of covered benefits.
In fact, there is a credible evidence base for inclusion of many complementary and integrated care services. In 2017, an Australian study found evidence for acupuncture’s effectiveness for 122 treatments comprising 14 clinical areas. Another meta-analysis of 39 clinical trials involving over 20,827 patients published in the Journal of Pain (May 2018) found acupuncture to be an effective chronic pain treatment. As an American Academy of Family Physicians (AAFP) report noted, the benefits of acupuncture were found to persist over time and were not explainable simply as a consequence of the placebo effect.
With an ongoing opioid public health crisis, the use of effective non-pharmacologic treatment options such as acupuncture and other interventions has acquired a new urgency. According to the Centers for Disease Control (CDC), more than 700,000 people died from a drug overdose from 1999 to 2017. In 2017, about 68 percent of the more than 70,000 drug overdose deaths involved an opioid. The number of overdose deaths in 2017 involving opioids (including both legal and illegal) was six times higher than in 1999.
These figures describe a mounting public health crisis, one with roots in the corrosive influence of Big Pharma on medicine. “The human toll of opioid overprescription now represents one of the largest iatrogenic epidemics in history,” write Scott Poldosky, MD, and colleagues in The New England Journal of Medicine (NEJM). It is a “story of unconscionable corporate (and individual) profit at the expense of the public’s health.”
According to the U.S. Government Accountability Office (GAO), pharmaceutical and biotechnology sales revenue increased from $534 billion to $775 billion between 2006 and 2015. Notably, GAO also reports 67 percent of drug companies increased their annual profit margins during these years, with the 25 largest companies reporting an annual average profit margin somewhere in the 15 to 20 percent range. To put this in perspective, GAO notes the average annual profit margin globally for the 500 largest non-drug companies varies between 4 and 9 percent.
More than ever, health care providers need alternatives to opioids, both safer pharmacologic and non-pharmacologic treatment options. Notably, the Joint Commission, the accrediting body for many healthcare organizations, now requires accredited hospital organizations to provide such non-pharmacological treatment options such as acupuncture to meet pain management standards.
Holistic Care Model. If the United States eventually adopts a single-payer health system, expanding coverage for essential health services will underscore the need for a more encompassing or holistic model of care. This is a point made by Margaret Chan, MD, former director-general of the World Health Organization (WHO) in her 2016 keynote address at the International Conference on the Modernization of Traditional Chinese Medicine.
As Dr. Chan observes, as health systems expand essential medical services, not only do expectations for care rise, but also necessary costs. “Faced with this dilemma, and most especially the costs of treating lifestyle-related chronic diseases, many experts see a need to shift the model for health service delivery away from a strictly biomedical model, focused on individual diseases, towards a more holistic approach,” says Dr. Chan. “This is an approach that stresses prevention as well as cure, offers integrated services that address the multiple determinants of health, and asks people to take more responsibility for their own health.”
As such, acupuncture and herbal medicine can play a positive role within the larger health system, suggests Dr. Chan. There are variants of such practice already existing in some modern health systems, such as in Japan where herbal prescriptions (“Kampo medicine”) are integrated into physician practice under the national health insurance system.
Further, in our modern society where not only stress, but traumatic stress is common, therapies that address the psychophysiology of illness can more fully serve the well-being of communities. This includes not only different types of psychotherapy, but mindfulness practices, yoga, acupuncture and related bodywork therapies. Interestingly, Bessel van der Kolk, MD, psychiatrist and author of The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma (Penguin Books, 2015) recounts how in the wake of the 9/11 terror attacks in 2001, he participated in expert panels in New York City organized by the National Institutes of Health and other organizations to recommend treatments for people traumatized by the attacks on the World Trade Center.
After much discussion, the experts only recommended psychoanalysis and cognitive behavioral therapy. As it turned out, few New Yorkers took advantage of these publicly sponsored services. Later, Dr. van der Kolk told The New York Times, data gathered on mental health care for more than 10,000 survivors of 9//11 found acupuncture the most popular service used to overcome the effects of the experience, followed by yoga, massage, and EMDR therapy (a form of psychotherapy).
This anecdote speaks to the need for more integrative approaches to health care, in response to the pervasive psycho-social burdens and traumas modern society imposes on individuals. Certainly health care justice starts with accessible and affordable care. But health care also means elevating the human touch in medicine, normalizing connection and compassion as markers of a health system that truly serves every individual in need. Health care is social solidarity at the most direct level.
In this sense, humane medicine involves more than parsing results from randomized controlled trials to establish what is “scientific medicine” and thus legitimate practice. After all, medicine is an applied science, an evolving body of knowledge that draws upon multiple sources of research, clinical observation and judgment, and patient input to find effective paths to healing and well-being.
Now, in an age where cruelty reigns in politics, where the hardened, vision of the far right threatens violence all over the globe, where racism and misogyny, poverty and exploitation rear up like a monstrous hydra of inhumanity, the vision of a just, humane health care system might appear to be little more than a wistful dream. It is not. In fact, the struggle for health care justice in the United States is inseparable from the larger political and social challenges involved in defeating the slide into barbarism that now confronts humanity.
From Big Pharma to the insurance industry, medical devices manufacturers, investor-owned hospital systems and more, corporate capitalism distorts medicine from what should be a humane mission into just another profit stream. To defeat corporate health care and its profiteers is possible, but it will take more than passively placing our hopes in Congressional Democrats, many of whom are afflicted with the tendency to embrace progressive demands like single-payer only when such demands have little chance of implementation.
The widespread popular support for Medicare for All represents a potentially unstoppable popular movement. But if we want a just, equitable public health care system, the people have to speak out, rally and get politically organized. If we want to truly liberate medicine from the profiteers, a mass grassroots organizing campaign is the path to change what needs to change.