Philip R. Lee’s 1986 Call for National Health Insurance
Summary: A UCSF and US titan of health policy, Philip R. Lee, nearly 40 years ago described our health insurance options, and wisely preferred national health insurance. Our country chose differently, relying heavily on private insurers and incremental fixes that missed the opportunity for efficiency and heath justice. We must fight for Dr. Lee’s choice.
This Date in UCSF History: National Health Insurance Ahead?
UCSF Student Voices
Synapse
April 23, 2024
(Originally authored by Dr. Philip R. Lee — a UCSF professor of social medicine and director of the Institute for Health Policy Studies — and published in Synapse on April 24, 1986.)
Twenty years ago, states throughout the country began to implement federal legislation (Title XIX, Social Security Act) establishing a national program for medical care for the poor (Medicaid). In the same year, 1966, the federal Medicare program began providing hospital and medical insurance for the elderly.
With these two public programs, the public sector began to fill the major gap in private health insurance.
Private health insurance was largely provided on a group basis, through employment, with employers paying the bulk of premiums.
In the 1960s and early 1970s the idea that access to health care was a merit good or a right of citizenship was widespread.
It seemed only a matter of time before the remaining gaps would be filled by universal health insurance, albeit with a mixture of public and private payment mechanisms.
In the 1970s and early 1980s, as costs of health care rose rapidly and as efforts to contain costs seemed ineffective, the idea took hold that national health insurance was impossible and that health care was not a merit good.
Instead, many advocated that health care should be treated like other goods and services, and that price competition and the marketplace should be the primary approach to resolving the problems of cost, access and quality.
Policies established by Congress and the Reagan administration have strongly supported this approach.
Many states, including California, have adopted pro-competitive policies. The results of the recent policy changes have been mixed.
The rate of increase in health care costs has slowed, hospital admissions have declined, length of hospital stay has been shortened and hospital occupancy has been reduced. All this seems to be for the better, but patients have found themselves discharged from hospitals “sicker and quicker.”
Posthospital services, described as a “no-care zone” by UCSF Professor Carroll Estes, have been unable to cope adequately with the changes.
The number of people who are uninsured or underinsured has risen rapidly and local governments, such as San Francisco County, have found themselves obliged to care for increasing numbers of sick, disabled and poor.
Three future scenarios seem possible given the current environment:
> Continued reliance on price competition and the marketplace with the evolution of a “three-tiered” system of care consisting of fee for service, HMOs and public sector.
> A variety of incremental strategies to fill the gaps in coverage at the state level through mandated private insurance coverage, state funds to cover the uninsured and an expansion of Medicaid.
> Publicly funded national health insurance, along the lines of the Canadian model.
Although the odds are against national health insurance, this proposal would provide the most equitable solution to health care access with effective means to control costs while assuring freedom of choice for consumers and providers.
Personally, I believe it is the preferred solution.
Editor's Note -
To listen to the interview of Peter Shapiro, posted below, search for "Code Wack" in your Podcast App.-SPC
'Absolutely ruthless':
The brutal privatization of U.S. health care
by Peter Shapiro
“Private equity firms are moving in a big, big way into the healthcare field, just like
they're doing in real estate, because it's a great place where you can move in there,
buy up a troubled asset, downsize it, increase its value, and sell it at a huge profit.” -
Peter Shapiro
911. What's your emergency?
America's healthcare system is broken and people are dying.
Welcome to Code WACK!, where we shine a light on America's callous healthcare
system, how it hurts us and what we can do about it. I'm your host, Brenda Gazzar.
(music)
This time on Code WACK! What damage is private equity doing to our healthcare
system and what’s being done to curb it? And what cues can California single-payer
activists take from the state’s active immigrant community? To find out, we spoke to
Peter Shapiro, a retired letter carrier and author of Song of the Stubborn One
Thousand: the Watsonville Canning Strike (Haymarket Books 2016). He
represented his union at the founding conference of the Labor Campaign for Single
Payer in 2009 and has been involved with the issue ever since. He currently
represents the Alameda Labor Council on the board of Healthy California Now, a
single-payer advocacy coalition. This is the first episode in a two-part series with
Peter Shapiro.
Welcome to Code WACK! Peter!
Shapiro: Thank you. Glad to be here.
Q: Glad to have you! First tell us a little bit about yourself and your work in the
single-payer movement in California.
Shapiro: My work in the single-payer movement started when we were living up in
Oregon. It was right around the time the Affordable Care Act passed. I was an active
working letter carrier at the time, and my union sent me back to the founding
conference of the Labor Campaign for Single Payer. I was supposed to write a
report and send it to the national office, which I did, but I also just became a
convert on the spot. I mean, I felt strongly for a long time, you know, this is
something that we needed.
I mean, my wife back in the ‘80s was in billing, medical billing for a medical oncology
clinic in Berkeley. And, you know, she would come home with horror stories every
night. I'd listen to her talking over the dinner table and I would just get, the blood
would drain from my face. I would be so angry about people who were fighting for
their lives and having to hassle with their insurance companies at the same time.
‘Do you really need that fourth round of chemo? I mean, the first three rounds
didn't do any good.’
I mean, how do you stomach something like that? But I came away from the
founding conference of the Labor Campaign, and by the way, I really recommend
that people look it up, Labor Campaign for Single-Payer Healthcare, I came away
from there convinced of two things. One is that unions have a huge interest in
relieving themselves of this burden of having to negotiate health benefits for their
members at the time when the cost of health care is going through the roof. And
the second thing is that given what we're up against in trying to win single-payer,
we're up against a very, very well-heeled industry with a huge lobbying apparatus
and in a lot of ways, it's a fairly technical issue. And when you get into the weeds,
people can get very easily confused if we don't do a good job of educating them
beforehand. So you really need organized labor behind this because they have the
resources, they have the clout, they have the organization, and theoretically at least
they have the interest of all working people at heart. So they've got that motivation
too. You know, everybody in nobody out. Solidarity that's what's supposed to be
what it's about. So that was how I got involved.
I got down to California and Pilar Schiavo, who was working for the Nurses Union at
the time, is now our state assembly person from Southern California, she pretty
much recruited me into the coalition then – it eventually became Healthy California
Now and I represent the Alameda Labor Council right now on their board.
Q: So let's start with a brief review of what's wrong with the U.S. healthcare
system. For one thing, it's a market driven system that consumes about 18% of
our Gross Domestic Product. Briefly, what is its financial impact on patients,
families, business, and government?
Shapiro: Well, God, where to begin? I mean, first of all, we spend $4.5 trillion dollars
a year on health care in this country. That's about twice as much as the rest of the
world and yet our outcomes stink. We have lower life expectancy, higher infant
mortality, higher maternal mortality, more people dying of diabetes who could be
saved if they had proper and timely care, on and on. I mean, by most markers, we
lag way behind most of the developed world and even some underdeveloped
countries. I mean, Cuba actually has, I think, a better healthcare system than we do.
It's certainly more accessible. They help a lot more trained doctors there, so much
so that they send them out to other countries who need help. But in terms of
personal stuff, I think there are a hundred million people in this country carrying
some kind of medical debt.
And those are not just poor people. These are people, a lot of 'em are people who
make over $90,000 a year. Medical bills are still the leading cause of personal
bankruptcy. It's been that way for a long time. It shows no signs of letting up. You
have a whole industry that's grown up around basically helping people finance their
medical debt. You know, hospitals can't collect on their bills, so they bring collection
agencies into it, and it's become a really big business. And of course, it just, you
know, because of interest payment and stuff, it raises the cost. Frankly, I think most
of us are probably one medical emergency away from being in that kind of a
situation. And I think it probably contributes a lot to the homeless crisis, you know,
in a lot of our cities. I mean, I can cite a bunch of personal examples.
You know, I have a close friend who's battling Parkinson's, and she makes a little
too much money to qualify for Medi-Cal, but not enough to pay for the care that
she needs. And we've been struggling for weeks to try to figure out how to help her
out. And it's just like walking through a labyrinth to see what's available, what's not
available, and so on. And some of the long-term board and care facilities that she's
been recommended to or steered to are just, they're clip joints, you know, they're,
they're not properly run. They're not safe. They're not clean. They just can't wait to
get their hands on that, you know, on those Medicare and Medi-Cal dollars. And as
soon as they're not available anymore out the door you go. The state of nursing
homes is really disgraceful in this country and you've got some of the lowest paid
workers there as well and they're understaffed.
Q: And what about private equity?
Shapiro: Private equity firms are moving in a big, big way into the healthcare field,
just like they're doing in real estate, because it's a great place where you can move
in there, buy up a troubled asset, downsize it, increase its value, and sell it at a huge
profit. And I think the nursing homes industry was one of the first places they went.
Now they're getting to a lot of other areas too, like primary care and dentistry,
hospitals in underserved areas. They buy them up and they shut down the
maternity wards and the OB/GYN wards and whatever, just because it's (an) undue
expense. And as a result, you've got healthcare deserts that are just proliferating all
over the country.
Q: Yeah, that was exactly my next question about the concern of the role of
private equity that it plays. As we're saying, it's an increasingly dominant role in
our healthcare system. How else do you think it's affecting the experience of
getting health care in the U.S.?
Shapiro: Well, what it really boils down to, I mean, the problem with private
insurance has always been that you've got people making decisions about care who
know nothing about medicine, and doctors have to expend a huge amount of time
and energy and expense just haggling with claims adjusters. Well, you bring private
equity into it, they're not even in the health insurance business, they're just there to
sort of buy up an asset and flip it, you know, and sell it to somebody else at a profit.
And they've been absolutely ruthless in the way they've done this. And, you know, I
think it's extremely damaging, and especially because the whole trend in terms of
health policy makers and government has been to take viable public programs like
Medicare and privatize them and the Veterans Health Administration just to sort of
relieve some of the expense on the federal budget.
And I think half the people on Medicare now are in private plans, which restrict who
they can see. You know, if you go out of network, you get stuck with a huge bill. This
is why so many people go broke, you know, over their medical bills and private
equity, it’s simply ramping up that whole process because they are moving into the
field, they're making their investments. And I think the more private capital drives
our healthcare system, the worse conditions are gonna get and the more people
are gonna suffer. And that's what we have to reverse.
Q: Right. And aren't we also being forced to pay more because of this role that
private equity is playing in our healthcare system?
Shapiro: Well, you know, here's just one statistic I ran across. Medicare Advantage,
which is sort of the privatized version of Medicare, I mean I got sucked into it rather
against my will. I've always had Kaiser, you know, as my health insurer and once
you hit 65, if you want to stay in the Kaiser system, you have to be in their Medicare
Advantage plan, which wipes out one of the big advantages of Medicare, which is
that you can see whatever doctor you want. You don't need to be preauthorized or
anything like that. You don't get stuck with an out-of-network fee, which can run
into the thousands and thousands of dollars. Well Medicare Advantage is supposed
to save the government money, but actually is overpaid by $140 billion the last time
statistics were taken. That's the sum total of all of the payments that people make
for their (Medicare) Part B premiums.
It's enough to cover hearing and dental and vision, all the stuff that Medicare
doesn't cover. Most people enroll in Medicare Advantage plans because they need
those things. I do. I wear hearing aids and they're not cheap. If traditional Medicare
covered those things, there would be no need for Medicare Advantage from, you
know, from my point of view. And there was an effort, you know, I think, what was it
the IRA – Biden’s signature Economic plan came in early in his administration. There
was an effort made by Bernie Sanders to try to get Medicare, expand traditional
Medicare coverage expanded to include those things. It didn't take, but if it had,
nobody would be on Medicare Advantage now.
Q: That's so unfortunate 'cause I know Medicare Advantage lures a lot of people in
with these inexpensive plans, gym membership, dental, I think and vision but then
when people get sick, they realize that they can't get the care that they need,
They can't go to the doctor that they want. They’re really kind of trapped.
Shapiro: Yeah, you are, and actually I should mention that there is a bill before the
(California) legislature that would allow people who have been enrolled in Medicare
Advantage plans to shift back onto traditional Medicare once a year. You cannot do
that now.
That’s California Senate Bill 1236 that was introduced by Senator Blakespear, and
it just passed the Senate Health Committee on April 24.
Shapiro: One of the leading sponsors of that bill is the organization that advocates
for people with lymphoma and, you know, leukemia, which are really highly
specialized treatment that involves really highly specialized care that's not always
available in your in-network plan and you're likely to have to go out of network to
get that stuff treated. But if you're stuck in a Medicare Advantage plan, you got to
pay for that out of pocket. Most seniors are living on fixed incomes. You know, what
are you supposed to do?
Q: So even though the problem is national, many people think we can't win a
national solution. Instead they say, we should try to win single payer in individual
states like what California's trying to do. Why is that?
Shapiro: Well, I mean, ideally we should have national legislation. Unfortunately,
Congress is a mess. It's gridlocked. The Republican party has taken to nominating
people for Congress who have no interest in governing. To them, it’s just a kind of
performance art. They act like they're on Fox News 24 hours a day, you know,
preening and strutting around and trying to impeach this or that person. So, you
know, it's very difficult to get anything done at the national level. And it's always
been difficult because, you know, I think it's a lot more difficult to mount a national
campaign for something than to do it at a local level where conditions might be
more favorable. And that's always been the big argument for state legislation.
On the other hand, the healthcare system is a national system, and a lot of it
depends on getting… a state needs to get a lot of those federal dollars that go into
health care incorporated into its own healthcare system to make it work. And that
involves, you know, dealing with the federal bureaucrats who control the purse
strings. It involves getting certain policies waived and stuff like that.
So, you know, the state strategy is in a lot of ways it's a lot more viable in a lot of
ways. It's, you're never gonna be able to get the level of reform that you need at the
national level. It does involve some compromises, and it also means that states that
don't have the favorable political conditions are gonna continue to suffer. But I
think federal legislation is what we really need. It's much more difficult to get. State
legislation is never really going to be able to solve all the problems because there
are just too many strings attached in terms of federal programs, federal funds
coming into the state of California.
You know, I mean, it's interesting. We have a privately run system and yet 70% of
the money that funds it in California comes from our tax dollars, mainly from, you
know, Medicare and Medicaid and other federal programs and we have to figure
out a way to persuade the feds to let us have access to that money so we can fund
our system. You know, and that's a struggle in itself. Question of how to do it. You
know, so much of this is like playing chess and trying to figure out where to put
your rook or … when to castle your king or that kind of thing. I don't think there are
any hard and fast answers to it. I'm willing to try anything. And I think most people
involved in the single payer movement, if there's an opportunity at the federal level,
we're gonna go for it. If we can make some headway at the state level, we'll go for
that. You know, strategy is not something you raise to the level of principle. You just
do whatever works.
Right. Yeah, good point. And sometimes it takes a lot of experimentation to know
what could work.
Shapiro: Yeah, yeah. One thing to bear in mind is that when you're going for state
legislation, nothing's perfect. I mean, no matter what we do, they’re are going to be
shortcomings. And frankly, if I had my druthers, we wouldn't even be talking about
simply how we finance health care. We'd be talking about making delivery of
healthcare a public responsibility as well, and making sure that it got adequate
funding. Because they had a great system over in England for quite a while, and
then the Tories came in and the Neoliberals came in and they defunded it, and it's a
train wreck now. But the point is, when it was working, it worked beautifully. And
they didn't just, you know, they didn't just finance it with public funds. Doctors
actually worked for the state, you know, and they worked where they were needed
and, you know, care was much better distributed, you know, now there's like, from
what I understand, they're like rampant inequalities, you know, over there in who
gets access to care and what kind of care they get. And it all started with Maggie
Thatcher, but that's another story.
Q: Right. Interesting. It would seem that when it comes to winning single payer,
California has a lot of advantages over other states. Do you agree?
Shapiro: It does, and for a couple of reasons. One is that we're the fifth largest
economy in the world. We're slipping a little bit, I'm told, these days after Covid, you
know, and because the tech industry is sort of having a rolling readjustment, but
there's a tremendous amount of money in the state, and a lot of it is related to high
tech. Also, in terms of population, you know, we're the largest and that matters
because the whole question of how you finance, health insurance is all about
pooling the risks. The more people you have in the risk pool, the cheaper it is to
ensure everybody. And one of the problems that we have, one of the reasons our
healthcare system is so irrational, is because you have 57 different varieties of ways
of accessing health care in this country. You know, maybe half of them are different
government programs, each of which caters to a different demographic, or then
people go to private insurers and they're competing with each other, even they
compete against themselves.
I mean Kaiser (Permanente) has 24 different health plans available offered on the
Covered California Insurance Exchange. I mean, it's insane. Not only because it
raises the administrative costs, and not only because it just makes the system a
nightmare to navigate for just ordinary folks who are just trying to get coverage, but
also because you're breaking the risk pool up into these teeny little pieces. And the
whole advantage of sharing the risks is lost. Now, California has potentially a huge
risk pool, and that would make it much easier to make it pay. When I was in
Oregon, you know, we were trying to do this, one of the arguments I heard is, well,
we don't have enough people up here to make a risk pool. It's gonna be, ‘oh, it's
gonna be too costly and it's not gonna work.’ I'm not sure that's true, but it's
certainly a consideration. That was an issue in Vermont too, where they actually did
pass a single-payer bill and then they abandoned it because they didn't think they
could pay for it. But California doesn't have to worry about that, you know? So
that's one reason it's favorable here.
The other reason politically, I think, you know, we're a blue state, you know, we've
got a governor who got elected as a single payer….He made single payer (health
care) the centerpiece of his campaign when he was first elected in 2018. Of course,
in my opinion, the guy's a total flake and you can't count on him for anything, but at
least if you lean on him hard enough and say, ‘Hey Jack, we put you in office to get
single payer, where are you these days?’ How's the constituency that he has to
respond to?
We've also got a very strong, very powerful immigrant rights movement in this
state. And that's important. They were able to do something nobody else has been
able to do, which is get Medi-Cal benefits extended to all people, all residents,
whether they're documented or not. I don't think any other state in the country's
been able to accomplish that and that's because people organized for it. And
because the immigrant population of California is enormous, it's a huge portion of
the population and they know what it means to struggle, not just personally, but in
the political arena and they've had a lot to overcome and they've done it. This is
why I think the single-payer movement needs to learn from them. You know,
<laugh>. They're giving us a lot of positive examples to work from because if they
can do what they did, we should be able to get single payer through in this state,
too.
Thank you, Peter Shapiro. Stay tuned for next week’s episode when we dive into
the various strategies California single-payer activists are employing to
revolutionize health care in the state.
Do you have a personal story you'd like to share about our ‘wack’ healthcare
system? Contact us through our website at www.heal-ca.org.
And don't forget to subscribe to Code WACK! wherever you find your podcasts. You
can also find us on ProgressiveVoices.com and on Nurse Talk Media.
Code WACK!’s powered by HEAL California, uplifting the voices of those fighting for
healthcare reform around the country. I’m Brenda Gazzar.
Skepticism Is Healthy, but in Medicine, It Can Be Dangerous
I arrived at the hospital one recent morning to find a team of doctors gathered just outside a patient room. The patient was struggling — his breaths too fast and too shallow. For days we had been trying to walk the line between treating the pain caused by his rapidly growing cancer and prolonging his life.
Overnight he had worsened. His family, wrestling with the inevitability of his death, had come to a tentative plan, and I needed to make sure that his wife understood what was ahead. I explained that if we inserted a breathing tube, as she had decided overnight, her husband would be sedated. When the rest of their family arrived in Boston, we would take out the tube and he would die. We would not be able to wake him up — to do so would only cause him to suffer.
At this, his wife stiffened. Why wouldn’t he be able to wake up? I explained that his cancer was so advanced that to wake him would be to give him the conscious awareness of drowning. I watched as she took me in, this doctor she had never met before, telling her something she did not want to hear. Her expression shifted. “Why should I believe you?” she asked me. And then, her voice toughening: “I don’t think that I do.”
The room was silent. My patient’s wife looked into her bag, rooting around for a tissue. I glanced down at my feet. Why should she believe me? I was wearing sneakers with my scrub pants, and I found myself wondering whether she would have trusted me without question if I appeared more professional, or if I were older or male. Perhaps, but there was so much more at play in that moment. This was not just about one doctor and one family member, but instead, about a public for whom the medical system is no longer an institution to be trusted.
We are at a crossroads in medicine when it comes to public trust. After a pandemic that twisted science for political gain, it is not surprising that confidence in medicine is eroding. In fact, trust in medical scientists has fallen to its lowest levels since January 2019. As a result, more people are seeking out less conventional voices of “authority” that hew closer to their beliefs. Robert F. Kennedy Jr., a longtime vaccine skeptic campaigning for the presidency, is finding double-digit support in some polls and has made medical freedom a recurring theme of his candidacy.
Sign up for the Opinion Today newsletter Get expert analysis of the news and a guide to the big ideas shaping the world every weekday morning.
But our medical system relies on trust — in face-to-face meetings as well as public health bulletins. Distrust can lead doctors to burnout and can encourage avoidable negative outcomes for our patients. This is partly what is driving increasing rates of measles among unvaccinated children, failure to follow recommended cancer screening and refusal to take lifesaving preventive medications. There are no easy solutions here. But if we do not find ways to restore and strengthen trust with our patients, more lives will be lost.
This is relatively new terrain for American physicians. When I was in medical training, we did not talk much about trust. During my early years as a doctor, I barely trusted myself and in fact felt uncomfortable with the responsibility I had to keep my patients alive. Only recently have I found myself thinking about what happens when this ephemeral ingredient in the doctor-patient relationship is lost.
Medical skepticism is not the same as medical nihilism. The data behind the drugs doctors prescribe and the decisions we make need not be the purview of us alone; the public has the right to review the numbers and to make their own decisions about risk and benefit. But when that skepticism shifts into abject and irreparable disbelief, we see some patients make dangerous decisions. And when doctors respond with frustration, that only further separates us from those patients.
Trust can sometimes be repaired by clearly presenting facts and figures, but it is about more than explaining numbers. We tell patients things about the body that are unseen. We recommend lifestyle changes and medication to treat or to prevent problems that may not be felt. Surgeons refer to a profound version of trust called the surgical contract: the idea that when people go under the knife, they are allowing their surgeon to make them sicker — to cut them open — in order to make them better. That trust must be earned.
In emergencies, patients don’t have the luxury to choose whom to trust, and medical decisions must happen hastily, in minutes even. So part of our job is to build rapport quickly. That becomes harder, impossible even, when we enter into the climax of a medical crisis to find that whatever trust our patient may have once had long ago has been eroded. Many of our patients started their medical journeys wanting to believe in their doctors. But then the medical system that they wanted to trust failed them, in small ways and large, from haphazardly rescheduled appointments to real medical error. How do we begin the process of repair, both as a profession and as individuals, when time is short?
In medicine, we talk about the idea of shared decision-making, in which medical decisions are arrived at jointly by doctor and patient, in contrast to the paternalistic tone of years gone by. As doctors, we do not tell our patients what to do — instead we offer them the information necessary for them to choose the path that is right for them.
For all our training, our medical knowledge is useless if our patients are unwilling or unable to believe what we have to offer. And that isn’t a fault of our patients, no matter how bothered we might become. This is a fault of a system that does not deserve our patients’ blind faith, of a surrounding political milieu that has turned scientific fact into fiction in many people’s minds.
That is how I found myself in that room, early that one morning, with my patient’s wife, her disbelief and the weight of the decision hanging between us. I knew so little about her. I did not know her history or her interactions with the medical system. I did not know the story of her husband’s diagnosis and treatment, or whether he had struggled to find care for his cancer. In our fractured system, I was just meeting her that day. I had no way to make her trust me, except to sit with her, to give her what little time with her husband we could. And to hope that regardless of what came before, she would choose to believe what I was telling her.
I am not certain what she believed, but she chose against intubation. Her husband lived until the rest of his family came anyway. And when he died, they left without a word, carrying with them his bags of belongings and — I can only hope — faith that we had done the best we could.
Daniela Lamas is a contributing Opinion writer and a pulmonary and critical-care physician at Brigham and Women’s Hospital in Boston.
https://www.nytimes.com/2024/04/24/opinion/medical-skepticism-doctors-trust.html
