Blog: Canada’s single payer system produces better outcomes for CF patients than the US system

An important study was published this week in the Annals of Internal Medicine, “Survival Comparison of Patients With Cystic Fibrosis in Canada and the United States,” by Anne L. Stephenson and colleagues.1  The investigators used cystic fibrosis (CF) registries in the United States and Canada to compare outcomes for these patients between the two countries, and the bottom line made headlines in major media outlets: Canadian CF patients did better—much better—indeed they lived some 10 years longer than US CF patients.  The investigators found 34% lower mortality for Canadian CF patients even after controlling for a wide variety of patient and clinical characteristics, including genotype, an important marker of disease severity.  This difference was demonstrated in multiple subgroup analyses (for instance, when looking only at delta F508 homozygotes).    Moreover, over time, Canadian CF patients saw greater improvements in life expectancy.  Finally, they were also more likely to receive organ transplants.

Thus, despite the often-vaunted superiority of the American healthcare system, here is yet another piece of evidence that single payer public systems can deliver better results—indeed in this case the Canadian system even provided more high-technological care (i.e. transplants), which is supposed to be our specialty.

There is one additional finer point to make.  When examining US CF patients by insurance status, the investigators found that those with private insurance did not do significantly worse than Canadian CF patients, whereas the uninsured and those with Medicare/Medicaid (treated as one category) did.  Does this somehow provide evidence that private insurance is superior to public insurance, or does it weaken the overall point that the Canadian single payer system better served CF patients?  No, for a number of reasons.  First, Medicaid, as important as it is, does in fact sometimes provide a lower tier of access to medical care:  for instance, CF patients with Medicaid are less likely to be accepted for a lung transplantation in the US.2  Thus, even apart from the possibility of residual confounding given the association of Medicaid with lower socioeconomic status, it would not be surprising to find worse outcomes for those with Medicaid as compared to those with private insurance in the US.  Second, it is hard to use this study to say much about Medicare.  In part, this is because subjects with Medicaid and Medicare were combined into a single group, so it’s unclear which (or both) of these populations were driving the finding.  Additionally, those under 65 can only get Medicare if they are disabled.  Comparing this disabled CF population to a general Canadian CF population would leave the door open for residual confounding.

  1. Stephenson AL, Sykes J, Stanojevic S, et al. Survival comparison of patients with cystic fibrosis in canada and the united states: A population-based cohort study. Annals of internal medicine 2017.
  2. Quon BS, Psoter K, Mayer-Hamblett N, Aitken ML, Li CI, Goss CH. Disparities in Access to Lung Transplantation for Patients with Cystic Fibrosis by Socioeconomic Status. American Journal of Respiratory and Critical Care Medicine 2012;186:1008-13.

Body Count from ACA Repeal without real replacement, updated

Last November, I published a short post with rough estimates of the potential number of deaths per year that could result from a repeal of the ACA that was unaccompanied by a real replacement, and provided a rough range of 20,110 – 48,352 excess deaths (based on the “number needed to insure” from two studies as calculated by Sam Dickman et al. and the CBO’s estimate of 22 million more uninsured under Republican legislation).

Since then, we have some new estimates of the number of excess uninsured under repeal legislation.  Bernie Sanders tweeted about the number of deaths that could result from ACA repeal, relying on other assumptions:

The Washington Post criticized the number, and assigned Bernie’s tweet four “pinocchios.”  However, as Professors of Public Health David Himmelstein and Steffie Woolhandler (and PNHP co-founders) responded in an article also in the Post, Sanders number may actually be too low: they provided an estimate greater than 40,000 (based on 20 million uninsured).  Here’s Atul Gawande responding to Himmelstein and Woolhandlers’ figure:

Of course, depending on the exact assumptions used, a range of numbers of estimated deaths can be calculated.  The following table provides the potential range of estimated excess deaths per year depending on the assumption utilized.

 

 

 

Number needed to insure
Source Legislation Number uninsured “Low” estimate1 “Middle” estimate2 “High” estimate3
455 830 1094
HHS4 Number insured by ACA 20,000,000 43,956 24,096 18,282
Congressional Budget Office5

 

 

Restoring American’s Healthcare Freedom Reconciliation Act of 2015

(initial)

18,000,000 39,560 21,687 16,453
(subsequent) 27,000,000 59,341 32,530 24,680
(2026) 32,000,000 70,330 38,554 29,250
Urban Institute6 “repeal via reconciliation without replacement” 29,800,000 65,495 35,904 27,239

Needless to say, all are rough approximations.  What is important is that many body bags will be necessary if we gut the ACA, numbering in the tens of thousands.  Many of these are approximations are even higher than that of Woolstein and Himmelhandler.

Of course, even with the ACA, we will have an estimated 26 million uninsured for 2017, according to the CBO, so the status quo is also very inadequate.

 

________________________________________________

1  Sommers, B. D., S. K. Long, and K. Baicker. “Changes in Mortality after Massachusetts Health Care Reform: A Quasi-Experimental Study.” Annals of Internal Medicine 160, no. 9 (2014): 585-93.  Number needed to insure based on this study as calculated by:  Dickman, Sam, David Himmelstein, Danny McCormick, and Steffie Woolhandler. “Opting out of Medicaid expansion: the health and financial impacts.” Health Affairs Blog, January 30 (2014).  Available at: http://healthaffairs.org/blog/2014/01/30/opting-out-of-medicaid-expansion-the-health-and-financial-impacts/.

2 Sommers, Benjamin D., Katherine Baicker, and Arnold M. Epstein. “Mortality and Access to Care among Adults after State Medicaid Expansions.” New England Journal of Medicine 367, no. 11 (2012): 1025-34.

3  Wilper, A. P., S. Woolhandler, K. E. Lasser, D. McCormick, D. H. Bor, and D. U. Himmelstein. “Health Insurance and Mortality in US Adults.” Am J Public Health 99, no. 12 (Dec 2009): 2289-95.  Number needed to insure based on this study as calculated by:  Dickman, Sam, David Himmelstein, Danny McCormick, and Steffie Woolhandler. “Opting out of Medicaid expansion: the health and financial impacts.” Health Affairs Blog, January 30 (2014).  Available at: http://healthaffairs.org/blog/2014/01/30/opting-out-of-medicaid-expansion-the-health-and-financial-impacts/.

4 https://www.hhs.gov/about/news/2016/03/03/20-million-people-have-gained-health-insurance-coverage-because-affordable-care-act-new-estimates

5  https://www.cbo.gov/publication/52371

6  http://www.urban.org/research/publication/implications-partial-repeal-aca-through-reconciliation

________________

Updated to reflect “low estimate” of 455 number needed to insure, not 457.

 

If 22 million lose insurance, how many die?

Many commentators have noted that with the election of Trump to the presidency, the Republicans could very well go through with their promise to repeal the Affordable Care Act (ACA), or at least some of its biggest provisions.

As Sarah Kliff at Vox has noted, the Republican Congress already passed a bill—HR 3762—that would (among other things) repeal the major expansion provisions of the ACA (it was, as expected, vetoed by Obama).  As she notes, the Congressional Budget Office has estimated that 22 million individuals would possibly lose coverage as a result of the passage of HR 3762. The  breakdown, by insurance type, is as follows:

Change in covered individuals (millions)
Medicaid -14
Employer-sponsored coverage +10
Non-group coverage -18
Net Effect -22

It’s unclear if in fact the Republicans would actually attempt such a thing knowing that it wouldn’t be vetoed, but it’s worth asking what effect it might have on deaths.  To produce a rough and preliminary estimate, I’ve followed the approach of Dickman et al.,[i] who estimated the number of deaths resulting from states’ failure to expand Medicaid.

Dickman et al. calculated a high and low estimate.  The low estimate was based on a study of the effect of uninsurance by Wilper et al.[ii], which demonstrated a hazard ratio for death of 1.40 for the uninsured as compared to the insured (95% CI = 1.06, 1.84).  Their high estimate was based on the study of Sommers et al.,[iii] which found a relative reduction in all-cause mortality associated with state Medicaid expansion of 6.1%.  Dickman et al. assume a mortality of 320/100,000 for adults aged 20-64.  Based on the study of Sommers et al., they then calculate a “number needed to insure” to prevent one death of 455, and based on the study of Wilper et al., they calculate a number needed to insure of 1,094.  (Of note, a separate study of Sommers and colleagues[iv]—relying on the insurance expansion under Massachusetts health reform—produced an intermediate number needed to insure of 830.  An amicus brief [see pages 5 and 29] submitted by the American Public Health Association and deans, chairs, and faculty of public health relied on this latter number when they asserted that potentially 9,800 lives [8.2 million uninsured/830] could be lost a year if subsidies were withdrawn during the case King v. Burwell).

In any event, dividing the CBO’s 22 million estimated newly uninsured figure by the 455 and 1,094 “number needed to insure” figures drawn from Dickman et al.’s paper produces a potential range of 20,110 – 48,352 excess deaths annually as a result of the repeal in the insurance expansion provisions of the ACA.

Thus, in a piece being published tomorrow in Jacobin, I say that a repeal of the major expansion provisions of the ACA could potentially result in the deaths of 20,000 people a year, assuming 22 million lose insurance.

Of course, those deaths are in addition to the even larger number of deaths resulting from having 29 million uninsured with the ACA in full effect.  Putting these two death tolls together demonstrates why we cannot move backward, but instead must move forward towards a real universal healthcare system (more on that tomorrow).

————————-

[i]  Dickman, Sam, David Himmelstein, Danny McCormick, and Steffie Woolhandler. “Opting out of Medicaid expansion: the health and financial impacts.” Health Affairs Blog, January 30 (2014).  Available at: http://healthaffairs.org/blog/2014/01/30/opting-out-of-medicaid-expansion-the-health-and-financial-impacts/.

[ii] Wilper, A. P., S. Woolhandler, K. E. Lasser, D. McCormick, D. H. Bor, and D. U. Himmelstein. “Health Insurance and Mortality in US Adults.” Am J Public Health 99, no. 12 (Dec 2009): 2289-95.

[iii] Sommers, Benjamin D., Katherine Baicker, and Arnold M. Epstein. “Mortality and Access to Care among Adults after State Medicaid Expansions.” New England Journal of Medicine 367, no. 11 (2012): 1025-34.

[iv] Sommers, B. D., S. K. Long, and K. Baicker. “Changes in Mortality after Massachusetts Health Care Reform: A Quasi-Experimental Study.” Annals of Internal Medicine 160, no. 9 (2014): 585-93.

Chest: “Should Pulmonary/ICU Physicians Support Single-payer Health-care Reform? Yes”

I co-write an editorial with Phil Verhoef and Jesse Hall in which we make the case that intensivists and pulmonologists should support single payer.  It’s available (for now) here: http://authors.elsevier.com/a/1TKr62p-km2aS.  It’s paired with a counterpoint by Gilbert Berdine, and rebuttals from both sides.

 

Blog Post: What’s Wrong with Margot Sanger-Katz’s Single Payer Analysis

Yesterday, New York Times health care reporter Margot Sanger-Katz, whose work I very much respect, entered the debate on the costs of Sanders’ single payer plan in a piece I find problematic, headlined “A Single-Payer Plan From Bernie Sanders Would Probably Still Be Expensive.” I should first concede, however, the central argument of her article: it is true that a US single payer system would still be relatively expensive as compared to other single payer systems. We would, that is to say, continue to spend more than the United Kingdom or Canada if we transitioned to single payer. At the same time, there would nonetheless be enormous savings from such a transition, and these savings would allow us to affordably achieve real universal health care. This, in my opinion, would still be an excellent deal.

The background to this debate are two analyses of the Sanders’ single payer proposal—the first by economist Kenneth Thorpe and the second by the Urban Institute—both of which claimed that the actual costs of Sanders’ single payer plan would be significantly higher than what his campaign has predicted. The assumptions of each have been convincingly contested by colleagues David Himmelstein and Steffie Woolhandler: among other points, they argue that both analyses underestimate administrative savings and overestimate the cost of increased health care use resulting from a coverage expansion.

Anyway, without delving into the details, there is something rather puzzling when looking at the analyses of Thorpe and the Urban Institute from a broader perspective. How is it that single payer would massively increase costs in the United States, as these reports contend, even while countries with single payer-type systems—like Canada and the United Kingdom—have much, much lower health care costs than we do?

To answer, a quick side note: our total health spending is, by definition, equal to the quantity of health services delivered multiplied by their price. The US does not consistently use more health services than other high-income nations. Therefore, the fact that we have higher health care costs is mostly explained by higher unit prices for services, as Sanger-Katz and others note. Now us single payer advocates cite lower administrative costs (and lower drug spending) as the major sources of savings under US single payer (effectively lowering the “price” side of the equation). But Sanger-Katz argues that this would be insufficient: prices would have to be slashed across the board, and some services would have to be cut:

Making the American health care system significantly cheaper would mean more than just cutting the insurance companies out of the game and reducing the high administrative costs of the American system. It would also require paying doctors and nurses substantially lower salaries, using fewer new and high-tech treatments, and probably eliminating some of the perks of American hospital stays, like private patient rooms.

Such a transition would, she notes, have some scary sounding downstream consequences: “…making big cuts all at once to doctors and hospitals could cause substantial disruptions in care. Some hospitals would go out of business. Some doctors would default on their mortgages and student loans.” My understanding is that we aren’t really allowed to effectively default on student loans, but admittedly this all sounds rather dicey.

But this frightful health care meltdown isn’t even in the cards. She is correct in a narrow sense: it’s true that immediately lowering US health care expenditures to, say, that of the United Kingdom — i.e. from 16.4% to 8.5% of gross domestic product — would require major, disruptive reductions in spending across the board. However, nobody is contending that we do that. The central claim for US single payer is more modest. Use the enormous administrative savings generated under single payer financing in combination with pharmaceutical savings to cover everybody with comprehensive benefits and no cost-sharing. Overall national health spending would, it is true, remain roughly the same (though we could better control cost growth moving forward). But this scenario of widespread hospital bankruptcies and the end of private (or semiprivate?) hospital rooms is a fantasy: nobody wants it to happen, and it’s not happening.

It’s worth noting that there is also a jarringly inconsistent aspect to single-payer critiques that warn of the threat to health care workers’ income. As Woolhandler and Himmelstein note in an article in the Huffington Post, the Urban Institute simultaneously asserted that the coverage expansion under single payer would lead to an enormous increase in spending on physician services — by $1.6 trillion over a decade!—while simultaneously asserting that physician salaries would be “squeezed.” Whatever one thinks of how much physicians should be paid, it’s hard how these would both happen at the same time.

Transitioning to single payer will not mean reducing our health care expenses to British levels: that is probably not possible, and is certainly not desirable. But that’s not to say that the savings from adopting a single payer financing system wouldn’t be substantial—we’re talking hundreds of billions annually on administrative savings alone, plus more by reducing drug prices to European levels. With that money, we’ll build a much more decent health care system for all to use without having to worry about the cost of being sick, of being pregnant, or simply of obtaining preventive care. No wonder a majority of the country wants it.

Physicians’ Proposal for Single Payer

Yesterday was an important day for the single payer movement.  We launched the “Physicians’ Proposal for Single-Payer Health Care Reform” at a 1 PM press conference at the National Press Club in Washington.  Dr. Robert Zarr, president of Physicians for a National Health Program (PNHP), presided.  Participants (from left to right in this photo tweeted by AMSA President Kelly Thibert) included co-founder of Public Citizen’s Health Research Group Dr. Sidney Wolfe, National Nurses United Co-President Karen Higgins, Dr. Claudia Fegan, Dr. Zarr, myself, and Dr. Steffie Woolhandler:

The Physicians Proposal is a detailed blueprint for a single payer system, as well as a comprehensive critique of the shortcomings of our current system.  It was formulated by a 39 member working group, co-chaired by Dr. Marcia Angell, Dr. David Himmelstein, Dr. Steffie Woolhandler, and myself.  It was published yesterday alongside an editorial we wrote in the American Journal of Public Health.  The proposal is available here (and is open for more endorsements), and the AJPH editorial is open-access and available here.

The release has gotten some good coverage so far, including in:

US News & World Report (“Doctor Group Pushes for ‘Single-Payer’ Model”)

The Guardian (“‘We need fundamental changes’: US doctors call for universal healthcare”)

The Washington Post (“2,000 doctors say Bernie Sanders has the right approach to health care”)

The Hill (“More than 2,000 doctors join call for single-payer healthcare”)

Morning Consult  (“More Than 2,000 Doctors Back National Single-Payer Proposal”)

I also had the opportunity to discuss single payer on Thom Hartmann’s show “The Big Picture,” which aired at 7 PM last night:

 

The fight for universal health care in America continues.