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when they asserted that potentially 9,800 lives [8.2 million uninsured/830] could be lost a year if subsidies were withdrawn during the case King v. Burwell).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.

Blog Post, St. Patrick’s Day Edition: What’s going on with universal health care in Ireland?

In recent years, several nations have announced bold plans for sweeping universal health care reform. One of these is India, which, as it has turned out, has done basically nothing to achieve that goal under the BJP government of Narendra Modi. However, as today is St. Patrick’s Day, I’ll discuss the case of Ireland, which hasn’t made much progress either.

A recent article in the journal Health Policy (“From universal health insurance to universal healthcare? The shifting health policy landscape in Ireland since the economic crisis”) by Sara Ann Burke and colleagues at the Centre for Health Policy and Management at the Trinity College of Dublin School of Medicine explains this well. It’s very much worth reading (and is open access!). It traces the trajectory of “universal health care” reform in Ireland over the past 5 years. In what follows, I’ll summarize some of the main points of that article (interspersed with my own commentary) to give a sense of the health care scene in Ireland.

In 2008, Wall Street sunk and, as we all know, took the global economy down with it in the process. Recession brought about the era of austerity in Europe, and this had the effect of starving health care systems throughout the continent. Ireland was one of the nations facing fiscal and health system austerity. Nonetheless, as Burke et al. note, the 2011 election in Ireland put a new coalition government into power that declared the goal of achieving universal health care. Why was this necessary? Don’t all high-income nations except the US already have “universal health care”? Well, not exactly.

Ireland, for instance, has long had a “two-tier” public-private health care system, as Burke et al. describe. A public system, they note, which goes by the name of the “General Medical Services” (GMS) scheme, covers a substantial minority of the population: these low-income individuals get free GP services as well as low cost prescription medications (those without GMS coverage, on the other hand, have to pay more than €50 for a primary care visit). However, as they emphasize, almost half of the population is covered through private health insurance, a benefit that gives them superior access to hospital care.1

Now, as they note, the government’s 2011 plan for universal health care called for a level playing field, which sounds like a step in the right direction. However, this wouldn’t be through single payer transformation, but instead through a Dutch-style reform, with everybody mandated to purchase a plan from a for-profit private health insurance company.2

However, the Dutch approach has serious shortcoming, as I recently wrote about in Jacobin. I noted the following, in describing some of the parallels between the Dutch reform and the Affordable Care Act:

If the Netherlands model demonstrates anything, it’s that some forms of “universal” health care are less worthy of emulation than others. Expanding access the Dutch way (itself based on US policy ideas) would leave intact much of the waste of the current system — without achieving the equity implied by the term ‘universal health care.’

To be fair, as Burke et al. describe, the Irish government was also proposing that everybody would at least get free GP visits under the reform, which would no doubt be a significant and meaningful improvement. Regardless, basically none of this came to pass. As they describe, the last five years have seen no major change in health insurance coverage in Ireland: the percentage of the population with GMS cards saw no major change, while some evidence pointed to a rise in wait times. At the same time, they state, the government retreated from its previous calls for “universal health care” and free GP visits for all (it did expand free GP visits to those > 70 and those < 6, though that was about it).3

They thus conclude:

While there has been an intent of universalism in official government policy since 2011, the data presented here show little progress made on increasing the breadth, with decreasing depth and scope of coverage of coverage evident through increased user charges and numbers waiting for hospital diagnosis and treatment. The exception is the extension of free GP care to the youngest and oldest citizens in mid-2015 and a small increase in private health insurance in 2014/5.   This failure to progress towards universalism can be explained by the unrelenting pressure on the health system as a result of budget cuts since 2009 and by the lack of clarity on the exact form of universalism espoused and the mechanisms to achieve it.4

This paragraph lays out the problem very succinctly. On the one hand, the system was hard pressed by the financial demands of austerity. Others have emphasized the effect of austerity on health care in Ireland: at a time when people needed more protection, not less, coverage fell while copayments (“user fees”) rose. Here is Alexander Kentikelenis, for instance, in the European Journal of Public Health:

Ireland also implemented steep health sector cuts in 2012 as part of the fiscal adjustment programme agreed on with its international creditors, and introduced a rise in user fees. The onset of austerity marked a reversal in the extent of coverage, and tightened eligibility criteria for issuing [GMS] ‘medical cards’—a means-tested programme for the poor—resulted in the decline of people covered under this programme.5

And on the other hand, Burke et al. note that the “exact form of universalism” being pursued was unclear, which is exactly right: unlike a comprehensive national health insurance or national health system reform, the government, they suggest, envisioned a system run by private insurers as in the Netherlands or, to an extent, in the US.

However, even that reform didn’t come about. Ireland, like the US, as a result still lacks true universal health care, with equitable access to all. Looking ahead, Burke et al. write,

Ireland is at a critical juncture, veering between a potential path to universal healthcare and a system overwhelmed by seven years of austerity, which continues to maintain the status quo and a historical bias towards a two-tier unequal system of care.6

Unfortunately, people in nations throughout the globe are contending with similar problems: inadequate funding and unequal health system access. But private health insurance – whether dubbed “universal” or not – is not the answer, either for Ireland or the US.



1 Burke SA, Normand C, Barry S, Thomas S. From universal health insurance to universal healthcare? The shifting health policy landscape in Ireland since the economic crisis. Health policy 2015. In press.

2 Ibid.

3 Ibid.

4 Ibid.

5 Kentikelenis A. Bailouts, austerity and the erosion of health coverage in Southern Europe and Ireland. European journal of public health 2015;25:365-6.

6 Burke SA, Normand C, Barry S, Thomas S. From universal health insurance to universal healthcare? The shifting health policy landscape in Ireland since the economic crisis. Health policy 2015. In press.

LA Review of Books: “Is the Path to Racial Health Equity Paved with ‘Reparations’? The Politics of Health, Part II”

I have a review/essay in the Los Angeles Review of Books today.  It’s the second part of the “Politics of Health.”  The first part mainly dealt with health inequalities by class, whereas this part deals with health inequalities by race.  I review two recent books: Dayna Bowen Matthew’s Just Medicine: A Cure for Racial Inequality in American Medicine and Damon Tweedy’s Black Man in a White Coat. 

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.