The Affordable Care Act and single payer

By Alec Pruchnicki, M.D.
WestView News (New York City), June 2013

Part 1: How Does the Affordable Care Act Affect Us?

The Affordable Care Act (ACA), sometimes referred to as Obamacare, will affect us. It is a complex area of law with many pieces. In 2010, it passed Congress with many compromises, and mostly survived a Supreme Court challenge. Here are a few of its major provisions.

From the start, insurers can no longer cancel coverage if you become sick; there will be no lifetime limits on total cost of coverage, and more preventive care will be covered. Young adults (up to 26 years of age) can usually stay on their parents plan, and denials for pre-existing conditions will start to decrease. Drug costs under Medicare will start to decrease in addition to reimbursements for Medicare Advantage plans (Medicare MOs). A significant new provision requires insurance companies to spend at least 85 percent of their budgets on medical care. If they do not, they must send a refund to their enrollees.

By 2014, all denials for pre-existing conditions are to be eliminated. Medicaid coverage will be expanded for millions of individuals and essential benefits will define minimal coverage for policies. Individuals will be required to have coverage which could be purchased through newly established health care exchanges, with subsidies for those with low income. Persons who do not purchase or have their own insurance will pay a penalty that will eventually rise to $695 for individuals and $2,085 for families, or 2.5 percent of income. Employers with 50 or more workers will be required to provide coverage, or face a tax penalty. Employers with less than 50 workers will not be required to provide coverage, but subsidies will exist to encourage them to do so.

Although the ACA establishes many reforms in the area of health care and is one of the major pieces of legislation in this field since the 1960s when Medicare and Medicaid were established, there are significant weaknesses. Progressive politicians tried to include a “public option” in the bill, or at least a possible buy-in to Medicare or Medicaid. However, these were never included and now much of the increased coverage will be channeled through private plans, both profit and non-profit, rather than any government program. This will expand, and sometimes subsidize, the private sector often with government enforcement or government funds.

The exchanges set up within the states are still being established and their goal of significantly decreasing costs and widening consumer options has yet to be determined. Furthermore, since the Medicaid reforms were not supported by the Supreme Court decision, many states have refused to implement them. Whether or not these refusals persist and states continue to reject substantial federal funds also remains to be seen.

Possibly the greatest problem with the ACA is that only half of those without medical insurance will be covered by the provisions of the act, even if more states agree to participate in Medicaid reform, and as many as 31 million people will still not have coverage. Supporters of the act point to Massachusetts where a similar plan led to more coverage than projected, while critics of the act also point to Massachusetts for failure to adequately control costs, either on a state-wide or individual basis, and the coverage that does exist is often insufficient and leads to under-insurance.

As this complex act is implemented, its strengths and weaknesses will become more apparent and the need for further health care reform may arise at some time in the future, possibly very soon.

Part 2: What Is Single-Payer Health Care?

Single-payer national health insurance is a system in which one entity (usually a government agency) organizes the financing of health care, leaving the delivery of care mostly in private hands.

All residents would be automatically enrolled in the program at birth and be covered for life. Everyone would have equal access to comprehensive, high- quality health care, with no premiums, co-pays or deductibles.

Financed by a system of progressive taxation, the program would pay for all necessary medical expenses, including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug, and medical supply costs. Patients would have free choice of doctor and hospital. People would no longer be afraid of unaffordable medical bills and would never be bankrupted by medical expenses.

In some single-payer systems, such as in Canada, hospitals receive lump-sum government payments rather than depend on piecemeal billing and negotiations with insurance companies. Had we such a system, it’s likely we would have prevented the closing of St. Vincent’s Hospital and many other hospitals around New York City.

There is a bill in Congress, the Expanded and Improved Medicare for All Act, H.R.676, that would establish such a program. Polls show that its principles have solid majority support, including among physicians and nurses. The bill has been endorsed by many unions, civic, and faith based organizations.

Why do we need it?

We already spend twice as much as other industrialized countries on health care but we receive mediocre results. Some Americans benefit from very good health care but millions do not. Fifty-four percent of Americans report delaying needed care in 2010, while 25 percent report having trouble paying medical bills. Many must choose between paying for medicine and paying for food or rent.

Approximately 45,000 deaths each year in the U.S. are associated with a lack of health insurance. Sixty-two percent of personal bankruptcies are a result of illness and medical bills.

We spend 17.7 percent of our GDP on health care and this is a terrible drain on our economy. Our reliance on private, for profit health insurance companies wastes billions of dollars every year on administrative costs. This money could be going towards providing health care if we eliminated this expensive middleman who adds cost but no value to the system.

How do we know it would work?

We already have a single-payer-like system in this country and it has been working well for nearly 50 years: Medicare. We also have publicly financed nonprofit health care for the military, veterans, and the poor. They all could be improved but they work and pay half of our country’s health care bill.

A single-payer system would bring health care justice to our country. It would be transparent, publicly accountable, fair, and efficient. It is time to end the immorality of our unequal, chaotic, inefficient health care “non-system” and join the rest of the industrialized world in providing equal access to high-quality health care for all our people.

Dr. Alec Pruchnicki practices internal and geriatric medicine and serves on the board of the N.Y. Metro chapter of Physicians for a National Health Program ( He resides in the West Village.