Is Obamacare enough? Without single payer, patchwork U.S. health care leaves millions uninsured
Interview with Dr. Steffie Woolhandler and John McDonough
By Amy Goodman
Democracy Now, Oct. 7, 2013
Despite helping expanding affordable insurance, “Obamacare” maintains the patchwork U.S. health care system that will still mean high costs, weak plans and, in many cases, no insurance for millions of Americans. We host a debate on whether the Affordable Care Act goes far enough to address the nation’s health crisis with two guests: Dr. Steffie Woolhandler, a primary care physician and co-founder of Physicians for a National Health Program; and John McDonough, a professor at the Harvard School of Public Health and former senior adviser on national health reform to the U.S. Senate Committee on Health, Education, Labor, and Pensions. Between 2003 and 2008, McDonough served as executive director of Health Care for All in Massachusetts, playing a key role in the passage of the 2006 Massachusetts health reform law, known as “Romneycare,” regarded by many as the model for the current federal health care law.
This following is a rush transcript. Copy may not be in its final form.
AMY GOODMAN: We turn to a discussion on whether Affordable Care Act, or “Obamacare,” goes far enough in addressing the nation’s health crisis. The New York Times recently reported the new health care law will leave out two-thirds of the nation’s poor blacks and single mothers and more than half the nation’s low-wage workers who don’t have insurance. That’s because they live in 26 states controlled by Republicans that have rejected the vast expansion of Medicaid.
We’re joined by two guests: Dr. Steffie Woolhandler, professor of public health at CUNY-Hunter College and a primary care physician, visiting professor at Harvard Medical School and co-founder of Physicians for a National Health Program; and we’re joined from Boston by John McDonough, professor at the Harvard School of Public Health, director of the New Center for Public Leadership. Between 2008 and ‘10, he served as a senior adviser on national health reform to the U.S. Senate Committee on Health, Education, Labor, and Pensions. And between 2003 and 2008, he served as executive director for Health Care for All in Massachusetts, playing a key role in the passage of the 2006 Massachusetts health reform law known as “Romneycare,” regarded by many as the model for the current health care law. He recently wrote the book Inside National Health Reform.
We welcome you both back to Democracy Now! Let’s start in Boston with John McDonough. Your thoughts on this seven-day rollout, where most of the websites have not worked?
JOHN McDONOUGH: It was predicted, and it’s disappointing, and we hope they will get it fixed up as quickly as possible. And we recall what happened in 2006 with the rollout of the Medicare prescription drug program, which was plagued for many months with significant technical problems, and those problems were dealt with and addressed, and hardly anybody remembers them right now. What they remember is that the program is working pretty well for the tens of millions of Americans who are in it.
AMY GOODMAN: And, Dr. Steffie Woolhandler, your thoughts on this program that started October 1st?
DR. STEFFIE WOOLHANDLER: OK, well, the completer glitches will get sorted out, but the complexity that caused the computer glitches is baked into “Obamacare.” The exchanges have to deal with millions of enrollees and doing income verification. They have to deal with thousands of private insurance plans. It’s a very complex system. And unfortunately, that complexity also contributes to high expense. The private insurance industry that’s offering the coverage through the plans has overhead costs that are about four times as high as traditional Medicare. And in addition, we’re going to have overhead of about 4 percent added to insurance overhead just for the exchanges. So it’s a complex system, a very expensive system, and when we see the way it’s performing, we understand why we need a simple single-payer system that could save about $400 billion on administrative simplification.
AMY GOODMAN: For people who don’t have insurance or want to get cheaper insurance, do you encourage them to go to the websites to sign up for the new – under these new exchanges?
DR. STEFFIE WOOLHANDLER: Well, absolutely people need to take a look, but they also need to know that many of the new plans have high co-payments, high deductibles. They can have very restrictive networks. So, for some people, this will be a great deal. If your income is in the low range and you get a big subsidy, it can be a very good deal. If you’re sort of middle-income, I think you’re going to find you’re paying an awful lot of money for some very skimpy coverage through the exchanges.
AMY GOODMAN: Your response, John McDonough?
JOHN McDONOUGH: Well, yes, the law and the system around the law are complicated, and our underlying health care system is incredibly complicated, far more than it needs to be. I don’t really have a disagreement with my – with my friend and colleague, Steffie Woolhandler, about a division of what we would like to see. The reality is that this was probably the best we could have gotten in 2009, 2010. Getting anything even close to this would be politically impossible today. And, you know, I hope this is a movement in the direction toward a more rational and less complex system, but it is an important start and an important step forward for potentially tens of millions Americans, a lot of whom are going to get coverage that’s going to be very affordable and at almost no cost.
AMY GOODMAN: Is this a road to single payer, Dr. Steffie Woolhandler?
DR. STEFFIE WOOLHANDLER: Well, it’s only a road to single payer if we fight for single payer.
AMY GOODMAN: And what does that mean when we say “single payer”?
DR. STEFFIE WOOLHANDLER: OK, well, single payer is also known as expanded and improved Medicare for all, also known as nonprofit national health insurance. It means you would get a card the day you’re born, and you’d keep it your entire life. It would entitle you to medical care, all needed medical care, without co-payments, without deductibles. And because it’s such a simple system, like Social Security, there would be very low administrative expenses. We would save about $400 billion, which would allow us to afford the system. I mean, I just want to remind you that when Medicare was rolled out in 1966, it was rolled out in six months using index cards. So if you have a simple system, you do not have to have all this expense and all this complexity and work.
AMY GOODMAN: What do you mean, “index cards”?
DR. STEFFIE WOOLHANDLER: They didn’t have computers back in 1966, OK? So they expanded – went from zero to over 20 million people enrolled in Medicare in a period of six months. And because it was a simple system, based on the Social Security records, it was a tax-based system, you didn’t have hundreds of people programming the state of Oregon, thousands of different plans, tons of different co-payments, deductibles and restrictions – one single-payer plan, which is what we need for all Americans to give the Americans really the choice they want, which is not the choice between insurance company A or insurance company B. They want the choice of any doctor or hospital, like you get with traditional Medicare.
AMY GOODMAN: Democratic Senator Barbara Mikulski of Maryland has hailed “Obamacare” as a victory for women.
SEN. BARBARA MIKULSKI: [Forty-two] million people in the United States of America don’t have a doctor, don’t have access to a doctor, but they have hope because the health care is being implemented. We speak for the 150 million women in the United States of America who now have health care because “Obamacare” has been implemented. Being a woman in the United States of America is no longer considered a pre-existing condition by the insurance companies. We have been denied health care because of pregnancy, because of domestic violence and because of other things.
AMY GOODMAN: That’s the Democratic Senator Barbara Mikulski of Maryland. Steffie Woolhandler?
DR. STEFFIE WOOLHANDLER: Well, that’s great that there’s some guaranteed issue, meaning that the insurance companies have to give you coverage if you apply. But much of the coverage is going to be extremely skimpy and not particularly affordable. And there will be 31 million Americans left out of “Obamacare,” and about five million of those 30 million uninsured will be uninsured because of the red state governors opting out of Medicaid. But 25 million of those uninsured are uninsured by the very design of “Obamacare.”
AMY GOODMAN: How?
DR. STEFFIE WOOLHANDLER: They were never included in the original estimations of the bill. That’s because you have to take money out of your pocket to buy insurance, and as you get up into the middle-income levels, the insurance is extremely expensive, and many people won’t be buying it. About one-third of those people will be undocumented immigrants, but two-thirds will be U.S. citizens, mostly working poor, who still cannot afford – afford health insurance under “Obamacare.”
AMY GOODMAN: John McDonough, your response to that and whether you – how you see this transitioning? I mean, do you ultimately see expanded Medicare for everyone as the answer in this country?
JOHN McDONOUGH: Two very big questions, Amy. So, on the first piece, on the 25 million, so, you know, when Medicaid was started in 1965, it was voluntary for states to get in. It wasn’t until the 1970s that most – nearly all states were in, and it wasn’t until 1982 that all 50 states were in. Arizona was the last state to join, in 1982. I would predict that within five years all 50 states will be participating in this new Medicaid expansion, because the benefits of it are so great for states, and it’s – it will be a lot easier when the temperature on “Obamacare” as a political issue diminishes.
The other thing to keep in mind, of the 25 million, about a third of them are people who will be eligible for Medicaid and who fail to sign up for Medicaid. We would like those folks obviously to sign up and get all of the preventive care and primary care, but the important thing to understand is that when those folks show up at a clinic, at a hospital for care, they won’t be told, “We can’t treat you.” They can get signed up and qualify for Medicaid on the spot. So it’s a different relationship in terms of who will still be uncovered. There will still be a significant number uncovered, but they will have access to services, and they will not walk in and say, “Sorry, you’re going to have to pay, or we won’t treat you.” It’s going to be a very different situation for those people.
Whether this leads to a Medicare single payer, I think it’s way too early to say. I would hope that it would, because, frankly, I didn’t see any particular traction in terms of trying to move to that direction before “Obamacare.” And I think there’s enough changes going on right now that there may be some changes in terms of the prospects.
AMY GOODMAN: Dr. Woolhandler?
DR. STEFFIE WOOLHANDLER: Yeah, well, I’m very doubtful that people can just walk into any doctor’s office and say, “I’m uninsured,” and get care because somebody there happens to think they might get Medicaid. That’s not how things work now, and I don’t see why it would work that way under “Obamacare.” I mean, unfortunately, “Obamacare” is –
JOHN McDONOUGH: It works that way in Massachusetts now.
DR. STEFFIE WOOLHANDLER: – is a very expensive program that offers halfway coverage to half of the people who need it. And we need to be moving forward to single payer to make sure every single American can go to any doctor they want and be able to afford that.
AMY GOODMAN: President Obama –
JOHN McDONOUGH: The way –
AMY GOODMAN: Oh, go ahead. Go ahead, John McDonough.
JOHN McDONOUGH: No, I mean – no, the way it works in Massachusetts and the way it has worked since the health reform law in 19 – in 2007 is that if you are eligible for Medicaid, categorically eligible, and you go into a clinic, a community health center or a hospital, and you can get enrolled in Medicaid, you get enrolled in Medicaid on the spot. And so, you walk in – so, yeah, you were uninsured. You need medical services, you go in, and you’re covered. So, and that is the model for how the system is designed to work under the ACA beginning on January 1st.
AMY GOODMAN: President Obama has cited a woman named Natoma Canfield as inspiration for his Affordable Care Act.
PRESIDENT BARACK OBAMA: You know, there’s a framed letter that hangs in my office right now. It was sent to me during the health care debate by a woman named Natoma Canfield. For years and years, Natoma did everything right. She bought health insurance. She paid her premiums on time. But 18 years ago, Natoma was diagnosed with cancer. And even though she had been cancer-free for more than a decade, her insurance company kept jacking up her rates, year after year. And despite her desire to keep her coverage, despite her fears that she would get sick again, she had to surrender her health insurance and was forced to hang her fortunes on chance. I carried Natoma’s story with me every day of the fight to pass this law.
AMY GOODMAN: Steffie Woolhandler, would a woman like Natoma Canfield now have better options than before?
DR. STEFFIE WOOLHANDLER: Well, it really depends on her income. If her income is hovering around 400 percent of the poverty line, the health insurance would be very, very expensive indeed. And what we need is something that just covers everyone automatically.
AMY GOODMAN: So how are you doing that work now? I mean, you talk about how expanded Medicare, you know, Medicare for all, would be the path to go, but you see now the – just “Obamacare” alone has brought down the government. Or do you see “Obamacare” not as a step to single payer, that it makes sense to you that even – that Republicans would be objecting to this, as well?
DR. STEFFIE WOOLHANDLER: Well, “Obamacare” is the law of the land. And there are some good things. Certainly expanding the Medicaid program is a good thing. But we need to be thinking about single payer, moving forward. And our group, Physicians for a National Health Program, has about 17,000 members. And as you can imagine, there’s some disagreement. Some people are very pro-”Obamacare.” Some people are more tepid, like myself. But we all agree that it is not a solution, that we still need single payer, and we need to be moving forward and building the movement to go forward to single payer.
AMY GOODMAN: Dr. John McDonough, the issue of Medicaid being denied to so many millions of people around the country – was “Obamacare” framed around them actually getting that Medicaid so – what is your response to that?
JOHN McDONOUGH: Yeah, Title II of the Affordable Care Act deals with Medicaid. And the way it was written by the folks in the House and the Senate was that all states, on January 1, 2014, are required to open up their Medicaid programs to all uninsured people with incomes below 138 percent of the federal poverty line, which is about $14,000 to $15,000 for a single adult. And it was the U.S. Supreme Court decision in June of 2012 that changed that. The one substantive change the Supreme Court made in the ACA was to say that the Medicaid expansion had to be a state option. And so, we are faced with this really awful situation where, beginning January 1 of next year, the only Americans who will not have some form of health insurance available to them as a matter of law are poor individuals who live in states that have chosen not to expand Medicaid. So, it is probably one of the most cruel and despicable forms of rationing I can imagine that it is folks who are among the most vulnerable in some of the neediest states who are denied this coverage. I do think it’s going to change. I do think it’s going to happen relatively quickly. And again, I’d say within five years, I think just about all states are going to be part of this expansion.
AMY GOODMAN: Your response to that, Dr. Steffie Woolhandler? And how are you organizing for expanded Medicare, Medicare for all?
DR. STEFFIE WOOLHANDLER: OK, well, it depends a lot on your definition of “affordable.” Under “Obamacare,” someone my age with an income of about $45,000 a year or more would have to pay $8,300 a year in premiums, more than $8,000 a year in premiums. And very few people have room for that in their budget. And that’s why many middle-income people will remain uninsured under “Obamacare.” Plus, they’ll be paying a penalty for not purchasing that expensive insurance. It’s simply not going to be affordable.
Our group, Physicians for a National Health Program, has been working with Health care-NOW!, has been working with unions, and mostly working in our own community – that is, the physician community – to educate people about single payer, to advocate for single payer, to continue to push for single payer both at the state level and at the national level. And we feel that once people see what “Obamacare” really is, that it is not a solution to the health care crisis, once they realize “Obamacare,” whatever its strengths, is not a solution, they’ll be motivated to join the movement for single payer.
AMY GOODMAN: And how do they get – what do you think is the most critical first step now in that movement, given how the Republicans are even responding to this?
DR. STEFFIE WOOLHANDLER: Well, I think people need to educate themselves about single payer. They need to work in their communities around single payer. I think that the – what the Republicans are doing is reprehensible. I’m not supportive of that, obviously. But I think we need to be pushing, saying we want single payer. I mean, the Republicans have made a big deal out of about half of Americans reject “Obamacare,” but what they don’t tell you is that a third of those people reject “Obamacare” because they didn’t think it went far enough. And, in fact, in The New York Times on Saturday, they interviewed a very conservative guy in Georgia who said, “I hate ‘Obamacare.’ I support the Republicans. What we need is a single-payer system.” So, I think a lot of people are coming around to that view, and we need to continue to put that out there and push for that, because that’s what Americans need.
AMY GOODMAN: If we were going to single payer, expanded Medicare, today – or let’s say October 1st – what would have happened?
DR. STEFFIE WOOLHANDLER: Well, we could have just enrolled everyone automatically through the Social Security Administration, which already has the names of everyone through Social Security numbers or ITNs. It already knows our income. It knows at least where we work and probably where we live, so he wouldn’t have had to set up all these exchanges and new systems with all of these glitches and all this expense, because by going with a Social Security-based system, like they have in Canada, like they have in most of Europe, you save all that paperwork cost, and that allows you to devote more money to care. You know, other nations have nonprofit national health insurance and spend substantially less than we do and cover everyone, largely because they save on that administrative complexity and expense.
AMY GOODMAN: I want to thank you both for being with us, Dr. Steffie Woolhandler, now at CUNY-Hunter College – that’s City University of New York – and a founder of Physicians for a National Health Program; John McDonough, with us from Boston, the Harvard School of Public Health, has written the book Inside National Health Reform. He contributed to shaping “Romneycare” and then “Obamacare.”
This is Democracy Now! When we come back, an exclusive conversation with Ladar Levison, who ran the website Lavabit, until he shut it down. Edward Snowden used the email service, and the FBI came a-knocking. Ladar Levison will explain what happened next. Stay with us.