Is unaffordable underinsurance the best we can do?

By Gordon Schiff, M.D.

The following text represents the prepared testimony of Dr. Gordon Schiff at a March 22 public hearing in support of single-payer legislation before the Massachusetts legislature’s Joint Committee on Health Care Financing. The hearings were held in the Gardner Auditorium at the State House in Boston. For more information, visit

My name is Dr. Gordon Schiff. I am a practicing general internist (primary care physician) and work at the Harvard Brigham Center for Patient Safety Research and Practice, as well an associate professor at Harvard Medical School.

It is time to get back on track on the road to providing health insurance, real universal health insurance to everyone in the U.S., and particularly everyone here in Massachusetts. We need to continue lead the way in our commitment to do this in the highest quality, most affordable and cost-efficient way.

Look at the national figures: of 41 million people uninsured before the Affordable Care Act; 16.9 million (41 percent) have gained health insurance (RAND 2015) – hardly a passing grade if our goal was 100 percent.

This leaves some 25 million still uninsured nationally. And for most of those who have gained insurance what they have “gained” is either Medicaid (historically a poor program for poor people, looking better only because the other options are looking so much worse) or high deductible health plans – a cruel hoax – with deductibles of $5,000 a year or more in addition to premium payments and out-of-network costs, meaning such people are so seriously underinsured they can’t pay their medical bills should they become ill –what insurance was supposed to provide.

We have a plan that falls far short of what was promised and what we need.

The Obama plan of course is based on the Massachusetts Plan which the president chose to emulate – individual mandates for private insurance, Medicaid expansion, and bizarre expensive purchasing bazaars to shop for the best plans. This is Romney-care that former Massachusetts Gov. Romney has recently admitted came directly from Newt Gingrich and the Heritage Foundation (an extreme right-wing think tank).

Obama chose this route, even after repeatedly acknowledging the single payer was best when he was a state senator in Illinois (where I was living at the time) in order to achieve “bipartisan support.” In the end not a single Republican supported the plan; so this failed strategy has left us with this suboptimal plan – a plan that in order to maintain the power of the insurance industry and other special interests is so complex, so inadequate, so riddled with disparities, that it is time to honestly reexamine if this is the best route for achieving universal coverage.

Is unaffordable underinsurance the best we can do? We need a better strategy one that Massachusetts physicians and their patients want and need. They are frustrated, confused, and discouraged by the complexity, high cost, and waste in the current system.

Other countries are succeeding where we are failing in both holding down costs and improving access care. They offer universal access and coverage, free choice of physicians, and achieve quality outcomes that are as good as or better than ours at half the cost. They are based on caring for everyone, rather than market systems that drive up costs.

How do they do it? I would like to touch on two central features for improved quality and lowered costs, something they have and we lack: Simplicity and continuity – two attributes our current system is failing at, and that single payer achieves.


Can you as a legislator, or a consumer, even begin to understand the following?

  • Health insurance Marketplaces
  • Special Enrollment Period (SEP) in the Marketplaces
  • Premium Stabilization Programs
  • The Transitional Reinsurance Program – Reinsurance Contributions
  • Medicare Access and CHIP Reauthorization
  • End of Benefit Year Risk readjustment
  • Cost-Sharing Reduction Component of Advance Payments for Benefit Years 2014 and 2015
  • The Transitional Reinsurance Program
  • Reinsurance, Risk Corridors and Risk Adjustment
  • Consumer Operated and Oriented Plan (CO-OP) Program
  • FFM – federally facilitated marketplace agents and brokers regulations
  • Metal Tiers: Bronze vs. silver vs. gold vs. platinum plans
  • In-network vs. out-of-network providers
  • The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

And a few additional insurance features unique to Massachusetts:

  • Children’s Medical Security Plan
  • Mass Health
  • Health Safety Net
  • Commonwealth Health Insurance Connector
  • Connector Care
  • Closed/vs. Open Enrollment periods
  • Special Coverage after a Qualifying Life Event

Do you understand all of these different programs? I certainly don’t. Not to mention hundreds of insurance plans each with different qualifying criteria, deductibles, coverage and products Massachusetts citizens are supposed to be able to choose from, every year.

Nor can I keep these straight from all the forms I have to respond to from all the different insurance plans and drugs benefit plans.

This leads to huge amount of confusion, complexity, and waste for physicians and patients and hospitals and doctors’ offices every day. Where do these costs show up? The beauty of the current system in its ability to hide, obscure and avoid accountability for all this waste and hidden costs, inherent in keeping the status quo.

All this goes away with the simplicity of single payer, where the eligibility the criteria is being born, and disenrollment criteria is dying.

Continuity of Care

Can you imagine my horror when I received an email from one of my very depressed patients, stating in the subject line “This is My Final Note to You”? I always had some reservations about allowing patients to email, but receiving what I thought was a suicide note was quite a jolt.

Turns out, reading the body of the email, I learned she had been involuntarily switched to a new Mass Health plan and I could no longer continue to be her primary care physician. Even though I knew this patient best, having cared for her for a number of years, Mass Health required her to switch to a new MD. This makes no sense from a quality or cost point of view.

Physicians and patients prefer the simplicity, continuity, choice, and affordability of single payer, as poll after poll has demonstrated. The status quo is neither desirable nor sustainable. We urge you to act affirmatively on the single-payer bills you have before you, for the sake of the patients and doctors and other staff.