Lancet interview of David Himmelstein on the election

US Election reaction

The Lancet, November 11, 2016

Dr. David U. Himmelstein, co-founder of Physicians for a National Health Program, was interviewed by Richard Lane, web editor at The Lancet.

Richard Lane, The Lancet: David, welcome. You’re a health policy expert. We want to talk a lot about health care. But first of all we've got to talk about the extraordinary night that was Tuesday evening. Can I get your reaction to the election? Did you have any sense that this might happen?

David Himmelstein, M.D.: Well, we were worried that it might happen after Brexit and other events elsewhere. And frankly Trump’s performance in the primaries gave some clue that the polls might be off. So I didn’t expect it, but I was worried that it might happen.


RL: One of the biggest problems with the implementation of the Affordable Care Act, as far as I could see as a non-American from outside, was the way it was implemented that led to some terribly bumpy things along the way, didn’t it? Just the launch of the insurance market was a disaster, with the internet systems not working. But more importantly, over and above that, and this was the political fuel that the Republicans were almost rubbing their hands with glee with at the rally in Philadelphia last week, were the rising prices of premiums, because the insurance companies couldn’t get enough people to enroll in the program. So even though the Affordable Care Act had very laudable aims to extend its reach, and it did to 20 million people, its implementation has been deeply flawed, hasn’t it?

DH: The program was deeply flawed from the outset. It was enormously complex, and really represented a compromise that was pushed by the insurance industry. Most of the additional coverage was purchased through private insurance plans and increased the revenues given to private insurers. The structure of the program, in order to try and make it work, was tremendously complex, and that’s what really created the disorder in its startup, because trying to enroll people in hundreds of different plans around the country, each with differing offers of coverage, and deductibles – the amount that one must pay before the insurance kicks in – varied from plan to plan, as did the level of co-payments (how much you pay in addition to the insurance at each visit).  Those things varied from plan to plan, so there was tremendous complexity really baked into the program. It’s quite striking in contrast to our Medicare program which is the single-payer program for the elderly. That federal government program, which started up some 10 months after its passage by the Congress back in the 1960s before we even had any computers, enrolled 99 percent of all eligible people within that 10-month window without any notable glitches or confusion. So it’s quite clear that the structure of Obamacare was deeply flawed from the outset. And, as you say, the prices of the insurance rose quite steeply because they relied largely on market forces. I think I’m not alone in saying that the market doesn’t actually work in health care and we know that the U.S., which has the most market-oriented of health care systems, has by far the highest cost of our health care system, and it is no surprise that costs rose partly because sicker people were the ones who took up the offer of the new coverage, and they’re the most expensive people.

Podcast, 14 minutes:

Full transcript:


By Don McCanne, M.D.

Much of the interview is cloaked in uncertainty since we do not know yet precisely what Donald Trump, working with Congress, will do. But the discussion to date raises great concerns.

You would think from the media reports that there are only two positions - some form of repeal and replacement of the Affordable Care Act (ACA), or preserve and protect ACA. But the excerpt selected makes a very important point. The inherent fundamental defects in our existing health care financing infrastructure were not amenable to the tweaks of ACA. Although beneficial, ACA could not repair the glaring defects in the system.

So the battle should not be over protecting the existing financing system but rather it should be over what the replacement will be - a market-based system that leaves health care unaffordable for tens of millions, or a public single payer program that takes care of everyone? We have to be sure that Washington understands that this is the debate we should be having.