The Lancet interviews Dr. David Himmelstein on the U.S. election results

The following is an unofficial transcript of an interview that Dr. David U. Himmelstein gave to Richard Lane, web editor at The Lancet, on Nov. 10, 2016. Dr. Himmelstein is professor of health policy and management at the City University of New York School of Public Health and lecturer in medicine at Harvard Medical School. He is co-founder of Physicians for a National Health Program. You can listen to the interview at this link at The Lancet.

Richard Lane, The Lancet: Welcome to the latest podcast from The Lancet. I’m Richard Lane and it’s Friday, November 11th. This podcast comes to you from New York City. We’re in the United States because of the election, and what an extraordinary, dramatic election it has been. And I’m joined on the line by Dr. David Himmelstein for this podcast. 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: If you just put the news on – I was listening to CNN this morning in my hotel room – one of the first things that people are talking about, post-election, is what is Trump going to do. And one of the first things you hear mentioned is he’s going to do what he said he’s pledged to do, which is to repeal and replace Obamacare. So before we get some of the nitty-gritty of what that might mean – as a health policy expert, and you’ve been working in this field for many, many years – you must feel despondent.

DH: Well, we’ve made some progress. Surely the Affordable Care Act, or Obamacare, fell short of what we might have hoped for, but to simply roll it back, which is really the only idea that we’ve heard from Trump thus far – he says he’s going to replace it, but we have no sense of what he’s going to replace it with – rolling it back will be a health policy and public health disaster, I fear.

RL: Before the election, I tuned into a Republican rally at which Trump was speaking, but the person who did most of the talking was Mike Pence, who’s obviously going to be vice president with him. And at this Republican rally – this was on November 1st, which was the first day of the latest enrollment session for the Affordable Care Act for the insurance markets – each Republican, but particularly Mike Pence, was very, very strong that Obamacare was something that was wrong in their eyes and they wanted to return to what Mike Pence referred to as “the good old American way of doing things.” In other words, for health care, letting the private market take it out. Is that really what is going to happen? Because just the legal framework of creating the Affordable Care Act, which of course underpins Obamacare – to undo that would be a massive operation. Surely, whatever they come up with, Republicans next year, they are going to have to retain some elements of the Affordable Care Act, aren’t they?

DH: Well, they’ve said they’ll retain a few of the peripheral aspects of the Affordable Care Act, but its essence, we see, hear and think, they plan to simply do away with. That would throw about 20 million people out of insurance that they’ve newly acquired since the Affordable Care Act. We should say that even after the Affordable Care Act about 29 million people remain uninsured in the U.S. So adding 20 million to that would bring us back to the 49 million or so that were uninsured before the Affordable Care Act was passed. And that’s, I would say, unacceptable. But apparently Mr. Trump and Mr. Pence are prepared to accept it.

RL: So do you actually think – I mean this is this is a key question in the news media this morning, and we do appreciate it’s only just over 24 hours since we’ve had the election resolved – is your expectation that the 20 million people who are brought into insurance through Obamacare are going to lose their rights? They’re actually going to reverse that, rather than say, “OK, well you guys have got it, but we’ll make changes for any future changes to the insurance markets.”

DH: Well, we don’t really know, but I fear that that is what they have in mind. Much of the additional coverage was from an expansion of the Medicaid program, which is the program that’s administered by our state governments for very poor people. And the federal government under Obamacare had given very large additional funds to the state governments to expand the coverage of the Medicaid program, and not to just very poor people, but to people with incomes up to 133 percent of the poverty line. That brought in some 10 or 12 million additional people. We don’t know yet what they’re going to do, but their promise is that they’re going to roll back the Medicaid expansion. Now some of the Republicans have said in the past that what they want to do is just give a block of money to the state governments and let them do what they like with it.  They could use it for Medicaid, or spend it on other things. So some states may continue the coverage expansion under the Obamacare plan. Others in fact have refused it up till now. And still others are likely to roll it back.

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.

RL: Are there any elements of Obamacare that could be retained? I have heard mention that not refusing insurance to people with pre-existing conditions. This was a really key tenet of Obamacare. I have heard that that’s going to be retained with whatever the new Republican health plan is, and of course we don’t have what it is yet.

DH: Yes, you’re right. But they’ve said they won't fully retain the provision that one can’t be refused coverage no matter what pre-existing health conditions you have. What they’ve said is, as long as you maintain health insurance without interruption you would not be able to be refused a renewal of your health insurance coverage. Now that’s a considerable departure, in fact, because a lot of people have very temporary interruptions of their health insurance – if they’re traveling overseas or studying elsewhere or, in the case of one of my children, actually, there was a one-day interruption when she became too old to be covered under my policy, and her new policy through her university had yet to start up. So that kind of interruption would exempt the insurance companies from having to issue coverage no matter what your health.

And given your role for many years – your advocacy work, looking at a single-payer system which if I know your views, I think, is based on the Canadian system, isn’t it – any discussion now about universal health coverage within this new American system political system that we will have from the beginning of next year, talk of things like a public option and universal health coverage. Are these discussions now dead in the water?

DH: We have yet to really see. Certainly among people in the health care field, they’re not dead because we see the problems each day of a health care system which has both large numbers of people uninsured and growing numbers who have coverage but still can’t afford care. The New York Times featured an article some months ago about many people who’ve gotten Obamacare coverage but couldn’t afford to use it because it carried such high deductibles, often $5,000 before your insurance began to pay for anything. We have in fact a crisis of not just uninsured Americans but insured Americans who can’t afford care. And that crisis is not going to go away, in fact it’s likely to get worse under a Trump administration. So I doubt that that discussion will long be squelched about what to do about our health care system. Oddly enough, at one point in the past, Mr. Trump himself suggested that a single-payer reform might be a useful thing. He later went back on that, as he’s gone back on many of the things that he said. We’re not sure what direction debate will take, but we’re quite sure that debate about the need – really urgent need – for reform will continue. And frankly, surveys show quite an oddity in opinion in the U.S. Among Republicans the vast majority favored repeal of Obamacare. But some two-fifths favor implementation of a single-payer program. So that sentiment for single payer is quite widely shared across the spectrum. It’s about 75 percent of Democrats and 40 percent of Republicans. But overall the vast majority of the American people would want that kind of reform. We’ll see if Washington can be shaken up enough to really give it serious consideration. In the meantime, people in many states around the country are moving forward to think about what can be done at an individual state level to improve the health care system. In New York State, where I now live, one branch of our legislature actually passed a single-payer reform proposal last year, though the other branch demurred.

RL: That’s fascinating – that notion – a slight tautology, isn’t it? Irony about the support in many quarters for a single-payer system. Would that therefore logically be just an extension of Medicaid?

DH: More likely an extension of our Medicare program, which is frankly a much more successful program than Medicaid. Medicare is a program for all of the elderly and, as with any universal programs, they tend to be better maintained than programs that segregate the poor into a separate class of care.

RL: Final question, David. We don’t yet know who’s going to be the cabinet minister for health and human services. Do you have any idea who that might be and, even if you don’t, what role is there for advocacy organizations, experts like yourself, to potentially influence the direction of health policy by the Department of Health and Human Services?

DH: We have no sense yet of whom Trump will choose for Health and Human Services secretary. But surely there will be intense advocacy efforts in the in the months ahead. We know from past research that something like a thousand people die each year for every million people who are uninsured. So uninsurance remains one of our major causes of death. And if they do indeed throw 20 million people out of coverage, we expect about 20,000 additional deaths each year. That is a public health emergency that we can scarcely ignore. And I think advocates at all levels will surely join joint efforts in a very vigorous way to try and move our health care system forward. We at this point may not be able to move back to the ACA, but we’re hopeful that we could move forward to something even better. I mean we’ve already seen on the streets of cities around the country the deep concerns of Americans who didn’t vote for Trump. And frankly among the many people who did vote for Trump, we’re likely to see very grave concerns arise as the reality of a Trump administration emerges. We know that among white middle-aged people of lower income, who were largely Trump voters, their death rates are rising in this country and many of them can’t get the care they need. We know that medical bankruptcy is extraordinarily common among people with insurance, and those problems are likely to get worse, not better. And I think that provides a very strong basis for advocacy for change. We may see a few months of hiatus in real debate, but it will emerge again.

RL: Well it’s a fascinating discussion, David. I’m very grateful for your time so soon after the election result. Dr. David Himmelstein, many thanks for talking to The Lancet.

DH: Thank you.

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