Dr. Andy Coates: Single payer will enhance our lives across the board

Original article on PNHP.org

The following is a lightly edited, unofficial transcript of the second half of an interview that Dr. Andrew D. Coates gave to Ed “Flash” Ferenc, host of the labor-oriented, Cleveland-based America’s Work Force Radio, WERE AM 1490, on March 30, 2016. Dr. Coates is immediate past president of Physicians for a National Health Program.

In this segment of the interview, Dr. Coates talks about how a single-payer, improved-Medicare-for-All system would benefit everyone who lives in the United States. In the first half of the interview (not transcribed here), Dr. Coates describes how he came to support single payer, how a majority of physicians now support it, and how the Affordable Care Act, despite the gains it has achieved, has failed to resolve the health care crisis in the U.S. and has actually strengthened the hand of the for-profit sectors of health care, whose interests run counter to the nation’s health.

The audio of the entire program is available at http://awfradio.com/todays-show-3-30-16/. The first segment of the interview with Dr. Coates runs from the 17:20-minute mark to 27:30; the second segment, transcribed below, runs from the 30-minute mark to 54:38.

HOST ED ‘FLASH’ FERENC: [We’re speaking with] Dr. Andy Coates, Physicians for a National Health Program. He’s a professor of medicine at Albany Medical College. We’re here to talk about taking Medicare as you know it and expanding it to everybody in America. Now this is not a new system. Other countries have used this system that you’re talking about, that you’re supporting, and it’s working, right?

Dr. Andy CoatesANDREW COATES, M.D.: Indeed. Every other industrialized nation has some version of this system. We could talk about a program where the government owns all of the health care infrastructure and pays the caregivers – nurses, doctors, pharmacists, and so on – directly; that would be like the National Health Service in Scotland now or as it used to be in England. There are some other examples.

And there are systems like the Canadian, Taiwanese, New Zealand systems, where the government pays the bills but where the health care infrastructure remains privately owned and operated, but operated on a not-for-profit basis.

Then there are some hybrid models that came from the 19th century, where there is some version of “private insurance,” but the private insurance is usually – as in Germany or other European nations – where the private insurance doesn’t correspond to UnitedHealthcare, Aetna or the kind of insurers in the United States. It’s an insurance fund that came through religious health organizations or through the labor movement, unions, or from communities. These are heavily regulated and controlled by the government to make sure that everybody’s in, and nobody’s out. So to call those systems private insurance systems is really a misnomer.

So the way of organizing the payment of care is, in my view, the beginning of the way to organize the delivery of care. If you don’t have control over the elements that go into the system, then how can you make the system serve the people in the right way? It seems to me that in a modern democracy, health care being so essential to our lives, that we absolutely would have to have control over how everyone in the country has access to the best possible care. That would be a key responsibility of a truly democratic government.

HOST: So the plan that’s on the table right now, this is a piece of legislation that has been introduced, it’s House Resolution 676, it’s called the Expanded and Improved Medicare for All Act: I know it’s been introduced and reintroduced a number of times. John Conyers of Michigan is supporting it. It’s my understanding that there are about 60, maybe 70 members of the Congress that are behind it. It’s just a fraction – you’d need a whole lot more support. But you’re in favor of that bill, which would take essentially Medicare, the way we have it right now, and expand it to everybody – every man, woman and child in the United States – is that right?

COATES: Yes. The Medicare for All Act, or H.R. 676, is a very, very useful document. Listeners should look it up. It’s short; if you print it out, it’s about 30 pages – easy to read. It’s a blueprint of a system that we know, -- from the great deal of health policy evidence, -- would absolutely work. It would cover all necessary care, there would be no copays or deductibles.

By all necessary care, I’m taking about all prescription drugs – here, I’ll just read it to you: primary care and prevention, dietary and nutritional therapies, inpatient care, outpatient care, emergency care, prescription drugs, durable medical equipment, long-term care, palliative care, mental health services, the whole scope of dental services, including periodontics, oral surgery, and endodontics, but excluding cosmetic dentistry, substance abuse treatments, chiropractic services, not including electrical stimulation, basic vision care and vision correction (other than laser vision correction), hearing services, including coverage of hearing aids, and podiatric care.

So all necessary care. Many of these things are not presently covered by Medicare, so it would expand and improve Medicare.

And this idea would exclude charges due at the point of service by patients. And that’s very important. It’s been very popular for the last decade or so to talk about “skin in the game” – you know, making patients go shopping for care when they’re sick, as the way to drive down prices. This has become a talking point, and this is very much the kind of neoliberal nuttiness that led to the Affordable Care Act, which has the taxpayers subsidizing the private insurance companies. You know, the idea is that if people don’t pay for their care when they’re sick, then they won’t understand how things work. But it turns out that if people are asked to pay charges for necessary care, they will avoid necessary care. There’s a wealth of evidence that will show that, in all kinds of different ways.

So this bill, H.R. 676, will actually work for the patients, and it will take us in the direction that we need to go. On the one hand there’s a big question about how it would be paid for and I’d be glad to talk with you about that. But the other thing that I’d really like to talk to your listeners about is to think about what it would mean for our daily lives if we had a system like this.

HOST: Let’s start with No. 1, how we’re going to pay for it. Because you know the conservatives are going to say, “Oh, we can’t afford it.”

COATES: Well, it’s not just the conservatives. That’s what Hillary Clinton’s advisers have been yelling to the public too. I think that Hillary Clinton’s campaign has come out attacking this idea that we should have a national health program. Look – all of the existing – if you look at the taxpayer money in the United States that is funding health care right now – all of this calculated on a per-person cost basis, a majority of the care is already funded by taxpayers in the U.S. And if you compare the U.S. level of spending with all the other nations on the planet, the United States spends more taxpayer money on health care per person than any other nation spends in total. It’s an astonishing thing. On a per-person basis, we have more taxpayer money spent on health care than any other nation spends in total on health care.

So there’s plenty of money in the U.S. system already, plenty of taxpayer money. If the existing sources in our employer-based system – you know, the employers pay huge amounts into the insurance companies to cover their employees – I’m taking about the big employers that have the big plans, if that money were put into the system, there would be plenty of resources to cover everyone.

But more, there would be enormous savings of hundreds of billions of dollars because there’s an enormous amount of waste in having a myriad, a great big pile of insurance companies fighting over every penny – with the hospitals and doctors’ offices having many people, whole departments to fight for the money. Hospitals might have hundreds of coders and billers trying to fight for the money. There’s this incredible administrative waste, waste that comes down to chasing money in the system.  That would be eliminated, and so there would be hundreds of billions of dollars in savings there.

In addition, in the Conyers bill, H.R. 676, would convert the system to a not-for-profit basis. There’s a spectacular amount of waste in profits and profit-seeking. It might be difficult to make a hefty profit off the care of a sick person, but the effort to do so brings with it a great deal of administration. So when it comes to pharmaceutical prices and medical equipment, all kinds of efficiencies could be found in the system if there were only one payer – in other words, the pharma companies would have to bargain with the people over prices. So the savings in the single-payer system would be spectacular from that point of view, and could liberate all of those resources so we could cover everyone.

There’s also a myth that some of the uninsured and sick patients would come flocking into the system and that would burden the system unduly. It turns out that, for example, when Medicare was built, and that was when the elderly in the United States had no one to pay for their care, it wasn’t the case that patients overwhelmed the system.

Furthermore, the single payer, because now we’d have a way for every patient’s care to be compensated, we could plan to expand our health system – I think of some of the rural counties here in upstate New York that don’t really have hospitals or adequate clinics. Those places could now afford to have them. And so the expansion of care could take place could take place in a planned way.

HOST: If you think back to when Medicare was debated back in the ’60s – Medicare was instituted in 1965 under Lyndon Baines Johnson – the same arguments that you’re hearing today, “Oh, you can’t do that!” In fact, Ronald Reagan, as I recall, was one of the big opponents of Medicare. “It’s socialistic, they do that in communist countries, we can’t do that!” Now, if you ask a senior today what they thought of Medicare, they’d say it’s the best thing since sliced bread. So this would basically take Medicare and expand it to everybody. I tell you, we have a long way to go. We need to educate people on this. Let me ask you one more question before you go. Do you feel, as a doctor, as a medical professional, that eventually this is going to happen – because of the high cost of health care under the Affordable Care Act, that this is the only way to solve the situation of getting access to health care in America? What are your thoughts on that?

COATES: If the goal is to cover absolutely everybody, to make sure that all necessary care is attainable, so we don’t have the undesirable situation where many people are completely left out, lost to medical follow-up, not able to access the clinic … if the goal is to do that, and also to keep the costs from spiraling completely out of control, and to help control costs overall, then, this is the only system that’s going to work.

The other thing I’ve learned though, in my travels around over the last 10 years or so, talking to many different audiences – way beyond some kind of FOX News feature where there’s a phony debate about whether some people “deserve to die” of illnesses that they never asked for – I think virtually everyone believes that if you’re sick, you should be able to get the best possible care. It doesn’t matter if you live in the city or the countryside, if you’re wealthy or poor, in an African American community, Latino – it doesn’t matter.

HOST: Right.

COATES: Because that’s the way it should be. That’s what everyone understands, in some way. I hope what will happen, and I think what will happen, is what we’ll start to understand is how liberating it would be if we didn’t have to get health care through our employer, or through our spouse, or through our parents.

What it would mean to us if we didn’t have to worry about our children being unsafe, meaning without health care – getting out of high school and looking for work – at time of stress and insecurity for them, as they find their way? Imagine how liberating it would be for them not to have to worry about health care.

Imagine what it would mean for the union movement. It’s very hard to organize unions when the thought of a strike means they’ll discontinue your health insurance, and that means that your wife won’t have access, or for a working woman to keep her job because her husband ended up getting multiple sclerosis and she is afraid to leave, the “job lock” phenomenon.

Really, when it comes to health care, there are so many insecurities in our personal lives – for instance with a parent has to transition to nursing home because of a devastating stroke. This should not be a time when the whole family, I mean the expanded family, should have its finances decimated, with brothers and sisters, cousins all drawn into it because of one person’s health care crisis. This is really a terrible situation and undignified and all too common in the United States. 

But if you look at it the other way, how liberating it would be, how proud people would be of this country, if that were not an issue. Proud to know that the system would be there, ready for us, and the system was designed around the patients. I really think that’s completely attainable. I don’t think it’s that radical. I think it’s a very modest reform, if you will. It wouldn’t threaten anything – it would actually enhance life across the board. It would not only work but be a great thing for public pride.

HOST: There you go. Well said. If you want more information on this, here’s the website: pnhp.org, Physicians for a National Health Program. Dr. Coates, we love having you on the show. Let’s keep this conversation going. So maybe one of these days Congress will move forward and do the right thing.

COATES: Also, there are hundreds of unions that have endorsed H.R. 676 and it continues to be a great campaign. Let’s build the word of mouth about it in the union movement. We’re hopeful that the unions can show us the way forward.

HOST: So you keep up the fight, OK?

COATES: Thanks.