INTERVIEW: Adam Gaffney on the kind of single payer we need

As we prepare for the 2018 Lown Conference in April, we want to help you get ready as well. So we’re putting out interviews with some of our keynote speakers and panelists so you learn more about what to expect at the conference, and start getting excited!

This week we have an interview with Dr. Adam Gaffney, Instructor of Medicine at Harvard Medical School, practicing physician at the Cambridge Health Alliance, and member of the Physicians for a National Health Program Board of Directors. Gaffney is the author of To Heal Humankind: The Right to Health in History and blogs at “The Progressive Physician.”

Lown Institute: We talk a lot about the necessity of having the next health system be a single-payer system, but what kind of single-payer system? What would it look like in practice?

Dr. Adam Gaffney: At Physicians for a National Health Program (PNHP), we envision an “improved and expanded Medicare for All.” Universal coverage is necessary, but we could make Medicare even better. As it is now, Medicare has a lot of uncovered benefits and cost sharing, so in an ideal system we would not only expand access to care, but make coverage more comprehensive.

One crucial part of single payer is that it covers everyone equally. Right now we just talk about coverage in binary terms – are people covered or not? But we have a huge problem with underinsurance – people who have insurance but still have high exposure to health care costs from out-of-pocket spending. According to the Commonwealth Fund, 28% of working-age adults with health insurance spent more than 10% of their income on health care in 2016 (the threshold is 5% for low-income adults). We also see this pattern playing out with the growing trend of crowdsourcing medical costs.

And single payer is just the start. We have so many public health issues to address, as well as health care inequalities that won’t be solved with a single payer system alone.

Lown: How would we pay for health care in this system? Fee for service, global budgeting, salaries?

Gaffney: Having a global budget and doctors on salary for large capitated groups and fee-for-service in private practice makes sense to start. In the long run though, I think all physicians would be salaried.

But how you finance the health care system and how you pay doctors are different questions. Some are concerned that covering everyone in the country will put a strain on the health care system, that doctors won’t have enough time to see everyone. But it’s been shown that doctors can prioritize their time for the sickest patients. Also, there will be a lot of savings from getting rid of the excess administrative costs of our current system, which are much higher than in any other developed country

Lown: The moral argument for single payer, the idea of “health care as a right,” has become a major part of the movement for single payer. How long has this concept been a part of the health care conversation?

Gaffney: The idea of “health care as a right” is an extremely new concept, historically. It started taking hold in the middle of the 20th century, as part of FDR’s second bill of human rights and the UN declaration of human rights. However, it wasn’t a widespread idea until the 80s and 90s with the AIDS epidemic. Although we’ve had the right to “life, liberty, and the pursuit of happiness” as part of our nation’s history since the beginning, the “right to life” hasn’t been interpreted as the right to health care. But in India, the “right to life” is in their constitution and has been interpreted by the courts as the right to health care.

The current enthusiasm for single payer, although it probably won’t pass in this term, is encouraging. It shows that we’re moving toward more egalitarian values and starting to demand equality.