1. National healthcare is a public duty.
a. The duty to provide healthcare for all is an agreed national goal.
As a nation and as a community healthcare is a duty that we owe to all our fellow citizens in need. It is a moral, ethical, humanitarian and, yes, even a religious duty.
In this paper I argue that there is strong evidence that healthcare is not only an individual duty but is a public duty. That duty is not a partial one that is owed to some, but not others. It is a universal one. That duty is proven by an analysis of fundamental humanitarian values, by public opinion polls and by our existing laws and programs, and those supported or proposed by both political parties. They all agree that healthcare for all is a goal.
b. Single-payer is the solution, not the “free market.”
There are great policy differences on how and to what extent that duty should be fulfilled. But, experience shows that it cannot be met by the free market, even with government subsidies and other props. A single-payer system is the only practical and effective means of fulfilling our duty. It is validated on both pragmatic and humanitarian grounds. The evidence, the relevant data, demonstrate clearly that a government sponsored health insurance program is the most efficient and the only viable means of fully meeting the ethical and moral duty of providing good healthcare to all Americans
2. The duty is proven by ample evidence—
a. It’s proven by public opinion polls.
Indeed, a large majority of Americans do believe that the government has a duty to provide universal healthcare according to a survey by Pew Research Center on January 13th, 2017. It reported that:
Currently, 60% of Americans say the government should be responsible for ensuring health care coverage for all Americans.
b. Family and community values prove humanitarian duties.
The duty we owe to others is an inborn, genetic human trait. It is most evident in the loyalty we owe our family, our close relatives and loved ones — one that we each understand, believe in and (mostly) respond to. These are duties of care and compassion and sacrifice that we show to our parents, children, siblings and others close to us who are in need of help, especially those who fall ill or are injured and are in need of medical care. The scope of this human — or I say humanitarian — trait usually extends beyond family to friends and neighbors who we offer help to when they need it. The scope of compassion commonly expands further to the local community or community at large — which is expressed in charitable deeds, in donations and work for charities, clubs, churches and community organizations. The works and Universal Health Care as a Public Duty Page 2 efforts of charities are a clear recognition of the humanitarian duty of care. These efforts, though great, sadly fall woefully short of the total need. “One thousand points of light” are a welcome humanitarian contribution but fail when 100 million are needed.
As I have pointed out, recognition of our duty on the individual, family and community level is not debatable. It includes the duty of helping others close to us who are in need of healthcare. At this level — family and community — it is an undeniable human value and humanitarian duty.
c. Family and local community values of empathy naturally widen to extend to the national community.
So, humanitarian values of empathy extend to family, friends, neighbors and then beyond that to the local community. While the degree of empathy diminishes as its scope expands, there is no philosophical or ethical reason why those duties should not also extend to the national community? Should we not fulfill that duty if it is feasible, if it is in reach? An individual duty, a family duty, a community duty, should be, must be, also a public duty.
It is very clear, as I explain below, that, to some extent at least, the duty to fulfill the needs for healthcare nationally is recognized in our public programs — as a moral obligation, a humanitarian responsibility — which this nation owes to all its citizens. On this basic premise we all, in principle at least, really do overwhelmingly agree. There is consensus that we have a responsibility through our government institutions, programs and our laws to guarantee a basic level of healthcare to all regardless of ability to pay.
d. The duty is evidenced in the 1986 EMTALA law
This principle, this recognition of a public humanitarian duty, is manifested and has become enshrined in our legal system for decades. In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. That means that no hospital emergency room receiving federal funding can turn any patient away, whether the patient can afford to pay for treatment or not. So, when a patient arrives at the ER with a heart attack or injuries from an auto accident the patient cannot be denied treatment based on the lack of insurance coverage or other inability to pay. Since its enactment there has been no political movement or clamor for repeal of the EMTALA. What this law effectively does is accept the public duty of healthcare by creating a sort of de facto universal healthcare system; that is, since no one presenting at the ER, even those with non-emergency injuries or illnesses, can be turned away, we really end up having a crude version of “free” medical care for all. The EMTALA stands as a legislative recognition of the duty to provide emergency healthcare regardless of the ability to pay and thereby creates a healthcare system that provides last-resort healthcare for all comers.
e. But emergency treatment, though creating de-facto univeral healthcare, is costly, inefficient and is no substitute for a true national system..
Relying on ER care puts a great financial burden on hospitals because they have to provide uncompensated care and that burden is passed on to all the rest of us Universal Health Care as a Public Duty Page 3 through higher hospital, medical and insurance costs. Emergency room care is expensive and inefficient. A non-emergency visit takes on average five hours. Emergency rooms are not designed or equipped to provide preventive care, long-term monitoring or non-emergency surgery. Many who must resort to emergency care as their only option do so only after a severe health crisis, having postponed or ignored earlier symptoms. The website thebalance.com says that:
Before Obamacare 46% of emergency room patients went there because they had no other place to go. They used the emergency room as their primary care physician. This is a big reason for the rising cost of medical care.
So, yes, the duty of universal healthcare is clumsily fulfilled by the UMTALA (no one is left to die on the emergency room door) but it is a terribly inefficient and inadequate system with a very high cost to all of us who have to pick up the tab for uncompensated hospital care that the hospitals and private healthcare providers pass on to us and our insurers who have to pay for the rising costs resulting from those unpaid hospital bills.
f. States also recognize the humanitarian duty of healthcare by requiring charity care.
Many states recognize a similar duty. They help doctors and other healthcare providers in terms of tax credits and other incentives to those who provide charity care. Washington and New Jersey have outright requirements to provide charity care, another illustration of the recognition of the public duty to help meet this need. Our tax dollars go to recognize and support this charitable duty. It is a safe assumption that most hospitals would not deny treatment to emergency patients even without this law, because it would seem unjust and inhumane to let a patient die at the emergency room door because he or she had no insurance.
g. Doctrines of all religions promote humanitarian duties of charity.
Health care is also a religious duty. James Martin, a Jesuit priest, consultor to the Vatican’s Secretariat of Communication, and author of “Jesus: A Pilgrimage” wrote this for the Los Angeles Times: That Jesus “asked his disciples to care for the poor, the sick, the forgotten, the stranger.” Believers have a duty to care for those who are impoverished as seen in Matthew 25:34-40. Jesus consistently criticized wealth and inequality. https://www.openbible.info/topics/sharing_wealth. OpenBible.info contains 100 bible verses urging or suggesting compassion, care and sharing of wealth. All religious creeds — as well widespread cultural mores and secular ethics – support, teach and urge compassion for the sick and poor.
So, do we not, as a national community, owe the same duty of compassion to all those in our community who are in need of healthcare and can’t afford it? If it is a private moral, ethical and humanitarian duty, a family duty, a religious duty, a community duty, why is it not a national public duty?
3. Can the free market alone meet the need?
Having acknowledged the public duty and having seen it popularly recognized and expressed in law, how can that duty be fulfilled in a fair, responsible, efficient and comprehensive way? Since we live and function financially in a capitalist/free market economic system, many say that competition and the free market is the solution.
a. Laws of supply & demand work well for some things.
But the free market cannot fulfill t hat duty. Clearly it cannot meet every essential human need. Based on the laws of supply and demand, the system is generally fair and efficient for the production, distribution and acquisition of most goods and services. It has certain natural, built-in advantages that work well for some things, but do not work well — that is, efficiently, fairly and comprehensively — in meeting certain fundamental and essential public needs, such as police protection, fire protection, roads, bridges, airports, schools and the like. These are historically common roles of the government and they often also include many utilities such as water and electricity. These are almost universally accepted as traditional roles of the government — mainly because the private sector cannot furnish them effectively, efficiently, comprehensively or at an affordable cost. They are duties to provide for human needs that cannot be very well met by the private sector or by pure market solutions.
b. But markets do not not always work for people.
Thus, to whatever extent it works for some things-— refrigerators, TVs, groceries (59¢/lb. for bananas, who can beat that?) clothing, etc., — the free market cannot always efficiently, fairly and comprehensively meet every worthwhile basic human need. Some basic human needs are just not amenable to pure market solutions. People are not commodities; their needs are vital personal needs that cannot be sold to the highest bidder. Human needs for health and life are high moral values owed by all of us to those who cannot afford to buy them at the market price.
c. When markets fail, the government steps in.
Whenever the market largely fails the government must – and usually does – step in to fill the gap. It does this with such government programs as Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) and government costsharing payments to medical insurers. Social Security and unemployment insurance also fill a gap that the market is unable to cover. All these programs illustrate how the government is called on to step in to fill a gap caused by market failure. Neither political party nor any viable political figure or interest group is calling for repeal of these programs. Even the most conservative politicians steadfastly defend them. These programs exist for the sole reason that the market cannot fulfil the need. If the free market could fulfill the needs that these programs are aimed at it would do so and we would not need Social Security, Medicare, Medicaid or any of these established, cherished programs.
The cost of filling these gaps ultimately falls on taxpayers. It is a system of spreading the cost, sharing the burden of acknowledged human needs and fulfilling a duty to do so. And, incidentally, many who have contributed eventually benefit.
The government’s healthcare duty and the inadequacy of the free market to meet that duty is plainly demonstrated in the existence of Medicare, Medicaid and CHIP programs. The fact that no one is advocating for repeal or abandonment of these programs is all the evidence you need to prove: (1) the duty and (2) the inadequacy of the free market.
d. The many proposals In the healthcare debate exemplify the government’s effort to meet the country’s healthcare needs when the market fails.
The need and indeed the duty of the government to provide some greater or better form of healthcare is also recognized in the congressional debate over replacing the Affordable Care Act (ACA, a/k/a “Obamacare”). An important point to note is the Republican strategy in opposition to the ACA. Their plans to replace that law are an implicit recognition by the Republicans themselves that the government has a healthcare duty. The key factor to notice here is that the Republican plans all included replacement. They wanted to do healthcare but just do it in a different way. If Republicans did not recognize and agree that they had a public duty to provide some form of healthcare reform why wouldn’t they just have called for repeal of the ACA instead of seeking replacement? The ACA and the commitment to fix or replace it is a recognition by both parties that the government has a healthcare role, a duty that is yet to be fulfilled. Republican replacement plans are an implicit admission that they did not intend to go back to the previous totally unregulated system; that they believed they had a duty to provide some level of government help that wasn’t there before the ACA.
The main problem with the current or recent plans, both Affordable Care Act and the Better Care Reconciliation Act (the last Senate version), is that each one fails to meet the need because these are largely market-based plans that are doomed to fail based on market principles. The market cannot meet this need fairly and comprehensively.
e. Coverage of pre-existing conditions is a challenge because economic principles require a large pool of participants.
For one thing, the ACA and the original Senate plan both prohibit insurers from denying coverage because of pre-existing health conditions. The ACA made eligibility at any time for anyone unconditional. It was a solemn and repeated pledge of Trump during his campaign and of most Republican politicians as well, that their replacement would not allow insurers to deny, charge more for or limit coverage based on preexisting health conditions.
The problem with that is a fundamental economic one: that without sufficient market incentive (such as the individual mandate — that the Republicans hate and vow to terminate) hardly anyone who is young and healthy is likely to feel great need or will want to pay the cost of obtaining insurance when they are still healthy and don’t feel the need or the risk. But they would be clearly in desperate need to purchase insurance once they became sick or got injured. It is the old specter of signing up for health insurance on the way to the hospital. That “freeloader” phenomenon — mostly young healthy people who don’t think they need health insurance and who forego buying it because they can get it after they have symptoms — results in an insufficient pool of participants paying premiums into the system to sustain health insurance at a reasonable cost. The remaining pool of participants then tend to be older or have serious health problems.
The same market problem dogged Senator Cruz’s plan to sell cheap, stripped down plans as an option to full regulated coverage. These so-called junk policies will divide the market into three groups:
- Young people in good health whose lower premiums and lower numbers of participants in the pool are insufficient to generate enough premium income to cover the costs of everyone in the pool, especially the older and less healthy
- Other people, the “freeloader” group mentioned above, who gamble on skipping signing up for even the stripped down policies in the belief they are unlikely to need coverage (or knowing that since they can’t be declined for pre-existing conditions they can get insurance once a serious problem or diagnosis arises, thus generating no revenue until they get really sick) and sign up, thus burdening the insurance system with the high cost of their serious medical care that they didn’t contribute to pay for until the need arose.
- Older less healthy participants with greater medical needs who would then be faced with the dilemma of obtaining a cheap policy they could afford (but, as indicated above would not generate sufficient premium revenue to cover their care) or somehow get better coverage at a much higher unaffordable cost to cover the kind of health problems they would be likely to face.
Any plan that attempts to cover pre-existing conditions and that does not at the same time compel or effectively induce everyone to have insurance is economically unsustainable.
f. Shifting the burden to the states will not work, especially if they are given the right to waive coverage requirements.
The Republicans’ final attempt to “replace” Obamacare, the Graham – Cassidy plan, simply punted the ball to the states — disastrously it would have allowed the states to waive the requirement of coverage for pre-existing conditions with vague conditions under which States could waive that requirement. But if the law was intended to preserve that protection, why include a waiver at all? Why not just continue to have a clear, unequivocal and unconditional requirement for covering people with pre-existing conditions? The duplicity of this measure and those who argued for it is distressing.
g. There are no market solutions to the pre-existing conditions dilemma.
So, none of these plans will work in the insurance marketplace. Worse yet, the House version and later Senate plans, proposed to make eligibility conditional on maintaining continuous coverage or require waiting periods up to 6 months, a clear violation of the Trump and Republican solemn pledge to (unconditionally) guarantee insurability regardless of pre-existing health conditions — and is an insufficient inducement to attract a sustainable market base as well.
4. The current healthcare system consists of a collection of incompatible private and public programs.
All plans also awkwardly attempted to lump together into a single nationwide system a number of disparate healthcare markets. The system is inevitably an inefficient, fragmented and ultimately inadequate hybrid system. It tries to meld together those differing, really incompatible, markets. Here is the breakdown and how legislation has attempted to address the varying issues of each:
a. Employer-provided health insurance is a widespread market based system that has severe coverage shortcomings.
This is a market-based system that developed and became dominant during and after WWII. It is a market system with some state and minimal federal regulation. Most significant is the Employee Retirement Income Security Act of 1974 (ERISA), which is primarily concerned with reporting, disclosure, and administration of employee health plans. It does not regulate coverages. Robert Pair of the New York Times reports that more than 155 million American workers and their families are covered by employerbased medical plans. This statistic is confirmed by the Kaiser Family Foundation (KFF) which also calulates that this amounts to 49% of the U.S. population as of 2017.
This market has worked well for decades and remains popular but is declining mainly because of increasing healthcare costs and weakened bargaining positions of unions and a larger labor supply of non-union workers. Employer covered health plans are covering less, costing more and are offered by fewer employers. It now covers only about 40% of the work force. To make matters worse, the Republican replacement plans call for eliminating the ACA’s provision requiring large employers provide health insurance to their employees. So, this market will continue to shrink. Only half of small employers (with less than 50 employees) provide healthcare insurance to their employees.
A further drawback of employer-provided healthcare is that many large employers (Nordstrom for example) provide insurance with severely limited coverage such as a 40% copay. So, an insured employee at Nordstrom, earning $16 per hour, who has a 3-day hospital stay may wind up owing $8,000 in uninsured medical expense, which could ruin the employee’s credit or lead to bankruptcy. These limitations essentially put those with minimal employer-provided health insurance — called “underinsured” — essentially in the category of the uninsured in the individual marked (discussed next). In summary, fewer people are being insured under employer plans, their deductibles and co-pays are higher, and their coverage and benefits are lower.
b. Individual market coverage is expensive, limited in benefits and unaffordable for most Americans.
According to Mark Farrah Associates, a healthcare analysis firm, as of 2017 there were 17.6 million people in the individual market (KFF says 20.5 million, about 7% of the population), 5.4 million of whom bought policies outside the health exchanges, where premium help is not available. It is a market-based system that is at the heart of the dilemma about how to regulate it and yet achieve affordable cost. Until regulated by the ACA this market was understandably riddled with exclusions, limits and gaps in coverage.
When insurers can’t write their own coverage limitations they of course charge more. These ACA rules that:
- prohibited or limited deductions, copays, caps and the like
- required insurability in spite of pre-existing conditions without higher cost and
- required a package of basic medical services
— of course, resulted in higher premiums, as should have been expected as a natural consequence of market forces (unless, in the improbable event that a large pool of healthy people would sign up). It was inevitable and not a sign that the system was broken or of a flaw or defect in Obamacare. An unavoidable free market principle is that as increased benefits are mandated premiums rise. On the other hand, as benefits are reduced premiums can be reduced. In either event, of course, the shortfall could be made up in volume with increased participation — that is, a larger pool of participants. But, as already pointed out, without an incentive for mass participation that is not going to happen. That’s how the free market works. And the Republicans’ plan to reduce benefits would have, as the Congressional Budget Office (CBO) predicted, ultimately reduced premiums. A market economics truism is that if you get less you pay less; if you get more you pay more. The only way to reduce the impact of that rule is to increase the size of the market. Everyone knows that. In view of established market principles, it is highly unlikely that healthcare consumers will see any total out-of-pocket savings. Premium savings will be offset by higher deductibles, copays and other limitations which will require consumers to pay for procedures no longer covered. An inescapable rule of the free market is, as is often said, “You get what you pay for.” Inevitably, if premiums are reduced coverages will be reduced or out-of-pocket costs will increase in the absence of a greater volume of participants. As a result, even under Obamacare, the cost of an average medical insurance plan for a typical middle-class family of four costs about (an almost unaffordable) $1,700 per month. Typical open market plans now feature a $7000 per year deductible. These are costs that few in the individual market can easily afford. It is an illustration that the individual market cannot provide reasonable healthcare at an affordable price.
Subsidies and mandates attempt to fill the individual market gap.
ACA attempts to address this problem in two ways: (1) by including subsidies to insurers and consumers along with tax credits to bridge the gaps that the market cannot otherwise meet and (2) imposing a penalty on those who do not sign up for insurance, the dreaded “individual mandate.” Republican plans would maintain some subsidies, but the fate of these subsidies is much in doubt. Still the inclusion or consideration of any such government help by Republicans is an unmistakable recognition by them that the market is inadequate to meet the need.
Subsidies to insurers are a major component of the ACA plan. They are called cost-sharing reductions (CSRs) and include the risk adjustment program. They are necessary to help insurers lower the amount you have to pay for deductibles, copayments, and coinsurance in the health insurance marketplace. The risk adjustment program is designed to level out differences in revenue and costs among different insurers. These programs are essential to the survival of the Obamacare plan. Subsidies, as supporters say, are necessary to “stabilize the market.” They have been attacked by Republicans as bailouts to prop up the insurance companies and president Trump has carried out a threat to end them — which will totally wreck this market. While it may be argued that Obamacare is broken, one thing is clear and that is that President Trump is determined to wreck it. A bipartisan plan was underway to restore the CSRs. The real point to note here, though, is that if insurance companies have to be propped up in order to provide adequate affordable care and still make a profit, that is clear, irrefutable proof that the private insurance market cannot meet the public’s needs. Under the laws of supply and demand private insurance cannot provide adequate, affordable healthcare for all without substantial government support — a cost currently estimated to be 20 billion dollars over the next two years.
Republican tax measures threaten to kill the individual market.
The Republican tax code revisions, adopted at the end of 2017, included a measure that would eliminate the individual mandate beginning in 2019. 6.7 million Americans who flouted the mandate requirement paid a total of about $3 billion in tax penalties in 2015. Ending the penalties will cause an additional 4 million people to be uninsured in 2019 and 13 million within a decade, according to the nonpartisan Congressional Budget Office (CBO).
President Trump’s executive orders ending the individual mandate, cost reducing subsidies and the risk adjustment program were clearly intended to — and are likely to — kill the fundamental functioning of the Affordable Care Act and put us back in the dark ages of unregulated, free market, insurance dominated healthcare, thus achieving a goal that the Republicans could not achieve in Congress.
c. Medicare is America’s popular and successful single-payer system for older citizens.
Medicare is a governmental system financed by payroll deductions. It is similar to single-payer systems in other countries. It basically covers people over age 65 who have been employed and paid into the system and their spouses and in some cases their children. KFF calculates that 42.8 million people (14% of the population) are enrolled (some others estimate 60 million, the difference may be because of a differing time frame), including some 9 million disabled people. Its funding is trending toward inadequate as the retired-beneficiary population lives longer and grows in relation to the working-contributor population. While the Medicare trust fund is predicted to go broke in a few years, fixes have eluded Congress.
Medicare proves the failure of the free-market.
The very existence of Medicare and the lack of any political plans for repeal or to change it is a widespread acknowledgement of the public duty to care for the health needs of the older and retired population — as well as living proof that the marketplace is inadequate to meet those needs.
d. Medicaid provides government paid healthcare for the poor.
There are over 65 million Medicaid recipients (21% of the population) according to KFF. Medicaid is a total government financed system, intended to provide medical care for the poor. Syndicated columnist Paul Waldman explains that the idea of Medicaid “…was that no one should go without health insurance because they can’t afford it, so the [ACA] program was expanded to cover millions of Americans who, though extremely poor, weren’t eligible under the often-restrictive rules set by states.” Neither political party is seeking to end Medicaid, so again there is here an implicit acknowledgement of the public duty and the failure of the market to meet it.
But Republicans seem determined to gut the program. So, the debate simply concerns how much money the federal government will contribute, who will be entitled to receive benefits and who will be left out. Republicans want to slash Medicaid by $830 billion, which they justify with the fantasy that cuts will reduce waste and induce undeserving recipients to get jobs — this without offering any government jobs program except for tax cuts for the wealthy (that are supposed to trickle down to create jobs for all the unemployed) and this without recognizing that many in this group are in fact the poor who already have jobs. It is estimated that some 20 million Medicaid recipients will lose their coverage under Republican proposals and the total number of uninsured — those who won’t qualify for Medicaid — will rise to 70 million over the next decade, flooding emergency rooms everywhere and raising risks to public health. That seems real mean.
e. Military & VA Medical Care.
Finally, there is one more totally government managed and financed system: That is the medical care that is provided to active service members and to retired military by the Veterans Administration. KFF includes this in a group it calls “Other Public” amounting to 4,588,200 beneficiaries (1%).
Complaints have been raised about long waiting times for appointments, but this has happened mainly because of under-funding and failure of the government to hire enough doctors and staff. The gap has been partly closed by allowing vets to seek treatment from nearby private clinics. Despite shortcomings, no one is advocating turning the whole system over to private insurers. These are total government financed and managed (basically socialist medicine) programs that are completely acceptable to the free market advocates.
f. Many uninsured remain.
This leaves then, according to KFF, over 27.7 million uninsured Americans (9% of the population). The millions of uninsured — and underinsured — people who receive uncompensated healthcare, are a heavy burden on the medical and healthcare insurance system and a burden that is passed on to all the rest of us who have to pick up the tab. The result is market distortion, inefficiencies, waste and cost shifting (from doctors and hospitals to insurers and inevitably to us, the insured with ever increasing and unaffordable premiums and increasing tax burdens — a terrible way to run a healthcare system — to say nothing of the fact that we are falling far short of the goal of universal coverage.
5. Free-market health insurance, even with government support, costs too much, the coverages are inadequate, and it leaves millions uninsured or underinsured.
A significant problem with the functioning of the free market, especially in the individual market, is that many insured patients who sustain large or even relatively modest expenses for illnesses or injuries will be unable to pay their medical bills even though they have insurance because their insurance just does not cover enough of the cost, leaving them faced with unpayable medical bills. Also, there are considerable numbers of poor, uninsured patients who are unable to pay for even less severe emergency care. Medical expenses are a major cause of bankruptcy filings. It is estimated that 62% of bankruptcies were related to medical expenses. These debts will be discharged in bankruptcy and/or written off as uncollectible and the loss to hospitals and doctors is passed on to everyone else in the market in increased medical bills or insurance premiums, that is, to the rest of the paying public. Bankruptcy is the safety valve for breakdowns in the market system and we, the rest of us, are left holding the bag — a terrible waste.
Despite all of all these programs and systems — the private insurance market, Medicare, Medicaid, employer-based systems under Obamacare and all the subsidies, props and supports — as of 2017, almost 28 million people remain uninsured according to thebalance.com. The National Coalition on Health Care puts the number of uninsured at 45 million. Which number is correct doesn’t matter; either way it’s a big number and it should be zero. These figures do not include other millions who are significantly underinsured. These numbers will get much worse now that Congress has eliminated the ACA’s individual mandate in the new tax law. Republicans are not advocating for repeal of Medicare, Medicaid or CHIP. They just want to cut them back and shift the cost to the states. They’re okay with inadequate financing that meets part of the need but not all of it. Why not meet all the need if we can do that?
a. American healthcare is a complicated patchwork of incompatible public and private systems.
All plans and proposals — the ACA itself and proposals to replace it, such as, the House American Health care Act and the Senate Better Care Reconciliation Act — are a hodge-podge patchwork of differing and incompatible remedies for differing groups. No wonder it is complicated, costly, unpredictable and unreliable. Obama’s , being partly a market-based system, is inevitably unfixable, As explained earlier, if preexisting conditions are covered but with no individual mandate it is unsustainable. It was never projected to cover everyone and, of course, doesn’t. It was a gift to the insurance industry. Republican plans won’t fix it either; they will make it worse. There are no wonderful magical market solutions to this deep healthcare dilemma. It’s time to quit propping up insurance companies and to give up on the impossible dream of free market solutions and avoid turning it into a costly nightmare.
Why did Congress tinker around trying to meet an undeniable need and to fulfill an acknowledged public duty with such wasteful, inefficient and halfway measures? These laws and proposed fixes are a complex hodge-podge patchwork of disjointed, unworkable and inadequate market based and government run systems. If there is a significant unmet need and a public duty to meet it, why are so many people left out and so many overcharged?
b. Insurance companies control individual healthcare decisions and are prone to red tape and high administrative costs.
In the final analysis, should we really be relying on private insurers — whose main objective is to make a profit — to be in charge of providing this vital human need, this life and death service? Private insurers are famously inefficient because their profits are based on providing healthcare benefits at the least cost to them and charging for it the most that the market will bear. The worst kind of waste, abuse and red tape is insurance company waste, abuse and red tape.
Objectors contend that single-payer would put the government in charge of making individual healthcare decisions and would interfere with the doctor-patient relationship. But that is exactly what medical insurers are doing right now. Insurers, for example, often decide what treatment is “medically necessary” and prohibit insured patients from seeing a specialist without a referral from a primary care physician. They can limit the number of visits to a therapist that they will pay for. They won’t pay for treatment by an “out of network” practitioner or that is deemed “experimental.” Nothing could be worse than the insurance company nit-picking that goes on all the time.
Perhaps such curbs are necessary, but they would be no worse and probably far less if administered by the government because when everyone has the same coverage there is less room for uncertainty or argument and fewer healthcare decisions need to be made. And we are hearing more and more “disaster” stories of insurers pulling out of the market in certain states and regions where they can’t make a profit.
So, we have an entire free market business dedicated and structured to deny or limit coverage wherever possible, with the government trying to regulate it or patch holes in it with various regulations and subsidies paid to insurance companies.
Attempting to prop up an unsustainable market is costly, inefficient and insufficient.
c. Americans pay more and get less than patients in other countries with government managed healthcare.
Nowhere in the world of developed nations does the population as a whole receive less healthcare at a greater cost than in the United States. The US spends 18% of its GDP on healthcare, which amounts to $9892 per capita, compared with Canada, for example, that spends 10.6% of its GDP or $4,752 per capita on healthcare.
Our healthcare cost is on average twice as much or more than spent by any other nation with a government healthcare system.
The ACA, for all of its improvements and expansion of coverage didn’t solve this problem nor did it achieve coverage for all Americans.
6. Single-payer provides a comprehensive, cost-effective system with better healthcare outcomes.
Indeed, the only way for America to fully live up to its moral obligation to provide healthcare for all is to abandon major reliance on insufficient market solutions — with their accompanying government props and regulations — altogether — and adopt a comprehensive single-payer system (also called or likened to “Medicare for all”).
7. Single-payer opponents raise multiple specious objections.
Among these objections are the following:
a. First, they erroneously say it is too expensive, that we can’t afford it.
Opponents contend that single-payer would require burdensome tax increases that we can’t afford. But if France can afford it, Germany can afford it, Sweden can afford it, why can’t we, the wealthiest nation on earth, afford it? Of the 33 developed countries in the world 32 of them have universal healthcare and they are all have democratic forms of government. The objectors then reply that “We’re not France … or Sweden, etc.” Maybe so in some manner, but not because of our governmental or legal system. The real difference is that the American healthcare economy is dominated by the politically powerful and deeply entrenched insurance and pharmaceutical industries, backed by their multi-million-dollar political contributions and army of lobbyists. That is a formidable obstacle as evidenced by their success in shooting down Bill and Hillary Clinton’s healthcare initiative. And Pres. Obama had to work out a plan that was quite beneficial to the insurance industry in order to get Obamacare through Congress.
If cost, in terms of taxes or insurance premiums to the government are the issue, the real question to ask is: What would be the total cost to the average American taxpayer for healthcare? The answer is that it would cost most taxpayers less than they are paying now for the combined total of taxes and private medical insurance. The principal difference would be that instead of paying premiums to an insurance company, taxpayers would be paying medical insurance premiums to the government and the total cost would be less. So, increases in medical insurance premiums to the government (call them taxes if you want) would be more than offset by the elimination of private insurance premiums. Even under cost projections of singlepayer critic Charles Blahous, at the Koch-funded Mercatus Center at George Mason University, Medicare for All would save the average American about $6,000 over a decade.
Employers, too, who have been at a competitive disadvantage in the international marketplace would be relieved of the cost of contributing to health insurance for their employees (at least if the employer is paying all of the health insurance premium), thus saving more than 12% in labor costs and leveling the playing field with foreign competitors (who do not have to pay for employee healthcare costs). This could allow American companies to include the savings in their employees’ paychecks.
The plain truth is that, according to well documented statistics and the experience of other nations, in the long run the total medical cost to taxpayers will be substantially reduced, on average compared to the cost of the current private insurance market system. Government run systems cost less to run because they eliminate complicated insurance administrative and advertising expense as well as profit. In 2003 the New England Journal of Medicine reported that 31% of all health spending in the US was for administration, versus only about 16% in countries like Canada. One third of the insurance companies’ operating cost is for administration, advertising and profit instead of patient care. Currently hospitals and medical clinics in the US regularly employ more billing personnel than doctors. Some people claim that administrative costs run as high as 65% of health costs in this country, contrasted with Medicare/ Medicaid administrative costs at approximately 3%. The website formosapost.com calculates that over 95% of US households would save money under single-payer. Whatever the arguments might be about the exact accuracy of these statistics, it is clearly a huge difference. Hospitals, medical insurers and drug companies spend enormous sums on advertising. Single-payer would eliminate or greatly reduce such unnecessary expense. Wasteful medical bankruptcies would be eliminated as well. By eliminating all of those costs taxpayers will, instead, be paying a medical insurance premium to a public managed insurance agency that will amount to much less totally than what they are paying now in private insurance premiums. So, under single-payer, the total healthcare cost to Americans, even with increased taxes (in the form of medical insurance premiums) to a government managed healthcare system, will be less not more.
Under single-payer the government is the insurance company. The cost of a government run system would be paid for by an insurance premium payable by every taxpayer calculated in the aggregate amount necessary to pay for the cost of medical care for the entire population, including everything from minimal to the most severe.
There are those, I suppose, who have good health and don’t worry that they would ever need costly medical treatment, but who object to paying a tax to cover the very high cost of medical care for those with severe illnesses. But this is an insurance program and like all insurance it is a matter of spreading the risk. That is the essence of insurance, spreading the risk. The many lucky pay for the few unlucky. So, no one who has fire insurance on their home, for example, has any room to complain that they have to pay a high premium to cover someone else’s losses just because their house has never burned down.
b. Government healthcare can be paid for in the usual mannert: by premiums paid to the government and by rollback of tax cuts.
The answer to the single-payer naysayers’ concerns over cost is that national healthcare will be paid for by a combination of insurance premiums paid to the government healthcare agency from:
(a) individual taxpayers (who don’t have employer provided insurance), the premium amount would be graduated based on net income — those on Medicaid would pay nothing
(b) by payroll deductions of those with employer systems similar to the Medicare tax currently paid;
(c) by increasing the employer portion of Medicare tax on all large employers, most of whom were maintaining and paying for employee healthcare before enactment of the law.
(d) and a rollback of some of the recent Republican tax cuts to the wealthy and to corporations.
From a strategic point of view as well as an accurate functional characterization, payments to the government healthcare system should be seen as and called “insurance premiums,” which they are, not taxes.
(a) individual taxpayers (who don’t have employer provided insurance), the premium amount perhaps graduated based on net income, (b) by payroll deductions of those with employer systems (3) and a rollback of some of the recent Republican tax cuts to the wealthy and to corporations. From a strategic point of view as well as an accurate functional characterization, payments to the government healthcare system should be seen as and called “insurance premiums,” which they are, not taxes.
c. Opponents falsely claim that patients will not have choices and will endure long wait times.
They contend that patients will be deprived of choices and will have to endure long waits for care as reputedly happens in Canada. But remember this too: That all nations of Western Europe, Canada and other developed countries who have adopted single-payer are democracies. They have adopted and continue to maintain these systems through elections and other democratic processes. People can vote for what they want and against what they don’t want. And in spite of the tax burden or whatever grumblings they have about treatment delays and other imperfections in their health systems, voters in those countries are not clamoring for repeal of their healthcare systems and no viable or sane politicians are advocating for an American-style medical insurance system.
While it is statistically true that wait times of 4 weeks or more for the average medical appointment is rather small in the US compared to countries with government run healthcare systems (about 4.9% compared to 11.9% in Germany to 56.3% in Canada) (per thebalance.com). Canada seems to be at the extreme end of the wait time spectrum but, as reported by Global News in the article of February 16, 2017,“Canadians Wait Longer,” that, in spite of long wait times, still 74% of Canadians rated their care very good or excellent. I highly recommend the article “Five Myths About Canadian Health care” by Aaron E. Carol, MD, MS, dated April 16, 2012 published in AARP.ORG for a thorough discussion and explanation of the wait time issue, especially as it relates to Canada. In America according to my own experience delays of up to a month or two for appointments with specialists are not uncommon and my Canadian acquaintances seem to be okay with the wait time issue.
I contend that delays are not necessarily inherent in government run health systems. Wait time is not a relevant factor in rating the merits of different healthcare systems because all delays occur simply because there are more patients needing care than there are doctors available to treat them. It’s a simple matter of supply and demand. In an unregulated free market system delays occur and are tolerated on the supposition that the doctor is just too busy. In a government run system similar delays are not so easily tolerated and are blamed on the government. But the relevant consideration is that delays in government run healthcare systems, to whatever extent they occur, are simply the result of deliberate cost-control policy decisions made by policymakers in those countries. Policy decisions are made by balancing cost and efficiency against availability of prompt treatment. The objective of the policy is to keep doctors and hospitals busy so as to maximize efficiency and keep costs at a minimum. If they wanted more prompt treatment (or more choices too) they could choose to raise taxes to train and hire more doctors. It’s a policy choice and not an inherent feature of single-payer care. Basically, voters in these countries are satisfied with their government provided healthcare system overall and are in no mood to abandon it for an American style healthcare system and, in any event, are in no mood to pay more to shorten wait time.
d. “It’s “socialism!”—the bogus socialist menace.
The critics of single-payer always raise the bugaboo of “socialism.” They object that single-payer is “socialism!” And that it would amount to a government “takeover” of our healthcare system. But those contentions are just labels, empty, timeworn slogans. They say it is “extreme” and “radical.” But those claims are just opinions; they are not facts. It is simply rhetorical trick to scare and confuse people and to divert attention from the proven merits of the program and from the evidence — by giving it a politically pejorative, but really meaningless label. Anyway, a takeover has actually been accomplished already by the insurance industry. Single-payer will rescue our healthcare from their oppressive grip.
Incidentally, by the critics’ definition of socialism, Medicare, Medicaid, CHIP and VA are also socialism, but apparently these are now acceptable kinds of socialism to them. And how “extreme,” how “radical” is it if at least 32 functioning democracies around the world have successfully adopted and maintained similar government run systems for a long time without significant political opposition or objection from voters.
Critics often charge that government healthcare is inconsistent with a free market economy. Not so, according to some open-minded Libertarians from the Niskanen Center, who have discovered, based on their research, that “The nations that have the freest markets also generally have the most generous welfare states. The two are not in opposition. In the real world they go together.” See David Brooks, syndicated columnist, “A manifesto for a new centrism,” Seattle Times 12/23/18.
What is also obvious from this is that what the opponents of single-payer really fear most is that once single-payer is in place voters will like it, as they do in every democratic country that has adopted government healthcare; it will be so popular it will become as untouchable as Social Security is now. The opposition is dedicated to scaring and fooling the American public. It is a life-or-death issue for them, the very existence of the mighty medical insurance industry that is at stake. They are in mortal fear of their gigantic profits disappearing in a wave of public awakening. Why would we be on the side of the insurance companies in which we have no vote.
e. Claims that private healthcare results in higher quality care and stimulates research and innovation are unsupportable.
Many critics falsely claim that America has the highest quality of healthcare anywhere in the world and for that reason we should not abandon our current private, insurance-based/market system. In some areas that is true. But that quality is not available to everyone or at least available at an affordable cost to all. It is only available to those who can afford it or available at an unreasonable total cost to the nation as a whole. Overall, according to worldwide healthcare statistics, the US has a rather modest to poor record in terms of healthcare outcomes compared to other developed countries — ranking 28th in the world according to the United Nations. The third leading cause of death in the US is medical error. We fall far short in life expectancy of countries like Japan, which holds the world’s record. According to the Peterson-Keiser Health System Tracker, the US lags behind the following countries in death rates amenable to healthcare: (listed in order, starting with the best) France, Australia, Japan, Sweden, Netherlands, Austria, Germany, and UK. Similarly, the US is ranked behind the following countries in the category known as disease burden, which is years lost to disability or premature death: (leading the list again) Japan, Switzerland,’ France, Australia, Netherlands, Austria, Canada, UK, Germany, and Belgium. All of these countries who beat out the US in healthcare outcomes have national government provided or managed healthcare systems. And in categories such as infant mortality, America is no better than some third world countries. With singlepayer everyone would have equal access to medical care and quality would consequently improve.
Does a free market healthcare system incentivize research, innovation and technological medical advancement more than government managed systems? That is a connection, if there is one, that is unexplainable. The quality of healthcare is basically a function of medical education and is in the hands of research institutions and medical colleges where research is done and medical technologies developed and where doctors are trained. None of this would change for the worse under a government managed system. How doctors and hospitals are compensated for care of their patients, whether payment is from the government or from insurance companies or individual patients, has no intrinsic connection with or influence on technology or innovation or quality of healthcare that is provided. As a matter of fact, most medical research is financed by government and foundation grants going to research institutions, colleges and universities and to drug manufacturers. And much of it is funded in the US by grants from agencies such as the NIH, CDC and CMS. US regulations also help maintain high standards of healthcare and quality of drugs and medications.
f. Finally, critics charge that free healthcare will result in overuse.
A final bogus objection is that government healthcare will encourage overuse and will lead to unnecessary treatment. I am having a hard time visualizing a whole lot Universal Health Care as a Public Duty Page 18 of hypochondriacs or lonely people making unnecessary trips to the doctor without a health complaint. How many do? I have no statistics on this, but it can’t be large. Anyway, if this is a real problem a simple solution would be to require a modest co-pay for each visit, being a sum that would vary depending on the patient’s taxable income. Already under current conditions people covered by Medicare Advantage plans, Medicaid and many high-end medical insurance plans can visit a doctor as often as they want with no additional cost or only a small per visit co-pay. So universal (so-called “free”) healthcare won’t stimulate a large increase in usage. And even if it does, that would be a good thing on balance, because it would encourage early intervention as more people would be inclined to seek prompt diagnosis at the first sign of a health problem rather than delaying until the condition worsens requiring costly intensive care or until it’s too late — as they often do when affordability is a concern. So overall national health outcomes would be improved and costs reduced.
g. The perception of drastic change in our employer-based healthcare system is a perceived obstacle that can be dealt with.
The only real hurdle for single payer to overcome is the perception of drastic change, and no change could be more drastic than eliminating America’s entrenched employer-based system. It is a system that so many workers for so long have relied on and benefited from. It seemingly costs workers nothing. It’s usually not a payroll deduction and is not itemized. So, the cost is hidden; but workers actually pay for it indirectly. Wages are set by market conditions. The cost of health insurance is part of the wage bargain. That means it is an un-itemized (somewhat hidden) wage deduction. The perception of workers is that health insurance is free. Changing to a government plan would mean that workers who previously got their health insurance seemingly for free, i.e., paid for by their employers, would now have to pay for it themselves, directly and recognizably. The perceived additional cost would be shocking.
There may be several answers to that dilemma, however. I suggest a few. One might be this: If a government plan were adopted it could require that those employers who were previously providing health insurance must add the prior health insurance amount to the employee’s pay checks as an itemized tax-free bonus, perhaps for a year or two after adoption of a government plan. After that employers would be free to eliminate this benefit. But they would then be under great market pressure not to cut wages in doing so. Or the $10 trillion that employers currently pay for private insurance premiums could instead be redirected to the government run system as medical insurance premiums or they could be deducted from paychecks as payroll taxes. The transition will be difficult but will be manageable if done gradually, in incremental steps.
h. Despite objections, universal, single-payer healthcare is favored by most and Americans.
A growing majority of Americans support single-payer healthcare according to Catherine Rampell as she reported in the April 17, 2017 edition of The Washington Post. The hope must be that truth and reason will ultimately prevail over false claims.
8. Compromise measures, though attractive, are problematic.
But if full-fledged public funding of healthcare is not politically feasible just now in the US some politicians believe intermediate measures would be an acceptable compromise.
a. The public option is one-such halfway measure.
The option to participate in a government run healthcare system, running alongside the private insurance system, may be more politically achievable in the short term and could resolve in some measure all of the defects in the current market system. It would allow people to opt-in to a government single-payer system, while allowing the existing healthcare financing mechanisms to compete. Republicans will obviously fight it vigorously, correctly seeing it as an intermediate step — a gateway — to a full-scale single-payer system. Yet some supporters of single-payer, such as Steffie Woolhandler, a physician on the faculty of Harvard Medical School and an ardent advocate for single payer, cautions that a public option would allow insurance companies to figure out a way to “cherry pick” healthy customers, putting a disproportionate cost burden on the option plan that would be left to cover the remaining high cost patients.
b. Another compromise proposal is the all-payer plan.
Some candidates vying for the Democratic Party presidential nomination have advocated an “all-payer” policy as a worthwhile step in the right direction. But that is nothing more than a system of price controls of charges for medical services and would do nothing to improve coverage, so millions would remain uninsured even if adopted.
9. The single-payer decision is not really a partisan political issue; it is instead a basic business proposition supported by practical, cost/benefit analysis.
Full scale single-payer is demonstrably, according to sound empirical data, far less costly than the American health insurance system and produces equal or better health results. Single-payer is more streamlined, less complicated, more fair, efficient, uniform and comprehensive. Everyone who has studied the issue carefully and has an awareness of the facts and the statistics knows that this is true and that the American system is actually really foolish.
This healthcare debate has been characterized as a political and partisan issue. The media and politicians want to call it a clash of conservative vs. liberal values, left vs. right doctrine. Critics label government managed healthcare as “socialism” and anti-capitalism. It is none of those things. It is a pure economic issue. It is a straight forward business proposition that should be judged — as any wise business executive or any committed free-marketeer would — unemotionally on a data driven, statistical cost/benefit analysis. From that approach, single-payer for Americans as a whole is the clear winner.
The only people who seem staunchly opposed to or who have reservations about single-payer are politicians. Where did all the compassionate conservatives go? I have cited much evidence showing that single-payer works better, produces better health outcomes and costs less than our present system. Much more evidence could be cited, especially considering that there are at least 32 democratic countries with long-standing experience in these systems, going back at least as far as 1912 when Norway was first to adopt a national universal healthcare system or to Prussian autocrat Otto von Bismarck who in 1883 established a government system as a means to unify Germany.
There is no better evidence than actual experience. And it is overwhelming. If enacted, single-payer would replace private for-profit health insurance and would meld Medicare and Medicaid into an efficient, single, seamless unified system. It would replace the present wasteful and inadequate, incongruous and unworkable mixture of public and private insurance with an economical, uniform system providing good care for all Americans equally regardless of their economic status.
Never has there been a clearer and more powerful example of the limitations of the free market than has been evidenced in the many futile and flawed efforts to cover the nation’s health needs with the free market. It is time to take healthcare out of the hands of the for-profit insurance industry. We know we have an unmet need and an undeniable public duty to meet it fully. If we owe a duty to some of our citizens, we owe it to all. If we have a partial duty, we have a full duty. The value of any single human life is no greater than another, so the poor should receive exactly the same level of healthcare that can ordinarily only be afforded by the rich. We can and should do our public duty, fulfill our moral duty of good healthcare for all — 100% of all Americans — and abandon the costly, inefficient, inadequate and totally senseless patchwork of insurance markets propped up with massive government support. Halfway measures, whatever you call them —
- That President Trump disparagingly describes as “insurance company bailouts”, or
- That Republicans scornfully call “handouts” or “giveaways” or
- That Democrats euphemistically describe as, “cost-sharing payments,” that they say are needed “to stabilize the insurance markets”
— these measures can’t do the job; it doesn’t matter, the market can’t fulfill the entire need, except at an excessive, wasteful and unsustainable cost. So why shouldn’t our government just fulfill this acknowledged ethical and humanitarian public duty and do the whole thing? It is the only entity that has the means and resources to provide good, affordable care for all.
10. Individual, personal benefit is not the ultimate issue.
I am on Medicare and have a modestly priced Medicare Advantage supplement plan with Kaiser Permanente that I’m fairly well pleased with. So, would universal healthcare benefit me? No, I don’t think so. Would it benefit my kids and grandkids? Probably, some. Would it benefit America and make American healthcare great? Definitely, YES. It’s the humanitarian and practical thing to do — it’s the right thing to do.
Please also see ‘Universal healthcare is an economic necessity’ essay 1/6/2018 by Dr. Michael Mulroy at http://digital.olivesoftware.com/Olive/ODN/SeattleTimes/shared/ShowArticle.aspx?doc=STCD %2F2018%2F01%2F06&entity=Ar00702&sk=17EF5B84&mode=text
Jerome R. Cronk, Shoreline, WA, first major draft October 2017, updated 06/19/2019
 Some supporters of universal healthcare say it is a right: They don’t focus on duty as a rationale. But it makes better political sense to argue that it is a duty. Either way, whether a right or a duty, it is a vital, indispensable human need.
ELIZABETHWARREN’S POSITION ON HEALTHCARE
Warren speaks in favor of single-payer healthcare in 2017 In the 2008 book, Health at Risk, in the chapter Get Sick, Go Broke, Warren wrote that “We approach the health care debates from a single perspective: maintaining the financial stability of families confronting illness or injury. The most obvious solution would be universal single-payer health care.” Warren supported the Affordable Care Act and has opposed Republican efforts to repeal it however in June 2017, she said that Democratic Party should start running on a new national single-payer plan: “President Obama tried to move us forward with health-care coverage by using a conservative model that came from one of the conservative think tanks that had been advanced by a Republican governor in Massachusetts. Now it’s time for the next step. And the next step is single payer.” She has spoken against the 2.3 percent tax on medical devices introduced by the ACA. In December 2016, Warren was one of five senators to vote against the Obama administrationsupported 21st Century Cures Act, legislation increasing funding for disease research while addressing flaws in the American mental health systems and altering drugs and medical devices’ regulatory system.” In April 2017, Warren was one of five Democratic senators to sign a letter to President Trump that warned failure “to take immediate action to oppose the lawsuit or direct House Republicans to forgo this effort will increase instability in the insurance market, as insurers may choose not to participate in the marketplace in 2018” and that they remained concerned that his administration “has still not provided certainty to insurers and consumers that you will protect the cost-sharing subsidies provided under the law.” In September 2017, Warren said she would support Bernie Sanders’ single-payer plan that would expand Medicare to all Americans. Warren said that the plan would guarantee medical care for all at the lowest prices. In a message to her supporters she said, “Health care is a basic human right and it’s time to fight for it.” In January 2018, during a speech to a conference hosted by Families USA, Warren opined that it was time for Democrats to play “offense” on the issue of health care. She cited alternatives to a single payer plan including creating a public health insurance option in the Affordable Care Act and authorizing individuals to buy into Medicaid. Warren stated that “giant insurance companies have pretty much run the show” for too long and that progress needed to be made in holding American insurance companies accountable. In December 2018, Warren was one of forty-two senators to sign a letter to Trump administration officials Alex Azar, Seema Verma, and Steve Mnuchin arguing that the administration was improperly using Section 1332 of the Affordable Care Act to authorize states to “increase health care costs for millions of consumers while weakening protections for individuals with pre-existing conditions.” The senators requested the administration withdraw the policy and “re-engage with stakeholders, states, and Congress.” In December 2018, Warren introduced legislation that would vest a to-be established governmental agency (“Office of Drug Manufacturing”, to operate within the HHS) with the authority to manufacture generic forms of pharmaceuticals for which the US government has licensed a patent whenever there is “little or no competition, critical shortages, or exorbitant prices that restrict patient access.” Universal Health Care as a Public Duty Page 23 In January 2019, during the 2018–19 United States federal government shutdown, Warren was one of thirty-four senators to sign a letter to Commissioner of Food and Drugs Scott Gottlieb recognizing the efforts of the FDA to address the effect of the government shutdown on the public health and employees while remaining alarmed “that the continued shutdown will result in increasingly harmful effects on the agency’s employees and the safety and security of the nation’s food and medical products.”