The transformative potential of single-payer

An excerpt from Timothy Faust’s ‘Health Justice Now: Single Payer and What Comes Next.’

Our highways are crumbling. Our trains, where they exist, are failing. Our sewer systems are disintegrating. So, too, is the health infrastructure of America. Under decades of for-profit domination, it has healed only some of us, while leaving the wounded rest behind. Those of us who are yet cared for know we’re just a snap of a thread we can’t see from falling and being lost. Our neighborhoods have been made unsafe; our water has been made poisonous; we are hostages, trapped in our own bodies, to the billing departments of American healthcare.

Our money is wasted by the unworthy and uncaring, wasted on insurer advertising and administrative costs, and it can be won back only by switching to single-payer. There is money to be reclaimed by the weight and force of a single-payer’s price-setting power. This is not “bonus” money; it is not money that can be given as appeasement or tribute to the wealthy and powerful; it is a small sliver of our money, which has for generations been stolen from us.

What do we do with our money?

We reclaim it, we invest it, and we rebuild. We use single-payer to liberate people from the torture of medical costs and reallocate our healthcare spending to take care of everyone in the long term.

We build primary care clinics in rural areas, where it’s not profitable to stay open. We reopen the clinics — the 97 of them that have closed since 2010, plus unknown scores more in the decades before — that tried to stave off the market’s inevitable condemnation of caring for a sick but unprofitable rural population however they could, until they collapsed.

We fund community health centers in poor neighborhoods; in communities that have been systematically preyed upon, drained of capital, punished for it, then punished again for suffering. These are communities that get sick more frequently, more severely, and in different ways than wealthier neighborhoods. This burden, compounded with each generation, will not be relieved by a program from a benevolent patrician class, but from a mass reversal of interwoven structural exploitations. A well-funded and well-staffed community health center, locally designed and locally controlled, can offer the specific kinds of care and support a community needs to stay healthy: direct healthcare and pharmacy services, social cooking classes, childcare and child development classes, and other vital resources to help a neighborhood stay healthy.

Most importantly, we return the money to the people who do the work. There are millions of utterly devalued healthcare workers who through their labor are the backbone of American health: nurses, social workers, custodial staff.

Take, for example, home-health aides. It’s one of the fastest-growing jobs in America: it’s expected that there will be 1.2 million home-health aides by 2026. Home-health services are billed at an average of $120 a visit, which is significantly cheaper than an inpatient stay at a hospital or nursing home.

But gentle and convenient as this whole arrangement is, that money doesn’t do much for the home-health aides themselves. For that $120 visit, these aides are paid a nationwide average of $11/hour — much, much lower in many states. The very same healthcare executives who found they could profit by denying patients home healthcare evolved to learn they could profit in the other direction by corporatizing it, contracting it out, and paying their workers as little as the local economy permits. They have folded and refolded the people who need long-term care and the people who provide it into crumpled, bloodied scrap.

The market won’t solve this; the market caused this. So we use single-payer to allocate the money the private market has taken from us to do what it refuses: pay fair wages for essential care, which we guarantee to every person who needs it.

Is this not the most humane, the most just, the most obvious use of our collective wealth? Are we to believe that we should deprive ourselves from being a nation with well-paid home-health aides, or that we must keep their wages low so we can build another F-35?

I saw an excellent example of how investment in an expanded home-health labor force can produce better health outcomes when I visited a hospital in Little Rock, Arkansas. Arkansas, with high obesity and smoking rates, is one of the diabetes capitals of the United States. If you leave diabetes alone long enough, it’ll erupt into a heart attack. So quite a few people from all around Pulaski County and beyond come to this hospital to seek treatment for cardiac failure. Often, they need pacemakers. But over a quarter of them are readmitted to the emergency department within a few weeks for cardiac complications or cardiac failure. That’s not good. So this hospital, which was being penalized by Medicare for its high readmission rate, set out to bring these numbers down.

Take a second to think about it. Who, or what, do you think most affects a person’s chance of going back to the hospital after cardiac failure? Is it the quality or skill of their highly paid cardiologist? Is it the quality and engineering of their expensive pacemaker? Is it the $40,000 data package sold to hospitals* that lets nerds monitor pacemaker metrics? No, of course not — those are just the people who get to bill the most. What determines a person’s likelihood of returning to the hospital are the living conditions and quality of life available to them. In this case: food and exercise.

So this hospital hired nurses, social workers, and nutritionists to see patients after their heart surgeries, to listen to them and ask them questions and encourage them to join Medicare- subsidized group classes at a hospital facility three times a week. There, patients join other patients of the same age group and heart condition to receive physical therapy, training, and exercise in a social environment. More importantly — for heart health is made, like abs, in the kitchen — they received group cooking classes, preparing (and eating) healthy food together. The nurses proudly told me that readmission rates fell from 26 percent to four percent.

Our doctors, our diagnoses, our prescriptions, and our clinical time are often considered the fundamental components of healthcare. But that’s shortsighted. We exist far beyond the walls of the hospital, and we are made healthy or ill long before a doctor sees us. Even after we see a doctor, our health outcomes are driven by non-diagnostic, extraclinical care: by social workers, by patient advocates, by nurses, by home-health workers, by the whole army of people who do the exhausting and tedious labor of being nice and patient with us. We are dependent upon their compassionate labor. These are the people chronically unrecognized, undervalued, and underpaid, and they’re the primary actors who re- ally make a difference in population health.

These are basic ideas! These are simple demands! We understand the social forces that make people healthy; we understand the structural forces that make people sick! Yet in the face of this knowledge that health has structural and social causes — knowledge we’ve had for decades — capitalism’s response is to blame population illness on an aggregate of atomized individual choices, then package them into “healthy lifestyle” commodities. We’re offered step trackers, cookbooks, various smartphone apps, all intended to somehow (it’s not specified how) push or pull us into being “healthy” — at least long enough that we’re no longer our insurance company’s problem.

But despite what tech companies insist, there are no apps that bring about better health. A “how to survive on $4 a meal” cookbook, well-meaning as it may be, doesn’t do shit for people who only have $4, if that, per meal. Programs that penalize you for going to the ED at the wrong time don’t do a single thing to make you healthier outside the hospital.

None of this is news. None of this is new. None of this would surprise a child. But somehow the multi-payer private model, in its half-century-long sandbox, has yet to figure this out. It hasn’t even pretended to take it seriously. No private insurer has seriously invested in population health; none have invested in compassionate labor, or paying those laborers justly. And they never will.

Right now, your private insurer only bears the costs of you receiving care while they’re insuring you. Because you’re likely to change insurers in the future (sometimes every year), and eventually, god permitting, go on Medicare, they don’t actually feel pressure to provide you with that which keeps you healthy, or that which helps you become healthier in the future. Solutions to the basic problems of health inequity elude private insurers not because they don’t understand them; they understand them comprehensively; but because they refuse to reach — are unable to reach — for them.

Consider the hookworm. Hookworm is a disease endemic to the deepest depths of poverty, one that we thought we had all but eradicated in the United States by the eighties. We were wrong. Today, hookworm runs rampant through the poor and rural parts of the Deep South. The cause is devastating structural neglect. Sewer systems in rural counties — never intended to be stretched as thin as they are now — have fallen apart, or were constructed inadequately in the first place — and the state can’t (or won’t) approve the substantial funding required to retrofit them. So people make DIY fixes from PVC. These fixes break, and sewage piles up in people’s yards.

In Lowndes County, Alabama — a rural county outside Montgomery, where a third of the population lives below the poverty line and nearly a quarter of people have diabetes — one in three people among a sample taken in 2017 had hookworm. One in three! That’s a rate consistent with (and, in many cases, higher than) devastated and impoverished countries.

In 2019, Blue Cross Blue Shield of Alabama has a monopoly on selling ACA insurance in Lowndes County. They’ve had this monopoly for a few years now and, the way these things seem to work, will probably have a monopoly next year, too. Or maybe next year United will reenter the state for some reason and reclaim it, though I doubt it, because insurers tend only to enter new markets when those markets are urban areas with wealthy pockets. Either way, nothing will change. The insurance industry is incapable of addressing the foundational problems of healthcare: of reopening the 16 rural hospitals that have closed in Texas because of lack of Medicaid funds since 2013, of repairing the septic systems of Lowndes County — in almost the same way that a billionaire is incapable of lessening income inequality, or a cop is incapable of shrinking the prison-industrial complex. They cannot fix that injustice because they have been constructed by, and within, that injustice. They cannot solve these problems because they cannot exist without these problems, and thus existentially cannot conceive of them as problems in the first place. But we can. And we do.

And so if private insurance companies are so shackled to their need for profit and are thus unable to feel the pain caused by their choices, if they do not suffer when those they insure suffer, and if they continue to make choices that cause more and more pain to others, and are by their very nature unable to keep themselves from doing so, then we simply should replace them.

It makes perfect sense that the actor that does suffer when its people don’t get care — all of us, united against suffering, our bodies together assembled in the shape of our government — should be the actor that also guarantees that care in the first place.

This is the transformative potential of single-payer.

Timothy Faust's writing has appeared in Splinter, Jacobin, and Vice, among others. His book is available for pre-order.