Adam Gaffney is an instructor in medicine at Harvard Medical School and a pulmonologist and critical care doctor at the Cambridge Health Alliance. He is Secretary of the advocacy organization Physicians for a National Health Program and blogs at The Progressive Physician. We recently chatted with Adam about the current movement for Medicare for All, and DSA’s place in it.
A two-parter to begin: You’ve written that you believe Medicare for All should become a litmus test for Democratic politicians; do you worry that this can be misconstrued as a call for supporting a Medicare buy-in as was originally proposed in the ACA? Are we making a mistake by framing this as a fight for Medicare expansion as opposed to socialized medicine?
There are pros and cons to the phrase “Medicare for All.” The obvious advantage is that Medicare is a familiar and popular program that enjoys substantial bipartisan support: if it is so great for older adults, why not give it to everyone? But its primary drawback is that we’re fighting for something much bigger, and better, than Medicare. Medicare includes cost-sharing (copays and deductibles), and excludes important benefits like dental care and long-term care. Additionally, it has been partially privatized (i.e. so-called “Medicare Advantage” plans). For this reason, people frequently refer to “expanded and improved” M4A, which is more accurate. However, a second (and related) shortcoming is what you’re referring to, which is that our plan could be confused with the various other incremental proposals that are out there, like the “Medicare buy-in.” The Center for American Progress added to this confusion by calling its new non-single-payer plan “Medicare Extra for All.” Then again, it’s not clear what the best alternative is. “Single-payer universal health care” or “single-payer national health insurance” are more clear, although they lack the familiarity of M4A. My own feeling is that for the time being, both “Medicare for All” and “single-payer” work. Use both, and use them interchangeably (although M4A should be proceeded by “improved and expanded” whenever feasible). However, as public familiarity with the term “single-payer” grows, I’m guessing we will probably want to use it more and more.
Some on the left have argued that plenty of countries in Europe with nationalized health services, Britain chief among them, fall well short of what can be described as socialist societies. Just because we may win Medicare for All doesn’t mean we have vanquished neoliberalism. After Medicare for All is won, what's the next step to ensure it is secured and expanded upon?
The achievement of a single-payer universal healthcare system would be a profound and historic victory for the working class of this country, but clearly, much more needs to be done in the struggle for a more egalitarian, healthier society. First, even assuming we achieve a system similar to what we now propose, it will come under immediate attack from the Right, and from powerful economic interests seeking to defund and unravel it. Defending the new program, insuring adequate funding, and improving its quality will remain key causes. Don’t forget the goal is not merely a health program that covers everyone, but a program that provides world-class service to all—a goal that Aneurin Bevan emphasized. However, much more needs to be done. The pharmaceutical system, for instance, needs to be reformed in ways that go beyond public drug coverage. And healthcare is only one determinant of health among many: essentially every cause of the Left—ranging from economic justice to racial and gender equality, the housing struggle to the fight against climate change (to name just a few)—is needed to make for a healthier nation, and planet.
You have written extensively on where Pharma fits into this discussion. In your recent Jacobin piece you say: "Yet even with drug-price negotiations at the national level, and even with a public drug-development program, we might still be held captive by Big Pharma." Can you explain how this is the case and how we can avoid it?
To be clear, public drug-development programs do a lot of good. They bring down brand-name drugs prices by perhaps 50%: we estimate negotiations would save a bit more than $150 billion a year if we did them. That would be a step in the right direction, but major problems would remain. For instance, when there is a single drug that is best for the job, the company that owns the patent has all the leverage in negotiations, and can still demand enormously high prices or simply walk away. The drug R&D system is broken: drug firms are incentivized to develop “me-too” drugs that make money but don’t improve constitute an actual health advance; at the same time, they are allowed to monetize important developments that arise from public funded research. There are problems in drug regulation. The FDA is partially funded by the drug industry. Regulations on approvals have gotten too lax. Hence, we need a whole package of pharmaceutical reforms, including a pathway for fully-publicly drug development outside of the patent system, as we (the US/Canadian Pharmaceutical Working Group) recently proposed in the British Medical Journal (available here).
What do you see as the role of statewide efforts such as the New York Health Act in this fight; are they a help or a hindrance in terms of proof of the demand of a national program that isn't a patchwork of statewide plans of varying effectiveness?
This is an area of ongoing debate. On the one hand, some point out that there are real barriers to success at the state level, or look back at the disappointing outcome in Vermont. On the other hand, many activists see state-level organizing as the best approach to building a movement—and maybe achieving a victory—in the short-run. Ultimately, however we side on this debate, it’s important to remember that this is one movement, and that national legislation is the ultimate goal. In this respect, I think that national and state-level organizing can be complementary.
DSA M4A organizers in Harrisburg, PA, in June 2018. Courtesy of Philly DSA.
In your book, To Heal Humankind, you trace what you term the healthcare "rights-commodity dialectic" through history. Are we experiencing a shift toward decommodification today? And what role would you say activism plays in pushing the needle toward the realization of healthcare as a social right?
Unfortunately, in many respects, healthcare is becoming increasingly commodified in the United States today. Corporations are literally taking over not merely the financing, but the actual provision of healthcare. Corporations run many large doctors’ groups, hospitals, retail clinics, urgent care centers, dialysis chains, and—of all things under the sun—hospices. Big Pharma is of course more powerful than ever. At the same time, however, we are witnessing the growth of an increasingly vibrant and powerful healthcare justice movement that is pushing the needle in the opposite direction, to a construction of healthcare as a social right. The movement succeeded in moving single-payer from (relatively speaking) the political fringes to an admittedly tenuous position right at the political center. It was only last year that a majority of House Democrats got behind HR 676, and 16 Senators co-signed Sanders’ single-payer bill. Politicians were not leading activists in this regard—they were following them.
What, if any, pushback have you experienced in the medical community for your advocacy around Medicare for All? Have you found medical professionals who agree with you privately but are hesitant to publicly advocate for Medicare for All?
Physicians are more supportive of single-payer then is commonly realized—indeed, a recent poll found that a majority of them supported it. And that’s crucially important—we need the support of healthcare providers, including physicians, as we wade into the next stage of this struggle. But there’s still a lot of work to do.
Finally, what advice do you have for DSA organizers around the country who are just starting out in their fight for Medicare for All?
Winning single-payer will be about as bruising a political struggle as can be imagined. We haven’t even made it to the stage where the corporate opposition opens its war chests and fights us with everything they have. So, I’d recommend a few things. First, we can’t be discouraged as we hit bumps in the road, and we can’t be diverted by the various half-measures on offer (like a public option). Learning about some of the big policy issues is key to being able to effectively counter the misleading arguments of the opposition, and to inform the public about why single-payer is different from the various inadequate alternatives we’ll be hearing more and more about. And remember that there is a moral core to our movement that cannot be replaced by any number of corporate dollars or sleazy ads. When we win—and we will win—it will because of the tireless work of activists in groups like DSA. But we still have a long road ahead.
