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Ep. 24 Making the case for Medicare-4-All

Dr. Adam Gaffney

For an increasing number of Americans today, a single payer system seems to be the only conceivable next step in the cataclysmic and ruinous history of our healthcare system.  Our guest today is Adam Gaffney, MD, a longtime supporter of a single-payer system and president-elect of Physicians for a National Health Program.  He has kindly agreed to be subjected to our objections.


Adam Gaffney: Twitter and website


Watch the episode on our YouTube channel


  • Ep. 22 Free markets in healthcare: objecting to the objections
  • Ep. 10 Free market medicine is ethical, workable, and unstoppable


  1. Anthony M. Perry, MD on 08/31/2018 at 1:12 PM

    Your guest says that he doesn’t make decisions on what to prescribe based on what it costs the patient. Evidently he hasn’t thought the issue through since I’m sure he does. Of course he doesn’t take cost into account when the cost to the patient is very low or zero. Is he telling us that he would prescribe something the patient can’t afford and won’t obtain? Since he evidently doesn’t look into the matter, I suppose he does at times without knowing it and then perhaps complains about patient compliance. So instead of his pondering over the problem and helping the patient to make the judgment he prefers to let some distant government committee decide these matters.

  2. Anthony M. Perry on 08/31/2018 at 2:49 PM

    There is no need to speculate about what American “central payer” would be like since we already have the bona fide model, Medicare, up and running and refined with the government’s best efforts for 50+ years. Just as in the other advanced countries, it’s so pleasant to simply present your card and all is taken care of. Who can argue that the same should not be extended to everyone. But there are some problems lurking in this scenario.

    Money will be saved say the proponents. And yet the details of Medicare’s financial woes are well known but I think summarized best by the trustee’s estimate last time I looked that the unfunded liability, viz. the amount promised to present day citizens which is not covered by the present taxing structure, is in the range of $50 trillion. Consider that the benefits to today’s elderly recipients are being paid for by present day workers. What will be the result of the Medicare for All system that is being called for so blithely wherein the present day funders would as well become the beneficiaries and we would all be paying for each other. Incalculable! So much for the vaunted cost benefits.

    What about the administrative efficiencies. Since there is no fear of business failure, Medicare is not constrained by the problematic actuarial details faced by private insurance. But a major administrative cost of Medicare is in the form of mandated regulatory compliance. Studies abound detailing the massive waste of time and resources devoted to such effort which has only increased over the years. Are we to believe that this will be lessoned by extending the system?

    But the most problematic results of our Medicare system are the severe consequences implied in any centrally controlled system that have been detailed by the liberal economists and noted at length in your discussion.

    Prices in the Medicare world have lost their signaling function. Medical providers do not compete to offer the most efficient economical services, but instead attend to maximizing income through fitting their services to the regulations. Medical records now have documentation for compliance as their primary function. Doctors have limited idea of the cost consequences of their decisions and decide based on other considerations. Their patient consumers act likewise and accept anything that is offered that is not too inconvenient or unpleasant. There is no such thing as shopping for the lowest price.

    Prices are fixed by central committees and are often grossly unrelated to reality. Providers rush to perform overpriced services and ignore underpriced ones. Our medical offices actively resist modern methods of communication with patients since only face to face encounters are paid for. How many millions of hours are wasted as a consequence while committees all over the country go through the farce of debating whether telemedicine should be permitted.

    Drug and device manufacturers focus on efficacy and devote limited R&D attention to innovations in manufacturing so that, unlike the computer industry, new medical products are always more complex and more expensive. Like the rest of the system they are focused on what arrangements they can make with the third party payers. And so we have the spectacle of multiple drugs with the same mode of action from different manufacturers that are heavily advertised but with no discernable open price competition.

    As doctors rush in droves to employment with large medical conglomerates which are tapped into government funding how many articles are written decrying the plight of primary care, the pressure to see more patients in less time, the burgeoning number of medical administrators. Who knows what primary care should be? A free market would sort the problem out far better than any expert committee.

    The U.S. is not Canada or England or France. It is a behemoth of a free wheeling, highly demanding, legalistic and contentious public catered to by a very unwieldy often self-serving political and bureaucratic class. As a model of central payer the anti-competitive, wasteful, inefficient, fiscally unsound Medicare system is the best we can do. To extend it to all would be a disaster and then where do we go.

    • Michel Accad on 09/01/2018 at 7:18 PM

      Thanks, Anthony. I agree with everything you say but I think the financial and economic arguments, true as they may be, are not very effective as a public campaign against single payer. I just published a blog post about that (if you click the blog tab on the menu).

  3. Marc Fouradoulas on 09/01/2018 at 6:51 PM

    Hot conversation! Classical “public health” metrics talk versus pro-market reality check. Great question by Anish in the beginning: what is health care? -> basically anything a MD does and bills, consequently anything a patient asks for. Is that a useful definition? Hence, there are no boundaries and we don’t now what we’re actually talking about.
    Whats the point in comparing a system with a private sector? The system has metrics, the private sector has prices. It can’t be compared.
    Great points about prices as signals, hospitals as biggest employers, “far away bureaucrats” and “trust in central planners”!
    I find it disturbing to hear somebody fanatically believe in top-down control of people, regulating prices and knowing whats good for all. What hybris! But that doesn’t surprise. Critical care doctors literally “control” their patients, haha. The man wants control..

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