WHY DO AMERICANS STILL NEED SINGLE-PAYER HEALTH CARE AFTER MAJOR HEALTH REFORM?

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1 Pros and Cons of Obamacare: Is It What the United States Needs? WHY DO AMERICANS STILL NEED SINGLE-PAYER HEALTH CARE AFTER MAJOR HEALTH REFORM? Claudia Chaufan Many observers have considered the Affordable Care Act (ACA) the most significant health care overhaul since Medicare, in the tradition of Great Society programs. And yet, in opinion polls, Americans across the political spectrum repeatedly express their strong support for Medicare, alongside their disapproval of the ACA. This feature of American public opinion is often seen as a contradiction and often explained as incoherence, a mere feature of Americans muddled mind. In this article I argue that what explains this seeming contradiction is not any peculiarity of Americans psychology but rather the grip of the corporate class on the political process and on key social institutions (e.g., mass media, judiciary), no less extraordinary today than in the past. I also argue that ordinary Americans, like millions of their counterparts in the world, would eagerly support a single-payer national health program that speaks to their interests rather than to those of the 1 percent. I will describe the ACA, compare it to Medicare, explain the concept of single payer, and conclude that the task is not to persuade presumably recalcitrant Americans to support the ACA but rather to organize a mass movement to struggle for what is right and join the rest of the world in the road toward health justice. The American health care system is the most expensive in the world, even as it consistently ranks last in international comparisons with wealthy economies on most measures of performance, including access, quality, and equity (1 3). Improving it was the motivation behind the Affordable Care Act (ACA), signed into law by President Obama on March 24, 2010 (4). International Journal of Health Services, Volume 45, Number 1, Pages , , The Author(s) doi: joh.sagepub.com 149

2 150 / Chaufan Many have considered the ACA the most significant health care overhaul since Medicare, in the tradition of Great Society programs (5). And yet, in opinion polls, Americans across the political spectrum repeatedly express their strong support for Medicare (6) alongside their disapproval of the ACA (7). This feature of American public opinion is often seen as a contradiction and explained (away) as incoherence on the part of Americans a mere feature of Americans muddled mind (8). If only Americans chose the right presidential candidate, ponder some international observers, health reform would be at their reach (9). In this article, I argue that what explains this seeming contradiction in U.S. opinion polls about health reform is not, nor has it ever been, any peculiar feature of Americans psychology, but rather the grip of the corporate class on the political process and on key social institutions (e.g., mass media, judiciary), as extraordinary today as it was in the past (10). I also argue that ordinary Americans, like millions of their counterparts throughout the planet, would eagerly support a single-payer national health program Improved and Expanded Medicare for All that speaks to their interests rather than to the interests of the 1 percent. I will describe the ACA, compare it to Medicare, explain the concept of single payer, and conclude that the task is not to persuade presumably recalcitrant Americans to embrace the ACA but rather to organize a mass movement to struggle for what is right and join the rest of the world in the road toward health justice. IS THE AFFORDABLE CARE ACT IN THE TRADITION OF GREAT SOCIETY PROGRAMS LIKE MEDICARE? Since its inception, the ACA has been plagued by intractable problems. First, it has not resolved, and is unlikely to resolve, the problem of access. Even after expanding coverage to millions of Americans, as many as 31 million most of them citizens and legal residents (11) will remain uninsured by 2024 (12). Second, the ACA is unlikely to significantly reduce financial barriers to care. Indeed, the United States is unique in that medical bankruptcy, a leading cause of personal bankruptcy in the country, affects largely individuals who have insurance. Many Americans insured after the ACA have already expressed that the cost of care remains a significant barrier, because they cannot afford to actually use the policies they may afford to purchase (13). In 2012, 80 million people reported that, during the past year, they did not go to the doctor when sick or did not fill a prescription because of cost, 75 million reported problems paying their medical bills or were paying off medical bills over time, about 28 million adults reported using all their savings to pay off bills, and 4 million had to declare bankruptcy in the previous two years (14). Third, it is even more unlikely that the ACA will guarantee continuity of care. Like pre-aca health care, the ACA relies on multiple insurers and plans competing for customers (even if competition is virtually nonexistent in many markets dominated by insurance monopolies). As coverage and eligibility depend on

3 Single-Payer Health Care after Reform / 151 market considerations (e.g., price, profitability), so does access to a given source of care. The ACA also ties coverage to income and jobs. Thus Medicaid enrollees often churn in and out of the program and are forced to change coverage, hence providers, as their income, and subsequently their eligibility, change over time (15). For those with employer-sponsored coverage, coverage and source of care change with changes in job situation, not unusual in times of precarious, scarce, and flexible employment. In fact, coverage often does change even without changes in job situation, as employers try to cut their health costs and stressed-out employees struggle to understand yet another set of (forced) choices, which typically consist of higher payments for increasingly restricted services. The University of California San Francisco, for example, announced its annual health benefits open enrollment period with the slogan of Big Changes, New Choices. Finally, the ACA will not address spiraling costs (health care costs have increased worldwide, yet nowhere at U.S. rates), not explained by inflation, age structure, health status, above-average utilization, or medical technologies (although segments of the population may use more health care and advanced technologies, for millions of Americans the real problem is too little, not too much, care) (16). Even if the tinkering-around-the-edges cost-cutting approaches encouraged by the ACA electronic health records, pay-for-performance, greater price transparency, or cost consciousness were successful (and the empirical evidence supporting the cost-cutting abilities of these approaches ranges from dubious to nonexistent) (17, 18), none of them utilizes the power of economies of scale. For this reason, they cannot yield lower prices nor reduce administrative overhead savings that would amount to around $600 billion (all dollar amounts in U.S. dollars) annually (19, 20). Nor can they yield the savings that would ensue from ending overpayments to private ( Advantage ) Medicare plans $282.6 billion, or 24.4 percent, of total Medicare spending on private plans between 1985 and 2012 (21). Altogether, these savings would be more than enough to provide first-dollar coverage for every U.S. resident. Nor can any of these measures deal with inscrutable benefit packages, skimpy coverage, evernarrowing provider networks, or changes in coverage with changes in jobs or income level, among so many other problems built into the very design of the ACA. In stark contrast, less than a year into becoming the law of the land in 1965 as a national social insurance program administered by the U.S. federal government, Medicare had already enrolled, and was paying the bills on behalf of, more than 19 million seniors (99% of those eligible for coverage) with no websites, navigators, or the threat of penalties. How? Very simple. Most seniors were already known to the Social Security Administration, which used Social Security numbers for Part A (hospital services) and index cards for Part B (doctors services) enrollment, while creating jobs for 5,000 low-income seniors who went door to door to help contact those among the aged who were difficult to reach (22). As a government program that granted seniors full rights to the same comprehensive package of services and free choice of any participating provider,

4 152 / Chaufan Medicare dispensed with the pursuit of profit that is the lifeblood of commercial insurance, so the costs of marketing or of helping users navigate coverage options substantial with the ACA (23 25) were zero. Providers gained independence in medical decision making and the guarantee that their bills would get paid. There was, and there remains, much room for improvement in access, coverage, quality, and cost control. But the relevant feature of Medicare was, and remains, its financial structure: the program is organized as a social insurance system that spreads the financial risk associated with illness across society to protect everyone. Enrollees pay into the system according to their ability and are entitled to the same broad package of services according to their medical needs. Medicare, unlike the ACA, is a single-payer-like system. WHAT IS SINGLE PAYER? Single-payer national health insurance is a system in which a single public or quasi-public agency (or strictly regulated subsidiaries) organizes health care financing, that is, collects the money from users, purchases services in bulk, and negotiates rates and payment schemes with, and pays, providers. The delivery of care may remain or not in private hands (26). Nations that have adopted single-payer systems cut across cultures, political ideologies, and levels of development. They include countries as different as the United Kingdom, Iceland, Taiwan, Spain, and Cuba. In fact, all wealthy nations with the exception of the United States, and many poor nations, have organized their health care systems as variants of single payer (27). The Expanded and Improved Medicare for All Act, HR 676, based on a physicians proposal crafted by members of Physicians for a National Health Program and published in the Journal of the American Medical Association, would establish an American single-payer health insurance system (28). Under this system, all residents, documented or not, would be covered for all medically necessary services, including doctor, hospital, preventive, long-term, mental health, reproductive health, dental, and vision care; prescription drugs; and medical supplies. Dramatic overall savings would ensue from the system s power to purchase goods and services in large amounts, thus negotiate prices with providers associations, pharmaceutical companies, and medical device suppliers. Importantly, paperwork that does not contribute to more or better care would be eliminated (19). Wasteful paper pushing comes from essentially three sources: (a) the need of multiple insurers to market plans to profitable customers, authorize or deny services, pay handsome CEO salaries, and make a profit; (b) providers need to screen patients coverage and file claims to multiple insurers to get paid (or fight back when services are not approved ) (29); and (c) users need to juggle with an extraordinarily cumbersome system that requires thousands of

5 Single-Payer Health Care after Reform / 153 navigators to help them figure out which plans meet their needs (and fit their pockets), what services they are entitled to, and how to handle denied services (Table 1). A U.S. single-payer plan as proposed by HR 676 would do away with this waste: it would dramatically reduce prices, slash overhead, and utilize collective savings to purchase health care for all (20). Even as taxes might slightly increase, most Americans would save money, time, and distress, as they would no longer be compelled to comparison-shop for increasingly pricier and inscrutable plans, juggle with unpredictable (and unaffordable) out-of-pocket costs (premiums and out-of-pocket costs would disappear), or struggle to figure out which providers are in network, as most providers in the country would find it convenient to join the system. DO WE NEED TO PERSUADE AMERICANS TO SUPPORT THE AFFORDABLE CARE ACT? Why have the crafters of the ACA been unable to sell the legislation to the American public? Is it a matter of messaging (30)? Don t Americans understand the purpose or value of health insurance? Do they indeed have muddled minds? Or is it the substance of the ACA that makes it a hard sale? If we are to go by then-house Majority Leader Nancy Pelosi s statement before the passage of the 2,400-plus pages of regulations in the ACA we have to pass the bill so that you can find out what is in it (31) there is reason to believe that Americans have turned against it not because they shun socialism, lack solidarity, are incoherent, or fail to grasp the value of insurance, but because they know better. Indeed, most insured Americans are realizing that even after major reform, their health benefits are eroding their out-of-pocket costs are increasing, preferred providers networks are becoming narrower, and benefits remain as uncertain as pre-aca at the moment of use. The manifest function of the ACA was to achieve initially universal (and later near-universal ) health care by expanding coverage through Medicaid, (selectively) subsidizing commercial insurance in the individual market, or allowing insured Americans to keep their coverage if they liked it. Yet the latent function appears quite different: the law has done much to yield extraordinary profits for a few and even more to rescue the health insurance industry from the weight of its own incompetence incompetence, that is, to secure health care to Americans. OPEN SECRETS As President Obama pointed out early in his political career, you can have universal coverage, and you can have lower costs, but you need single payer to have both. Regrettably, as Democrats gained both houses of Congress and the White House, the party and their leader concluded that single payer was

6 154 / Chaufan Table 1 Comparing gains under ACA and single payer Universal coverage Full range of benefits Choice of doctors and hospitals Out-of-pocket Savings Cost control/ sustainability Progressive financing ACA NO. More than 30 million remain uninsured (mostly citizens and documented residents) by 2024 and tens of millions underinsured. NO. HHS provides guidance on essential health benefits. What counts as benefits decided on the basis of existing plans, i.e., by insurers themselves. NO. Insurance companies continue to restrict access through increasingly narrower networks of preferred (by them!) providers. YES. Varying degrees of co-pays and deductibles. Trade-offs between lower premiums (even if ever increasing) and higher out-of-pocket expenses, via consumer-directed plans. NO. Increases health spending by about $1.1 trillion. NO. Preserves a fragmented system incapable of controlling costs. Gains in coverage erased by rising out-of-pocket expenses, bureaucratic waste, and profiteering by private insurers and Big Pharma. NO. Costs are disproportionately paid by middle- and lower-income Americans and families facing acute or chronic illness. Single payer YES. Everybody is covered automatically at birth. YES. Covered for all medically necessary care. YES. Patients can choose among any participating provider. Most providers in the country would find it convenient to participate. NO. Co-pays and deductibles eliminated. YES. Redirects $600 billion in administrative waste and inflated drug prices toward care; no net increase in health spending. YES. Large-scale cost controls through economies of scale to ensure that benefits are sustainable over the long term. YES. Premiums and out-ofpocket costs are replaced with progressive income and wealth taxes. 95 percent of Americans pay less.

7 Single-Payer Health Care after Reform / 155 too disruptive (32) and at any rate, not politically feasible (33). They opted for ignoring single payer, dismissing it as too much socialism, or, when they could no longer ignore it, excluding single-payer advocates from the debate, if necessary by force (34). It may have helped that, as talk about health care gained traction in the run-up to the presidential elections, insurance and pharmaceutical corporations rushed to increase their political donations (33). The drug and health products sector alone gave Barack Obama $2,436,836 for his campaign, more than twice the amount given to his nearest rival (35). This surge in political spending may have led Congress and the president to conclude that single payer was unfeasible, and to opt instead for a plan that relied on market forces and was modeled after a proposal of the Heritage Foundation. The legislation was in large part written by a former insurance company executive from WellPoint, Liz Fowler, who went on to be hired by the U.S. Department of Health and Human Services to implement the law (36) and now works for a pharmaceutical giant (37). As the icing on the cake, leading academic journals, such as Health Affairs or the New England Journal of Medicine, dismissed single payer as little more than a fringe view at the (left) extreme of a continuum in which vouchers were at the other (right) extreme and the ACA at the center (38). They co-opted the concept of reform so that it would only mean what corporate interests considered permissible reforms (39), framed the debate so that the public option became the leftmost progressive alternative (40), and showcased corporate actors such as Karen Ignani, CEO of America s Health Insurance Plans, as merely one disinterested (i.e., declaring no relevant conflict of interests ) expert informant in the debate (41). Giving a token nod to the extraordinary complexity of the U.S. health insurance marketplace and faithfully toeing the official and corporate line, academics concluded that the failure of ordinary, usually lowincome, persons to grasp this complexity low health literacy (42) was a critical problem with health reform, whose solution was to use health care professionals as navigators to guide people through the insurance maze (43). Clarifying, simplifying, and standardizing the given marketplace set the boundaries of imaginable change (43). The judiciary gave the coup de grâce by limiting the federal government s ability to enforce the ACA s planned Medicaid expansion while upholding the individual mandate, that is, the individual obligation to carry a policy (44). The corporate media happily obliged and dutifully continues to convey expert (and corporate) opinion (45), carefully limiting improvements to more wellness programs (46), tradeoffs between affordability and coverage (47), or savvier experts to help users lobby the billing departments of insurance companies (48). And yet, polls show strong support for government-guaranteed health insurance when the questions are adequately asked ( Would you support or oppose a universal coverage program in which everyone is covered by a program like Medicare that is government-run and financed by taxpayers? ) (49) and most of

8 156 / Chaufan those who disapprove of the ACA still do not want to see it repealed but improved (7). Only a tiny fraction rejects it because they view it as socialized medicine (50) remarkably, given the strong establishment opposition to socialized modes of health care financing, manufactured confusion about lack of choice and competition under single payer (27), and outright falsifications about other countries publicly financed health systems (51). Polls also show that a majority of physicians, especially in primary and family care, support government legislation to establish national health insurance (52). The belief that only conservatives in government oppose single-payer national health insurance is untrue. The fact is, both major parties respond to their real constituents the medical-industrial complex that handsomely finances their campaigns and privileges (33). Finally, the argument that we the people cannot afford a single-payer system is simply false we are already paying for universal and comprehensive health care coverage, yet not getting it (53). THE WAY FORWARD None of the problems of the ACA should come as a surprise. After all, the law has implemented a system organized around profit-seeking insurers who manage their risk portfolio by adjusting their pricing to the estimated health care usage of their customers usage that they label medical loss. This market-based system treats health care as a profit source for Wall Street, like driver s insurance, one analogy that President Obama used to persuade Americans to embrace the individual mandate. Yet, as Dr. Margaret Flowers and Kevin Zeese, policy experts, corporate watchdogs, and political activists, persuasively argue, this uniquely American solution will allow the big drivers of the rising cost of health care insurance conglomerates, Big Pharma, for-profit hospitals to become only stronger, at the same time that it will institutionalize the wealth divide (36). They point out that while the privileged few, such as Senator Ted Cruz and his wife, will receive the best health care from their employer in their case, from Ms. Cruz s employer, Goldman Sachs many will be pushed into the so-called marketplace and divided into four classes of people based on their wealth. Many more will receive poor health care for poor people (Medicaid), and millions will remain in the cold. A few fortunate among these will be spared from paying a fine for not complying with the mandate, as they are found eligible for hardship exemptions (e.g., due to being homeless, a victim of domestic violence, or bankrupt) and granted the right to remain uninsured (54) provided they can make their case in court. As Flowers and Zeese assert and I agree: There was an easier, more politically popular route. All that President Obama had to do was to push for what he said he once believed in, Medicare for All. By dropping two words, over 65, the country could have gradually improved Medicare [and moved the country] toward the best health care in the world, rather than being mired at the bottom.

9 Single-Payer Health Care after Reform / 157 To replace [the ACA] with a single-payer system, we need to [oppose treating] health care as a commodity like a cell phone or, as President Obama suggested, like auto insurance [and] recognize that ending the corporate domination of health care is part of breaking the domination of big business over the U.S. government. Health care is at the center of the conflict of our times, the battle between the people and corporate interests, the battle to put people and planet before profits. In short, the battle for democracy and humanity. Acknowledgment The author wishes to acknowledge the invaluable feedback of Mark Almberg, Don McCanne, and Julian Field. She also acknowledges the continuing inspiration of all members of Physicians for a National Health Program in their unflinching determination to achieve health care justice. REFERENCES 1. Davis, K., et al. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. The Commonwealth Fund, New York and Washington, DC, publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf (accessed June 19, 2014). 2. Davis, K., et al. Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care. The Commonwealth Fund, May Mirror-on-the-Wall An-International-Update-on-the-Comparative-Performance-of- Americ.aspx#citation (accessed June 12, 2007). 3. Davis, K., Schoen, C., and Stremikis, K. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update. The Commonwealth Fund, New York and Albany, commonwealthfund.org/publications/fund-reports/2010/jun/mirror-mirror-update. aspx?page=all (accessed September 12, 2010). 4. Obama, B. Obama s health care speech to Congress. The New York Times, September 12, Gruber, J. Health Care Reform: What It Is, Why It s Necessary, How It Works. Hill and Wang, New York, Condon, S. Poll: Most Americans say Medicare is worth the cost. cbsnews.com/news/poll-most-americans-say-medicare-is-worth-the-cost (accessed April 21, 2011). 7. Kaiser Family Foundation. Kaiser Health Tracking Poll: July 2014: Share of Americans With An Unfavorable View of the Affordable Care Act Rises in July; Majority Continues to Want Congress to Improve, Not Repeal, the Law (accessed August 4, 2014). 8. Bernstein, J. Loving and Hating Obamacare with One Muddled Mind. bloombergview.com/articles/ /loving-and-hating-obamacare-with-onemuddled-mind (accessed August 26, 2014). 9. The Lancet, Americans choice for health. Lancet 380(9846):949, 2012.

10 158 / Chaufan 10. Navarro, V. The Politics of Health Policy: The U.S. Reforms, Wiley- Blackwell, Hoboken, Nardin, R., et al. The uninsured after implementation of the Affordable Care Act: A demographic and geographic analysis. Health Aff blog/2013/06/06/the-uninsured-after-implementation-of-the-affordable-care-act-ademographic-and-geographic-analysis (accessed June 6, 2013). 12. Congressional Budget Office (CBO). Insurance Coverage Provisions of the Affordable Care Act CBO s April 2014 Baseline cbofiles/attachments/ acatables2.pdf (accessed August 3, 2014). 13. Himmelstein, D. U., et al. Medical bankruptcy in the United States, 2007: Results of a national study. Am. J. Med. 122(8): , Rao, B., and Hellander, I. The widening U.S. health care crisis three years after the passage of Obamacare. Int. J. Health Serv. 44(2): , Fleming, C. Frequent churning predicted between Medicaid and exchanges. Health Aff (accessed March 2, 2011). 16. Anderson, G. F., et al. The prices, stupid: Why the United States is so different from other countries. Health Aff. 22(3):89 105, Himmelstein, D. U., and Woolhandler, S. Hope and hype: Predicting the impact of electronic medical records. Health Aff. 24(5): , Himmelstein, D., Ariely, D., and Woolhandler, S. Pay-for-performance: Toxic to quality? Insights from behavioral economics. Int. J. Health Serv. 44(2): , Woolhandler, S., Campbell, T., and Himmelstein, D. U. Costs of health care administration in the United States and Canada. N. Engl. J. Med. 349(8): , Friedman, G. Funding a national single-payer system Medicare for All would save billions, and could be redistributive. Dollars & Sense, March/April, 2012, pp Hellander, I., Himmelstein, D., and Woolhandler, S. Medicare overpayments to private plans, : Shifting seniors to private plans has already cost Medicare US$282.6 billion. Int. J. Health Serv. 43(2): , Social Security Administration. Social Security History. ssa/lbjmedicare3.html (accessed June 12, 2013). 23. California Healthline. HHS offers $150M to boost enrollment in state health exchanges. May 10, (accessed May 10, 2013). 24. California Healthline. Calif. Health exchange to spend $290M on public outreach efforts. April 13, Kaiser Family Foundation. Consumer Assistance in Health Reform. April 18, (accessed June 1, 2013). 26. Physicians for a National Health Program. What is Single Payer? facts/what-is-single-payer (accessed July 3, 2008). 27. Chaufan, C. Influences of policy on health care of families. In Encyclopedia of Family Health, ed. M. J. Craft-Rosenberg. SAGE Publications, Newbury Park, 2011, pp

11 Single-Payer Health Care after Reform / The Physicians Working Group for Single-Payer National Health Insurance, Proposal of the physicians s working group for single-payer national health insurance. JAMA 290(6): , Casalino, L. P., et al. What does it cost physician practices to interact with health insurance plans? Health Aff. 28(4):w533 w543, Lakoff, G. The policyspeak disaster for health care. Huffington Post, August 7, Real Clear Politics Video. David Gregory asks Pelosi about Pass the bill so you can find out what s in it comment /17/david_gregory_asks_pelosi_about_pass_the_bill_so_you_can_find_out_whats_ in_it_comment.html (accessed November 23, 2013). 32. Obama on Single Payer Health Care. p. https://www.youtube.com/watch?v= -hsqzskuc44 (accessed on March 13, 2013). 33. Geyman, J. Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform. Common Courage Press, Monroe, The Real News Network. Single Payer Advocates Protest Senate Hearing. therealnews.com/t2/index.php?option=com_content&task=view&id=31&itemid=74& jumival=3665 (accessed June 5, 2010). 35. Open Secrets, Presidential Candidates: Selected Industry Totals, 2008 Cycle (accessed March 29, 2010). 36. Zeese, K., and Flowers, M. Obamacare: The Biggest Insurance Scam in History. Truthout, insurance-scam-in-history (accessed November 1, 2013). 37. Stein, S., and Wilkie, C. Liz Fowler, top Obama health care aide, to lobby for Johnson & Johnson. Huffington Post, December 5, Fuchs, V. R. Health care reform Why so much talk and so little action? N. Engl. J. Med. 360(3): , Oberlander, J. Great expectations The Obama administration and health care reform. N. Engl. J. Med. 360(4): , Halpin, H. A., and Harbage, P. The origins and demise of the public option. Health Aff. 29(6): , Ignagni, K. Health insurers at the table Industry proposals for regulation and reform. N. Engl. J. Med. 361(12): , U.S. Department of Health and Human Services. Quick Guide to Health Literacy. (accessed August 6, 2014). 43. Sentell, T. Implications for reform: Survey of California adults suggests low health literacy predicts likelihood of being uninsured. Health Aff. 31(5): , Kaiser Family Foundation, A Guide to the Supreme Court s Affordable Care Act Decision (July): p pdf 45. Mandelbaum, R. Ezekiel Emanuel further explains his prediction that employers will drop health insurance. The New York Times, April 7, Ableson, R. Employers test plans that cap health costs. The New York Times, June 24, Pear, R. Lower health insurance premiums to come at cost of fewer choices. The New York Times, September 23, 2013.

12 160 / Chaufan 48. Bernard, T. Getting lost in the labyrinth of medical bills. The New York Times, June 23, ABC News/Kaiser Family Foundation\USA Today. Health Care in America 2006 Survey [cited 2006 November 15, 2006]; Available from: foundation.files.wordpress.com/2013/01/7572.pdf. 50. Kaiser Family Foundation. Kaiser Health Tracking Poll: March kaiserfamilyfoundation.files.wordpress.com/2014/03/8565-t2.pdf (accessed April 2, 2014). 51. Carroll, A. E. 5 Myths About Canada s Health Care System pnhp.org/news/2012/june/5-myths-about-canada%e2%80%99s-health-care-system (accessed April 20, 2012). 52. Carroll, A. E., and Ackerman, R. T. Support for national health insurance among U.S. physicians: 5 years later. Ann. Intern. Med. 148(April 1): , Woolhandler, S., and Himmelstein, D. U. Paying for national health insurance and not getting it. Health Aff. 21(4):88 98, HealthCareGov. Exemptions from the Fee for not Having Health Coverage. https:// (accessed August 5, 2014). Corresponding Author: Claudia Chaufan, MD, PhD Associate Professor University of California, San Francisco 3333 California St., Suite 340 San Francisco, CA

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