Linda Kimber is a 65-year-old retiree in Australia. When discussing how she was diagnosed with breast cancer last November, through a thick Australian accent, over the phone, Kimber is straightforward and direct. Frankly, she makes cancer sound like it's not a big deal.
At least one part of her treatment definitely wasn't: She didn't have to worry about the cost of the surgery, rounds of radiotherapy, and subsequent follow-ups. Unlike in the US, where the stress of financial panic often compounds a health emergency, Australia's universal Medicare system, which provides free health insurance for every citizen through a general tax and an additional levy on high-income earners, covered the bill.
Kimber says the care she received was stress-free as well. After she was diagnosed, she was given a list of doctors to choose from for her surgery, and it was scheduled for three weeks later at a public hospital. "Then they just told me a day for the operation and I came in on that day," she said. "That was basically it. From there, it was all in their hands. I've had radiotherapy. I saw a medical oncologist, and the follow-up has been absolutely fantastic. They bent over backwards."
Following her surgery, a nurse came to her house every day to check in on her draining tube. In addition, she says, the hospital gave her a large pink tote bag to carry around the instruments related to her drain tube care—and books to read while recovering. "It was wonderful," she said.
Australia's health care system is consistently ranked one of the best in the world and the best for positive health outcomes. Every Australian is covered by public insurance and the option also exists for people to buy additional private insurance. For regular doctor's visits in the public system, Australians either pay nothing or a small copay over what Medicare reimburses. (It's up to physicians to decide whether or not they charge a copay, and low-income citizens, citizens over 65, parents with a child under the age of six, and children under the age of 16 never pay a copay. Many doctors choose to waive the copay, or bulk bill, to attract patients and to make sure that money isn't a barrier to access.) And after that, if your doctor refers you to a specialist or recommends surgery to manage a condition, all visits and treatments are free.
Australia also has free, national preventative programs, since it's in everyone's best interest to detect diseases early on, when they're less expensive to treat. In Kimber's case, BreastScreen Australia, which calls in women between the ages of 50 and 74 for a free mammogram every two years, was able to detect the tumor in her breast while it was small and before it could spread to other parts of her body and cause additional, more serious complications. "Her prognosis is good," her general practitioner, Dr. Marie Shieh, told Broadly. In two weeks, Kimber has an appointment with her oncologist and an ultrasound, where she will find out if she is in remission.
When I asked Kimber if she would have wanted to go through cancer treatment in America, her answer was a resounding no. Who could blame her? In comparison, health care in the US is a gamble, and if you have cancer you might not also have health insurance.
Some people receive insurance through their employers, which might be comprehensive or skimpy, expensive or not. Others get it through the byzantine system of the Affordable Care Act exchanges, in which private insurers receive subsidies from the government in order to be able to eliminate preexisting conditions and keep costs down. People who fall below the poverty line and the elderly are insured through Medicaid and Medicare, respectively.
This patchwork of insurance schemes leaves holes everywhere. Without guaranteed, universal coverage, many Americans have to make dangerous calculations when they're sick. Instead of being automatically provided with the care that they need, they have to ask: Should I see a doctor or save the money?
Those who argue that the US government should directly pay hospitals and doctors for everyone's care are always met with the same rebuke: It's simply impossible to move the country to such a system. But it's really our current system, not single-payer health care, that should evoke incredulous reactions. Health care in the United States consistently ranks last among wealthy countries, despite being the most expensive by far.
Kimber says she doesn't know how Americans get by without the health security she has. "I think [health care in the US] is horrendous, to be honest. I think it's absolutely disgusting," she said. "If it's the middle of the night and you've got chest pain and something could be wrong with your heart, you wouldn't want to be lying there thinking that you can't afford to go to the hospital. How terrible is that?"
Dr. Shieh, now a general practitioner in Australia, used to be a family doctor in the US. Practicing medicine stateside, she saw firsthand how cruel our health care system is—and when she moved to Australia, she saw how much better it could be.
"When I was in the US, I knew there was a problem, but I didn't know what the solution could be. I worked in places where patients couldn't afford the medicines I had prescribed, where I would try to refer them to specialists and their insurance wouldn't cover those referrals, where they wouldn't come back to see me because it was too expensive," she said. "Once I couldn't order an electrocardiogram because it was too expensive for the patient. I just felt bad for people. I realized a lot of people just couldn't afford health care."
Ryan Wanninger, now 40, didn't have insurance when he was diagnosed with cancer two years ago. As a self-employed IT technician and freelance music instructor in Boston, he made enough money to disqualify him from the state's Medicaid program—MassHealth—and he didn't receive employer-sponsored insurance. Some years his IT business would do better than others, so on the good years he signed up for a health insurance policy, and when money was tight he dropped his policy and went without it.
Then the 2008 financial crisis hit. "When the economy crashed I lost half of my clientele in one week. They all called me and canceled contracts, dropped services, maintenance, everything," he said over the phone. "I had a couple big jobs that I had bid on—all of those were canceled. Every business was panicking when the economy tanked. That was horrendous." For the next few years he steadily forwent insurance because he no longer had the money to spare as he was trying to build his client list back up.
In early 2014, a few months after the ACA exchanges were up and running in Massachusetts, Wanninger finally attempted to get insurance again now that he had the money. But the state's ACA-compliant website was a complete failure. "Despite trying several times to use the website I was unsuccessful," he said. "I spoke with personnel over the phone about this because the national deadline was quickly approaching. I was first told that all applicants were having similar problems and that nobody was successfully signing up for any plans."
Wanninger says was told that because of the site's technical issues, he would be able to sign up after the national deadline. But when he tried again to get insurance through the exchange he was denied. Two months later, while Wanninger was finishing up a job, he started to feel horribly sick.
"I got in my car and I looked in the rearview mirror, and I saw my eyes were yellow and my skin was yellow. I was jaundiced," he explained. "I wasn't even sure I could drive home that day because I felt like I was going to pass out. I had to call a friend to talk to me just to keep me awake, and I drove right down to the hospital."
In the hospital parking lot, he called one of his guitar lesson clients, who happened to be a doctor there, for help because he had no health insurance or regular doctor. The doctor did blood work tests on Wanninger over several days and found large numbers of cancer antigen in his bloodstream. To find out exactly where the cancer was in his body, Wanninger needed a CT scan, but his lack of insurance became a problem.
"The CT scan was tricky," he said. "The hospital didn't want to allow me to have a CT scan—it was very expensive, a few thousand dollars, and I didn't have insurance to cover it."
Panicking and ill, he went to the counselor at the hospital to see what his financial aid options were. By some miracle, he says, he happened to be in luck: As Massachusetts's state health care system struggled with the transition to comply with the ACA, the state government allowed anyone to sign up for Medicaid, even if they didn't meet the income requirements.
The next morning he was able to meet with an oncologist, where he found out his prognosis was dire. He had a tumor on his colon, the original site of the cancer; a tumor on his liver, which had caused the jaundice; and tumors on his lungs. He was 24 hours from going into septic shock, his doctors informed him. If he hadn't been able to get a CT scan when he did and go in for surgery, he would have died.
"I'm lucky in some respects, but health care shouldn't rely on luck," Wanninger said. He was able to stay on the state's Medicaid program for seven months before the state finished the conversion to meet all the mandates of the ACA and they were able to review the cases of the applicants who had been covered by MassHealth during the transition period.
In other respects, however, he's not so lucky. By the time the seven-month period ended, Wanninger's condition worsened to the point where he had to stop working, so he qualified for Medicaid outright. When his cancer was detected it was already advanced; as of three months ago, the last treatment available to him stopped working.
Wanninger says the US health care system is to blame for his now-terminal status. "In retrospect, it was pretty clear that I had been neglecting myself and had been neglected by doctors, back when I had one, and the health system," Wanninger said in a video he made about his health care struggles in support of single-payer health care. "My father died of the same colon cancer at the age of 37 back in 1986. No one told me that because of this I should have been having regular colonoscopy screenings every three to five years, starting in my twenties." And in any case, he added in our interview, he didn't have health insurance to cover a colonoscopy.
"Health care should be a right. People should be able to have basic scans, testing, and things that can catch major diseases before they become a problem," Wanninger said. "My life will most likely be shortened because of this, and that's not fair to me. This could have most likely been prevented. A colonoscopy would have found a small tumor and it could have been removed safely."
Wanninger's treatments have all been covered through Medicaid, but, as he puts it, he's "lucky." As he works through his bucket list items—a trip to Spain funded by money his friends pooled together, a solo guitar concert that he will be putting on, which his doctors will attend—and looks to experimental trials for a possible cure, he at least does not have to file for bankruptcy. He says that within the first month of his diagnosis, he racked up $60,000 worth of bills, which he would not have been able to pay. In total, he says he treatments have cost more than $1 million.
"It's pretty obvious that the way our system is now doesn't work. We have to do something better," he said.
Despite the passage of the Affordable Care Act in 2010, 27 million people are still uninsured. Many people, like Wanninger, have been left out by the complicated scheme devised to make private insurance market tenable. People who are insured by the ACA have found that costs have been rising out of the realm of affordability because, as it turns out, giving sick people health care coverage isn't profitable for insurance firms. Even more are underinsured, meaning they have insurance that doesn't actually cover their health care costs.
Universal, single-payer insurance would entirely eliminate this dysfunction. And with the amount we spend on our piecemeal health care system—through premiums, Medicaid, Medicare, the ACA, and the VA—universal health care is not fiscally out of reach. Currently, the cost of managing chronic diseases accounts for 75 percent of the nation's health spending, according to the CDC; giving everyone access to free, preventative services would cause this to go down.
Cutting out the middleman—insurance companies—would also drive down costs. "What single-payer proposes is actually very simple," Dr. Carol Paris, the president of the advocacy group Physicians for a National Health Care program, which has written a policy paper on what single-payer could look like in the US, told Broadly. "Take all of the money we're currently spending in a very fragmented way on the financing of health care and create one risk pool. That's the single payer. It's really just a way of eliminating the administrative waste, and the profit of the health insurance industry that contributes nothing to the health of the American people."
By doing this, Paris says, we would save about $500 billion a year. "That's just by eliminating the bureaucratic waste and profit of the health insurance industry," Paris adds. "Then if we also negotiated drug prices, which we would be in a much better position to do, as a single negotiator for every person in the country, we could save another hundred billion dollars a year."
"…They don't ration care based on your ability to pay for it. No one is turned away because they can't afford care."
Paris says a single-payer system is "the only sensible way to manage the financing of health care." There are certainly flaws with Australia's health care system, as well as with the universal coverage schemes in other countries, "but it's absolutely better than what we do in the United States," she said. Ironically, a major problem with health care in New Zealand, where Paris has worked, and in Australia is that private insurers are allowed to exist alongside the public system. "But they don't ration care based on your ability to pay for it. No one is turned away because they can't afford care," Paris explained.
Now that the Republican's draconian efforts to repeal the ACA have been stalled, it's time for the Democratic party to stand up for something more ambitious; the proposed "bipartisan reforms" to the Affordable Care Act are not enough. For most people who live with the burden of the US health care system, the need for single-payer is clear. There's been growing support for single-payer over the last year, but Paris says we still have a long way to go to bring politicians on board with the idea.
"We are going to have to have a movement of movements. The American people are going to have to make it toxic for our members of Congress not to get on board with this," she warned. "When they actually feel like their ability to get elected is weighing in the balance, they're suddenly going to become outspoken advocates for a national health program, but they're not going to do it until then."
Wanninger says that if his story can help build that movement by changing even one person's mind about single-payer, that would check off another item on his bucket list.