Interview: Kevin Grumbach: Single Minded for Single Payer

By Andy Evangelista

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Profile: Kevin Grumbach, MD, chair of the Department of Family and Community Medicine, has been one of country's leading proponents of a single-payer national health insurance program. He is also the director of the UCSF Center for Workforce Studies and a researcher for the UCSF Medical Effectiveness Research Center for Diverse Populations. His studies on the health care workforce, access to care and minority health issues have been widely published and cited by national public-policy makers. He also practices family medicine and is chief of Family and Community Medicine at San Francisco General Hospital Medical Center.

What happened to the national health care reform movement of 10-15 years ago?

There was a point when we thought we had turned the corner. In 1993, President Clinton pledged universal health insurance. We had Proposition 186, the "health security" initiative, which was even more ambitious than the Clinton plan, on the ballot in California. But it was defeated (73% to 27%) after huge opposition by the insurance industry. That same year, the Clinton plan — the Health Security Act — went down in flames without even a vote by Congress. The conservatives, using the "Harry and Louise" commercials, frightened Americans with messages of Big Government, more taxes and no flexibility in insurance choices. We hit rock bottom in 1994. The Republican majority ruled in Congress, and for several years no one wanted to talk health care reform.

In 10 years, we've seen the same dreadful cycle — rising costs, deteriorating coverage, the number of uninsured increasing by more than 1.4 million a year, a middle class that is being squeezed. It's still the same mess. More than 45 million Americans were uninsured in 2003 — that's almost 16 percent of the population (according to a report by the Census Bureau). In the last three years, five million workers lost insurance that was paid by their employers [Kaiser Family Foundation report], and for those who have employer-paid insurance, their premiums climbed more than 11 percent last year. An Institute of Medicine report estimated that 18,000 people die each year because they don't have health insurance. As long as there is a health care system that is unfair, there will be people who want to change it.

You have studied and backed a Canadian-style, single-player plan. Why is this plan best?

The simplest way to guarantee coverage for all Americans is to make everyone in the US automatically eligible for health care under a single public plan. A single-payer plan would be like Medicare, except it would cover everyone, regardless of employment status or income. No one would have to worry about being denied care because they couldn't pay for it, nor would anyone have to worry that if they lose their job, they will lose their insurance, too. A single-payer system — in which the government reimburses providers — would have much lower administrative costs than our current system of complicated health plans and waste. There are doctor's offices that have more people working on eligibility forms than on patients. As much as 25 percent of health care spending goes to insurance. As a clinician, it's incredibly frustrating. I've seen cases of mothers and fathers who had to choose between their health and their family's financial well-being, people with high blood pressure who don't get medications and later suffer a stroke.

Critics argue that such a national single-payer plan will backlog and ration care — what is your response?

I find it hard to believe that we can't take the $1.7 trillion we spend annually on health care in the US — 40 percent more per capita than any other nation in the world — and not provide every American high-quality, accessible health care. Every reputable group — from the CBO [Congressional Budget Office] to the GAO [Government Accountability Office] to independent analysts — that has examined the economics of single-payer health insurance in the US has concluded that the amount of money that would be saved from curtailing administrative waste and excess profits would more than offset the costs of expanding care to the uninsured and underinsured.

This is not to deny that, once a single-payer system was implemented, we would have to become more rational in our approach to the diffusion of new technology and costly medical interventions to make sure that we are deploying them appropriately and efficiently. But here again, this is not necessarily an approach that would compromise quality of care. Given the epidemic of medical errors in the US today and the ever-present risk of harm from overzealous medical care, a more rational approach to the deployment of technology would likely make sense from both a cost and quality perspective.

What kind of health care plan can we expect from a reelected President Bush?

We will continue to experience the degradation of true security in our land: health security, social security, the security of a sustainable environment.

I believe President Bush will escalate his attack on government programs in health and other domestic programs and be emboldened in his goal of privatizing public programs. The Medicare reform during President Bush's first term is emblematic of what lies in store. Under the guise of adding a new prescription drug benefit to Medicare, the Medicare reform act was a massive giveaway of taxpayer money to drug companies and private health insurance plans. The act explicitly banned the one public policy that other nations have effectively used to control the prices of prescription drugs — namely, direct government regulation of drug prices.

What is the biggest roadblock to a universal single-payer plan in the US?

The fundamental problem is an underlying skepticism among Americans about the role of government in health care, exploited to the hilt by the special interests profiting from the status quo. Anytime that genuine reform gains momentum in the US, the drug companies, insurance companies, and other special interests mount shamelessly expensive and distorted PR campaigns designed to instill fear into the American public that their own health care will suffer if national health insurance is implemented.

The rhetoric has been essentially the same for the past 50 years: National health insurance would amount to a socialist takeover of health care with the government taxing you to death and telling your doctor how to practice medicine. The fact that all objective evidence from other nations indicates that people are better served by national health insurance tends to be drowned out by 30-second commercials shouting, Big government! Big taxes!

Will health care reform have to happen in individual states first?

Certainly one scenario is for a few states to implement ambitious universal coverage plans that could serve as demonstration models for the feasibility of this approach in the US. In California, for example, SB 921 [introduced by State Senator Sheila Kuehl, D-Santa Monica], would insure everyone in the state under a single-payer plan. In Canada, Saskatchewan was the first province to enact a public, universal health care plan after World War II. The plan proved to be so popular that other provinces soon followed suit. In 1971, the provincial plans were coordinated under a national health insurance act that added federal tax dollars and federal regulation for the provincial plans.

What are the most glaring examples of current health disparities? What is the first step to correcting them?

The most glaring is the 45 million Americans who are uninsured. I put this number one on my list because not only is there abundant evidence that lack of insurance extracts a heavy toll on people's health, but also because it is an eminently fixable problem. We could solve this problem tomorrow if there were the political will to enact universal coverage.

Another glaring problem is racial and ethnic disparities in health care and health. For example, African Americans have the highest mortality rate for 10 of the 12 leading causes of death in the US. But eliminating racial and ethnic disparities doesn't have a simple fix akin to enacting universal health coverage to eradicate the blight of lack of insurance. The causes of racial and ethnic disparities are multifactorial and deeply rooted in our national heritage of racism and discrimination. It's worth remembering that it was only 40 years ago that the enactment of Medicare forced an end to "separate and unequal" policies existing at the time in a preponderance of US hospitals, through Medicare's refusal to pay hospitals that maintained formal policies of racial segregation.

Your studies have shown that minority health professionals are much more likely to practice in underserved communities and care for uninsured patients. Still, academic institutions, including UC, lag in their enrollment of minorities. What is the first step to correcting this problem?

The first step is a renewed commitment to promoting diversity by leaders of academic health centers such as UCSF. A recent Institute of Medicine report made clear that creating better institutional climates for diversity begins at the top. In my view, improving the institutional climate for diversity should be as much of a priority for UCSF leaders as building new labs and hospitals at Mission Bay and competing for NIH research funding. I am encouraged by some recent developments on campus that suggest that our leadership is willing to take a more self-critical look at our current institutional commitment to diversity and develop a more energized strategic plan to once again make UCSF a national leader in this area.

UCSF's future plan is to create specialty hospitals at Mission Bay. As one of the chief proponents of primary care education and practice, do you favor such a plan?

The choice to build a new hospital at Mission Bay for women's and children's services and cancer programs is logical based on the needs of the medical center and the types of programs that would function well in a new and modest-sized hospital facility. My only concern is that we don't forget to always ask the question, How will a new hospital at Mission Bay address the most compelling health needs of the people of San Francisco and the Bay Area? From where I sit as a family physician working at San Francisco General Hospital, I see families in the southeastern neighborhoods of San Francisco ravaged by gang violence and unemployment, and facing inadequate primary care for basic conditions such as asthma and diabetes, mental health problems and substance abuse treatment. As we build a gleaming new hospital a stone's throw from Bayview-Hunters Point and Potrero Hill, we should be doing a bit more introspection about how this project will benefit those nearby communities in SF suffering the worst health care disparities. One strategy to at least partly address this issue would be to find a way to co-locate the UCSF Mission Bay Hospital with a new SF General Hospital, since SFGH is also facing a state-mandated deadline to build a more seismically sound acute care facility.

How did a white male become such a champion for minorities and the underserved?

Maybe the better question is why so many people are willing to tolerate the dehumanizing experience of perpetuating social injustice — or at least of looking the other way. This is of course a hard question to answer and I doubt I have much real insight into what motivates me. I don't know that I well up with tears whenever I hear a Martin Luther King Jr. speech on the radio or TV or walk through the FDR memorial in DC and read the excerpts from his speeches etched into the granite stones of the monument. These issues move me.

This work, however, is not about one individual, but rather about a social movement involving lots of champions. Some with UCSF ties come to mind.Bree Johnston, who is based in the geriatrics unit at the VA Medical Center, has been president of California Physicians Alliance for several years and a real champion of universal coverage. Vishu Lingappa, a professor of medicine, and his family physician wife, Krista Farey, coauthored Proposition 186. He is determined to create a biotech company that will translate his research into commercial products, with the goal of using the profits to fund a campaign for universal coverage in California.

Tom Bodenheimer, a professor of family and community medicine, has spent a lifetime crusading for social justice in health care. He received an award from the Senior Action Network recently for his work on Medicare policy and politics. Charlene Harrington, professor of sociology and nursing, co-wrote the Physicians for a National Health Program paper calling for universal long-term care insurance and is one of the most respected advocates for improved access and quality in long-term care. And James G. Kahn at the Institute for Health Policy Studies drafted language for a single-payer plan that contributed to the development of State Senator Sheila Kuehl's SB 921 bill, which is still active in the state legislature. So there are many people at UCSF playing very meaningful roles in advancing the cause of universal coverage.

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