Is now the time for single payer? [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

“Single payer is the solution. And the time for it is now.

A single-payer system would guarantee health care coverage immediately to every American. So whether a loved one gets sick from COVID, has a heart attack, or gets in a car accident, she will receive the care she needs without it causing financial hardship.

A single-payer system will eliminate employer health insurance contributions. This will provide huge relief to hundreds of thousands of struggling small businesses across the country. The money saved can go towards paying their employees a living wage or hiring new workers, which will help get our economy back on track.

A single-payer system will relieve the burden of finding health insurance from individuals. Freelancers and gig, self-employed, and per diem workers can pursue employment without having to worry about providing health coverage for their families. And with families relieved of the insecurities created by surprise medical bills and massive out-of-pocket costs, they will be more likely to contribute to our consumer-driven economy.

COVID has absolutely quelled consumerism; single payer can help to bring it back.”

Toby Terwilliger is an internal medicine-pediatric resident.

He shares his story and discusses his KevinMD article, “Is now the time for single payer?”

Did you enjoy today’s episode?

Please click here to leave a review for The Podcast by KevinMD. Subscribe on your favorite podcast app to get notified when a new episode comes out!

Do you know someone who might enjoy this episode? Share this episode to anyone who wants to hear health care stories filled with information, insight, and inspiration.

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Toby Terwilliger. He’s an internal medicine-pediatrics resident, and he wrote the KevinMD article “Is now the time for single payer?” Toby, welcome to the show.

Toby Terwilliger: Thank you so much for having me, Kevin.

Kevin Pho: So, we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Toby Terwilliger: So, I grew up in Rochester, New York. I’m the son of two middle school science teachers. Initially, I thought that I wanted to go into education like my parents, so I enrolled in one of the state universities in New York, in Geneseo, and I was initially getting ready to get my teaching certificate. But I had a roommate who was in a seven-year DO program, and he and I became EMTs together. I was involved in some cancer research, and throughout college, I kind of realized that medicine was my calling.

So I dropped the education path, did a year of research at the NIH, and then applied to medical school. I went to medical school at NYU. I was there for four years in New York City, and then I matched into internal medicine-pediatrics at Rutgers New Jersey Medical School in Newark.

Kevin Pho: And how’s everything going with the residency, and how is the pandemic affecting your training?

Toby Terwilliger: So, residency has been wonderful. I cannot speak more highly about the quality of the program and the program administration. I feel extremely, extremely supported, and I have wonderful co-residents.

The pandemic definitely shook things up in March and April, and it was something that none of us could have really prepared for, but everyone rose to the task. It was really amazing how all of the residents stepped up. They were doing many, many shifts that they weren’t scheduled for, and they were volunteering to help out extra time. April was tough. There were a lot of very, very sick patients, but we were very supported through the whole thing, and it was an experience that none of us will ever forget.

Kevin Pho: Sure. So, let’s get into your KevinMD article, “Is now the time for single payer?” Now, for those who haven’t read your article, can you walk my audience through it and perhaps share a story of why you decided to write it?

Toby Terwilliger: Sure. So, yeah, I wanted to write an article that maybe inspired some clinicians and health care providers to be more of an advocate for single-payer health care. I kind of came into health policy during medical school. When I enrolled in medical school in 2013, the ACA was kind of just starting to get rolled out, so I spent a lot of time trying to figure out what the ACA really was all about, what problems it was trying to fix, and where it succeeded and maybe where it could have gone further.

During medical school, I listened to a great lecture by one of our ER doctors, Daniel Lugassy, who gave a very impassioned lecture about the patients he was taking care of in the emergency room who lacked insurance and how they were more concerned with how they were going to pay for their care than necessarily what the outcome was going to be of their hospitalization. So he organized a bunch of us to go up to Albany, New York, and lobby some of the state assemblymen and senators in order to pass a bill that was on the table in New York State for single payer. While that bill still is in the state Senate, it was really an amazing experience, and after that, it just kind of took off for me.

So I was a founding member of the Physicians for National Health Program chapter at NYU. I’ve tried to be as involved as possible in PNHP since medical school and residency, and really, residency is kind of what has solidified everything for me. I work in Newark, New Jersey, which is a very underserved area. We have a lot of uninsured patients, and almost on a daily basis, I’m seeing patients who come to the ICU because they’ve rationed insulin because they weren’t able to afford it. I see children and their parents who are immigrants, and they’re not able to see a pediatrician because they don’t have insurance. And I see other patients to whom I’m not able to prescribe the medications that I want to because either they’re uninsured or a certain medication is not covered by their insurance.

So really, based on all that, it’s kind of solidified my belief that single payer is really what is necessary for our country and for our patients. And now, with the pandemic, seeing how many people have lost their jobs and, in doing so, have lost their employer-sponsored insurance, I think really the country is at a point where we really can build some momentum behind single-payer advocacy. And I think physicians are really, really in an integral spot where we can really make a big difference in terms of that advocacy.

Kevin Pho: So, given how our current health care system is structured, how do we get from here to there? Back when the Affordable Care Act was passed, the Democrats controlled all three houses of government, and all we got was the Affordable Care Act. So, given the structure of our government, how do you propose that the United States adopt a single-payer system?

Toby Terwilliger: Sure. It’s a really challenging time. I’m not a political science major, but it’s a very politically challenging topic. I think there are some proposals out there to get rid of the filibuster in the Senate so that if Democrats were able to get back a majority, they would be able to pass a single-payer bill, possibly through the House and then through an unfilibustered Senate. So they would only need 51 votes, and then we’d have to have a president who’s willing to sign it into law. And I know thus far Biden has been resistant to that.

But I think with the appropriate kind of public health campaign and advocacy on our part, and the part of our patients and whoever else feels passionately about this, I think eventually we can build the kind of political pressure that will lead to real change.

Kevin Pho: So, what are the arguments that opponents against single payer have? Of course, the cost. And single payer had been tried in Bernie Sanders’ home state of Vermont, and it wasn’t successful because of the cost. And I was wondering if you could comment on that, and if it couldn’t survive in, say, Vermont, how can it pass nationwide?

Toby Terwilliger: Yeah, and those are great questions, and they get brought up very frequently. So, I think one of the things that people don’t realize when they’re talking about the cost of single payer is how much we’re already spending on health care every single year. Our country is already spending close to $4 trillion on health care a year, and there have been a variety of studies that have shown that single payer is going to cost either the same or less than what we’re already spending. It’s just how we’re paying for it that’s changing.

So now, we have a very fragmented system, where part of it’s coming out of insurance premiums, part of it’s coming out of co-pays, part of it is coming out of the bills that you get from the hospital, and then part of it’s coming from the government, hospitals, and insurance companies. In a single-payer system, the government is the sole payer for health care. So instead of the $4 trillion coming out of these various sources, most of which ends up being put onto us, the people paying into the insurance companies, it all comes from a centralized form, such as the government. So it’s really not about it costing more. It’s about redistributing the money that’s already there to have it work better and more efficiently, as well as restructuring the system that exists.

And in terms of why it didn’t work in Vermont, I think that’s a very valid point. A lot of states have tried and failed to pass single-payer plans, and a big issue is that you need to have a big enough marketplace for this to work. You have to have enough people buy into the pool, the insurance pool, in order for it to work. And also, there’s a lot of crossing of state borders that can complicate things as well. So it’s not surprising that it might fail on a state level, but I really think with the greater purchasing power that comes at a national level, it really would have a greater ability to cut costs and insure everyone.

Kevin Pho: Now, when we’re talking about reforming our health care system, there’s really a couple of approaches. Of course, there’s the single-payer Medicare for All option, of course, and then strengthening what we already have, which is Joe Biden’s approach, by perhaps further regulating the marketplace and strengthening the Affordable Care Act. In the world, there are other health systems that offer universal coverage without single payer, like in Switzerland and Germany, that have highly regulated insurance products. What are your thoughts about some of those other options? Does it have to be only single payer? What about some of the other systems that are used throughout the world?

Toby Terwilliger: Yeah, so I think that single payer is the best way that we can insure everybody and most cost-efficiently. I think ultimately the goal has to be to achieve universal coverage. However we get there, that needs to be the ultimate goal, and there are other ways to do that, for sure. Like you said, a lot of other European countries have variations on it, where they still have market-based insurance, but it’s just more heavily regulated. And I think something like that could potentially work in the United States.

But right now, we have so much waste, in that insurance companies are bringing home record profits. Pharmaceutical companies are charging so much higher, sometimes six, 10 times higher, in the United States for drugs than in other countries. MRIs might be two to three times more expensive in the United States. All of these things need to be addressed in order to cut costs as well, and I think single payer does that most effectively. But that’s not to say that there aren’t other ways to get to universal coverage, as long as we also are taking these steps to help cut costs.

Kevin Pho: We’re talking to Toby Terwilliger. He is an internal medicine-pediatrics resident. He wrote the KevinMD article “Is now the time for single payer?” Toby, one of the issues that physicians push back on with single payer is that it’ll cut their pay, right? Physicians’ salaries will be regulated. Now, in a climate where American medical students often graduate over $200,000, $300,000 in debt, and physicians in America pay more in malpractice premiums compared to the rest of the world, what do you say to that critique?

Toby Terwilliger: Yeah, that’s a huge issue, and that’s on the top of a lot of physicians’ minds when they’re graduating from medical school, when they’re choosing their residency, when they’re choosing whether to subspecialize, and then when they’re trying to find out what job they want. They want to be able to pay off their loans and have the kind of lifestyle that they have thought of for themselves. I think that this needs to be a part of a bigger structural change in the way medical education is paid for and in the way that malpractice insurance is paid for and delivered, and I don’t think that this can all happen in a vacuum.

I think it’s very likely that physician salaries will be cut in a single-payer system, and I think the specialties that would be affected the most are the ones that tend to be the higher-paying specialties, whether that’s plastic surgery, orthopedics, or interventional cardiology. It needs to be addressed that physicians choose those specialties oftentimes because they know that they’re higher reimbursing, and they come out with half a million dollars in medical debt. And whether that is having loan forgiveness, whether that is making medical school more affordable for people, two years after I graduated, NYU announced that they were making medical school tuition free. So if more schools did that, I think that it would open up physicians to be able to practice and not expect the $600,000, $800,000-a-year salaries that they get now in some of these specialties.

Kevin Pho: So, in your opinion, given the current political climate, do you see single payer happening within the next decade in the United States?

Toby Terwilliger: I do, I do. I really think that the pressure is going to continue to build and that people are just so fed up with the system that we have right now, a system where patients are thrown around by their insurance companies. They don’t know when their bill is coming or how much it’s going to be. Doctors are getting fed up with going through insurance companies to try to get prior authorization or to figure out how much a procedure is actually going to cost.

And I think that there is this heightened sense of responsibility among younger physicians to advocate for our patients. When we see huge swaths uninsured, when we see people who are forgoing medications because they can’t afford it, I think there is going to be a lot of pressure in order to pass universal health care, and I think that’s going to wind up being single payer, honestly. I think the pandemic has really just put that all in the forefront. We see the health disparities that are heightened during the pandemic. We see how many people are losing their jobs. And I think that single payer is coming. I’m hoping that it’s sooner rather than later.

Kevin Pho: And my final question, Toby: Do you have a take-home message that you want to share with the KevinMD audience?

Toby Terwilliger: Yeah. Well, thank you so much for having me, Dr. Pho. So, I think my take-home message is this: This is such a pivotal time in our country, and I think many of us, especially the younger trainees, have never seen anything like this going on. And I think you can argue that this is a once-in-a-lifetime kind of event for physicians. We’re seeing how all of the disparities that exist in our health care are really brought to the forefront.

I think it’s our obligation, our moral responsibility, to stand up for our patients, to advocate for them, and I think that we can be the agents for positive change. And I really hope that my piece and us doing this interview can inspire some other young or older physicians to really get involved and hopefully make a better future for us and our patients.

Kevin Pho: Well, thank you so much for sharing your time and insight. Thanks again for being on the show.

Toby Terwilliger: Thank you so much. I really appreciate it.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes