The End Of Insurance?

Due to a proofreading error, the print version of this interview left readers hanging: the last word was missing.

The word is “take.”

We are embarrassed by the mistake and apologize to our readers, to interviewer Tracy Frisch, and to Dr. Coates.

— Ed.

 

As a boy growing up in rural upstate New York, Andrew Coates dreamed of becoming a physician. After high school he went through a period of rebellion, dropping out of college and supporting himself with jobs as a carpenter and in factories and restaurant kitchens. Returning to his education, he earned a master’s degree in American history before finally entering medical school at Columbia University at the age of thirty-two. Coates jokes that, unlike most doctors, he “once worked for a living,” adding that he believes his experiences as a young man have benefited him as a physician.

After a residency in internal medicine, Coates took a position at an Upstate New York hospital. There he saw how patients and their families were often made destitute by the high cost of healthcare. In particular, nursing-home care, a necessity for many who survive a devastating illness, is unaffordable for most people. Medicare covers everyone over the age of sixty-five but allows only limited stays in nursing facilities. Medicaid — a joint state-and-federal program for poor Americans — does cover long-term nursing-home care. But to become eligible for Medicaid, people must first empty out their bank accounts and sell their homes and other assets to pay medical bills. Coates saw medical expenses lead to the forfeiture of a family farm, even though three generations were living on the land.

Coates went on to further specialize in hospice and palliative care, which focuses on relieving the pain and stress of serious illnesses. (Hospice patients, for whom death is expected, make up a limited number of palliative-care patients.) In his palliative-care practice he helps people make difficult decisions about care, finding choices that reflect what’s most important to them, with an emphasis on quality of life for the patient and the family. Presently a full-time hospital-medicine physician, he also teaches medical students, interns, and residents at patients’ bedsides as well as in the classroom as a professor of medicine at Albany Medical College.

Coates’s early experiences in the profession have made him an advocate for a single-payer healthcare system, in which the government pays the medical bills of all its citizens, not just the poor and elderly. A public, national health-insurance program would eliminate the need for private health insurance altogether. Vermont senator Bernie Sanders made support for single-payer healthcare a centerpiece of his campaign for president in 2016. Coates believes we need to go a step further than Sanders proposes and also abolish profit-seeking in medicine.

I first became aware of Coates’s work many years ago when I heard him speak at a rally. He is the founder of the healthcare advocacy group Single Payer New York (singlepayernewyork.org) and past president of Physicians for a National Health Program, a physician organization that advocates for a single-payer healthcare system (pnhp.org). He and I spoke on a muggy evening last fall at his home, an old farmhouse surrounded by a suburban neighborhood. We talked for several hours about the inadequacies of the current U.S. healthcare system and his vision of what might replace it. He told me that he continues to find medicine an “incredibly compelling human endeavor.”

 

Frisch: You’ve been an outspoken champion of a single-payer (publicly funded) healthcare system, which is sometimes known as Medicare for All.

Coates: In my view, single-payer is an incremental step, a reform that pushes us toward a truly efficient and responsible system of healthcare. Single-payer is far from perfect and will not work without a few hard rules, including the elimination of out-of-pocket patient spending for necessary care, a system to annually budget for anticipated health needs for each community, and completely banning profiteering in medicine.

Frisch: Including for pharmaceutical companies and medical-equipment manufacturers?

Coates: Yes. There should be no profiteering in the delivery of healthcare. I’m not talking about whether highly trained physicians, nurses, or their support staff should be able to make a handsome middle-class living. As a society we should be proud to support professional caregivers. That’s different from people making money simply because they own the laboratory or the hospital or the distribution system. For example, nursing homes in the U.S. are mostly owned by private-equity firms like Warburg Pincus, Bain Capital, GE Capital, the Carlyle Group, and others. These corporate owners in turn hire myriad subcontractors to run every aspect of the home, from the kitchen to the janitorial service to the electronic health records to the laundry. And at every step there is someone taking a profit out.

I think it’s appalling that one person’s illness would be an opportunity for another to make money. The care of human beings should not be a commodity. Since the dawn of time people have done their best to tend to the injured or sick. That’s something very basic to humanity. When caregiving becomes a commodity, the goal of health collides with the goal of wealth. In American healthcare today an unbelievable number of interlopers have entered the fray. Their job is to figure out how to extract funds that could otherwise have gone to help the sick.

But the problem isn’t just that there’s money going out of the system. It’s also that this enormous, unnecessary insurance bureaucracy sits on top of the system, making it extremely inefficient.

Research shows that for-profit medical institutions produce inferior outcomes compared to not-for-profit institutions. If we change to a single-payer system, a bedrock requirement should be that all medicine be not-for-profit.

Frisch: What’s wrong with a for-profit system?

Coates: For one, money is often spent in the wrong places. In our town there are two big hospitals, and both have fancy parking garages and gleaming pavilions with pianos that play themselves. I’m not sure how all of this has improved the quality of care.

Frisch: It sounds like they’re just trying to attract patients.

Coates: Sure, if you have a spiffy parking garage and a nice pedestrian bridge that leads right into the ambulatory-surgery center, maybe that gives you a leg up on the competition. These hospitals are not-for-profit, by the way, but they’ve learned to operate like for-profit hospitals in order to compete. Wouldn’t it be something if the people of the community could decide what the experience of getting care should be like, rather than having competition drive showy expenditures? We could address real concerns, such as preventive care.

Frisch: The Affordable Care Act — also known as Obamacare — required that certain preventative services, such as cancer screenings and immunizations, be offered without deductibles, to make it more likely that people will get them.

Coates: Ending out-of-pocket costs is another part of what I see as the bedrock of healthcare reform. When people have to pay out of pocket for necessary care, they often avoid getting it. The policy term for out-of-pocket payments — whether it’s copays, deductibles, coinsurance, or cash payments — is “user fees.” Study after study finds that user fees amount to bad health policy.

Frisch: But if there’s no cost to the patient, what will prevent people from willy-nilly asking for all kinds of tests and procedures and specialists? Wouldn’t we have a hypochondriac’s paradise?

Coates: There’s almost no evidence that this would happen. In places where there’s been an expansion of access to healthcare — like when the U.S. enacted Medicare in 1965 — the system was not sunk by a glut of people seeking unnecessary treatment.

Frisch: A few days ago I spoke to a man who had retired from the police force with good health coverage and was now on Medicare and purchasing supplemental private insurance. He insisted that everyone should pay for healthcare, even poor people on Medicaid.

Coates: What about the nursing-home patients who can’t possibly work because they need round-the-clock care? What about sick children who aren’t yet old enough to have a job or will never be able to work? Is there a right time of life to get cancer, or have a heart attack, or contract an overwhelming infection?

Frisch: I think this former police officer feels he paid his dues. Why should he pay more to care for someone who doesn’t work?

Coates: If we all pay a small percentage of our income into the system, we can ensure that everyone gets care. Sure, some of us, disabled by illness, will not be able to pay. But the rest of us should proudly contribute, with the understanding that we are building a system that protects us all. Who knows when we might suffer an illness that renders us unable to work and therefore unable to contribute? Providing care to the most vulnerable is not altruism. It’s a form of social solidarity that benefits us, too, because someday we will likely need that system ourselves.

Frisch: Some people think undocumented immigrants are abusing the system.

Coates: If you’re undocumented and receive a paycheck, as most undocumented workers do, money is withheld from that check for Social Security and Medicare benefits that you will never be eligible for, because you don’t have a legitimate Social Security number. All of that money goes into the public till. Incidentally, the retired police officer you mentioned, who’s getting Medicare benefits, has his healthcare paid for in part by undocumented laborers. Meanwhile an undocumented worker who paid into Medicare and Social Security will never receive either. Our country’s cruelty toward undocumented immigrants is most shockingly revealed by medical deportations. Sick, hospitalized patients are flown by air ambulance back to their country of origin. This is unethical and a violation of human rights. Some are patients who need dialysis to stay alive after kidney failure. Many times the patient’s home country lacks the infrastructure to provide dialysis, so deportation can amount to a death sentence.

Frisch: Was the Affordable Care Act a step forward?

Coates: The ACA was one step forward, two steps back. It expanded Medicaid eligibility — in the states that chose to participate in the expansion — and also increased funding to health centers that provide care for underserved populations. These measures helped patients gain access to healthcare who previously couldn’t afford it.

Frisch: What about the individual mandate, which requires everyone to buy insurance?

Coates: The mandate has a curious history. Originally thought up by the Heritage Foundation, a conservative think tank, it was first implemented in Massachusetts by the private-equity millionaire and Republican governor Mitt Romney. The idea was to bring the magic of the marketplace to health insurance by forcing everyone to buy it or pay a fine. Barack Obama, the Democratic president, chose to champion the idea for his signature reform effort, initially expecting bipartisan support.

Under the ACA around 20 million Americans gained coverage, mostly through the expansion of Medicaid. These people would not have had insurance otherwise, and I’m sure this saved lives. But many features of Obamacare got much more credit than they deserved. For example take the policy of letting parents keep grown children on their insurance up to the age of twenty-six. The twenty-somethings who benefited all had parents with adequate insurance. That’s a relatively affluent portion of the population. Millions of young adults whose parents had inadequate or no coverage were left out. Nevertheless, within that group who did benefit, there were people who had life-threatening illnesses caught early and as a result got treatment.

Frisch: That’s the one step forward.

Coates: Yes. Then there are the two steps back. To make premiums as low as possible, the Obama reform opened the door for more plans with high deductibles or narrow networks of providers. Deductibles have risen and risen. We routinely hear about patients spending thousands of dollars out of pocket before the insurance kicks in. In short, costs have been pushed onto the sick.

In addition, the Affordable Care Act led to an enormous wave of corporate conglomeration — among hospitals, primary-care networks, insurance companies, and pharmacies — creating huge new entities, all in the search for profit and market share. Large corporate healthcare companies drive costs up, not down.

Frisch: If we had a publicly funded system, wouldn’t there be a constant danger that the party in power might deprive it of resources?

Coates: Sure, but healthcare funding always requires public vigilance, scrutiny, and participation. What better way is there to monitor health outcomes than to make the system public? Some government services are already widely viewed as necessities: having an adequately equipped fire department, for example. An effort to turn firefighting to a private, profit-seeking venture seems ludicrous. In healthcare, if people were used to having access to top-quality care, I believe it would be difficult to starve the system of resources. The health of the people — I can’t think of a more legitimate topic of public discourse for any modern democracy.

Frisch: Would health-insurance companies disappear?

Coates: Hopefully, yes. Competing private health-insurance companies are a very inefficient way to fund healthcare. The idea of insurance is that the larger the risk pool, the more evenly the costs are distributed. So the most perfect risk pool would be everyone in, nobody out. But that’s not how private insurance works. Instead it’s a perverse competition. Insurance companies are not competing to give the best coverage to those who need it most: the sickest among us. They don’t even want those customers. Health-insurance companies compete to find the patients who are both healthy and wealthy, so they will buy policies but not use them.

Frisch: Many employers offer some form of health insurance to their employees. Does that system work?

Coates: Big corporate employers spend so much on healthcare that it affects other decisions they make. Some employers are starting to realize that universal access to healthcare would give them more freedom. There was an entrepreneur in West Virginia who wanted to start an aerospace manufacturing company about a decade ago. I met him. He wanted to put the plant near his hometown, but his investors insisted he put it in Ontario, Canada, because the company’s healthcare costs would be so much less there.

On the other hand, some employers use employer-sponsored health insurance as a form of control over workers.

Frisch: Because employees don’t dare quit?

Coates: There’s job lock. If you have a sick person in your family on your plan, you’re afraid to leave your job, because your loved one needs the coverage. But I’m also thinking of how messed up it is to depend on your employer or your spouse or your parents for health coverage. Other forms of social control include how some employers demand a note from a doctor if you take sick days. And when you start a new job, if it offers health insurance, there’s a probationary period — three, six, or even twelve months — before you have access to the benefits. And I’ve heard of other insidious practices, like smokers having to pay more than nonsmokers and employees having to prove that they exercise.

Frisch: Some employees go on strike because their healthcare is so bad.

Coates: If you try to organize a strike, you will find your health insurance canceled as soon as the strike starts. Most union contract bargaining gets stuck over health benefits these days. With universal healthcare, unions could instead focus on wages and working conditions. Single-payer reform would strengthen the unions and prove incredibly liberating for working people.

Frisch: What do you think fuels the intense antipathy toward universal healthcare among so many politicians in both major parties?

Coates: I can’t say. In my interactions with everyday people, I don’t find much, if any, antipathy toward universal healthcare. Last week I was in Long Lake, New York, in the Adirondacks. I didn’t hear opposition there to the idea that every human being who needs medical attention should get it. Politicians loudly oppose universal healthcare, and yet they stop short of openly advocating that some human beings should be denied the care they need. The author of a U.S. Senate bill that would have enormously curtailed Medicaid across the country, throwing millions of people off the rolls, went on TV and lied and said his bill wouldn’t hurt those people. Talk-show host Jimmy Kimmel, whose son was recently born with a congenital heart condition, called out his lies on late-night TV.

Virtually all developed nations provide universal access to healthcare in some way. The single-payer model has worked well in Taiwan and Canada. Germany is an example of a multi-payer system, but government regulation ensures that all costs are uniform, whether you’re insured through a community organization or a company or a religious group. Scotland has a purely public health service, where every physician and nurse gets a paycheck from the government. Spain has the right to healthcare in its constitution. We could go on. The only developed country that has designed its healthcare system to leave people out is the United States.

It’s appalling that one person’s illness would be an opportunity for another to make money. The care of human beings should not be a commodity. Since the dawn of time people have done their best to tend to the injured or sick. That’s something very basic to humanity.

Frisch: How do U.S. health outcomes stack up against those in nations with universal healthcare?

Coates: Compared to other developed, wealthy nations, the U.S. comes in last across many indicators of health status. On a worldwide scale, dozens of countries have better health indicators than the U.S. Over the last couple of decades maternal mortality — the preventable death of pregnant women — has gone down in almost every nation on earth, but in the U.S. it has gone up. It’s shocking to think that our country, with so much talk about family values and so much debate about the unborn and so much attention to healthcare, would have worsening maternal mortality.

Frisch: Why is maternal mortality going up here?

Coates: The reasons are myriad, but the most glaring is that the wealthy have gotten super-wealthy, while the poor, who are many times more numerous than the rich, have gotten so much poorer. Women at the bottom aren’t getting proper prenatal care. Some life-threatening conditions that occur during pregnancy, such as eclampsia and gestational diabetes, can be prevented or treated if they are caught early. Too often they aren’t.

Frisch: Aren’t per capita healthcare expenditures in the U.S. also much higher than in other developed countries?

Coates: The U.S., on average, spends twice as much as most other developed nations on healthcare. That’s both per person and as a percentage of gross domestic product. We’re talking about a total of $3 trillion a year, or about ten thousand dollars per person annually. And more than half that money already comes from taxpayer dollars. In effect, we’re paying for national health insurance, but we’re not getting it.

Frisch: Where does all that taxpayer funding go?

Coates: Toward Medicare and Medicaid, health benefits for public employees, and tax credits that help employers pay private insurance companies. Of course taxes also fund veterans’ hospitals, the Indian Health Service, federally funded health centers, and research institutions like the Centers for Disease Control and Prevention and the National Institutes of Health and many other programs. The point is that public spending already allocated should be adequate to meet our full healthcare needs.

Cuba is an interesting comparison. It spends something like a fourth of what the U.S. spends on healthcare per person, but Cuban people have about the same health outcomes as Americans, including life expectancy, infant mortality, and so on. One reason for this is that Cuba has trained so many doctors. In fact, there are more doctors per person in Cuba than anywhere else in the world. And Cuban doctors learn not only to spend more time with their patients but to care for entire communities. What Cuba lacks in monetary resources appears to be compensated for by their many doctors.

Frisch: Could it be that our healthcare outcomes are worse because the pressures of contemporary American life and the food we eat are making us sick?

Coates: There are indeed great pressures. And it’s important for everyone to eat healthy, which is challenging for the poor, who often don’t have access to fresh fruits and vegetables in their neighborhoods. Yet comparative studies have been done, and controlling for the American diet and other lifestyle choices does not explain the inferior health outcomes in the U.S. For example, European nations with longer life expectancies actually have more smokers. In the U.S. we have many more people who live in poverty than European countries do. And we lead the world in incarceration. Poverty and the stress that comes with it have devastating health consequences. With growing income inequality, there’s a case to be made that Americans’ health is becoming worse, mostly for those at the bottom. People work two and three jobs and still can’t make ends meet. Intense social pressure leads to personal disaster. People become more prone to alcoholism and opiate addiction. Domestic violence devastates families. With economic insecurity people find themselves constantly on the move and without a sense of community. Many who are better off are now facing growing insecurity as the middle class disappears. In the hospital I see a stark picture that connects statistics with real human lives.

I’ve written about an uninsured landscaper who didn’t have a steady winter job. He ran a snowblower and drove a plow, but the work was pretty sporadic. When there was a major snowstorm, he tried to work a twenty-hour day, to make up for lost wages. But because he had an infected tooth and had not been able to eat much for a few days, he collapsed after sixteen hours. I ended up admitting him to the hospital.

Frisch: Did he survive?

Coates: Yes, he’s OK. I felt a little helpless, because all I could do for his tooth infection was prescribe antibiotics. We see so many social problems at the hospital, which often provides a refuge for people who have no place else to go. It’s distressing and makes me even more determined to fight for a single-payer healthcare system.

Frisch: Why didn’t the U.S. adopt some form of universal healthcare when other countries did?

Coates: The U.S. began to discuss national health insurance around the same time as European nations: in the early twentieth century. At the start of the 1930s a blue-ribbon commission called the Committee on the Costs of Medical Care recommended a system of compulsory insurance and healthcare planning for the whole country. The American Medical Association [AMA] attacked the idea as a communist plot, even though the panel was led by the Republican president of Stanford University, a medical doctor who had also once been the head of the AMA! President Franklin D. Roosevelt, who was inaugurated within weeks of the report’s release, chose to avoid the matter.

When World War II came along in the 1940s, the country entered an enormous industrial boom, and the government imposed a wage freeze to help the war effort. Looking to attract workers, employers offered healthcare benefits instead of higher wages. By the end of the war, employer-sponsored private health insurance was entrenched. After the war, in the United Kingdom, the Labour Party established the National Health Service, guaranteeing necessary medical care to everyone. As the troops came home in the U.S., the government expanded benefits and guaranteed healthcare for veterans, and President Harry Truman began to champion the idea of national health insurance. In response the AMA hired a Madison Avenue advertising firm to counter Truman’s initiative. They came up with the term “socialized medicine” to defeat Truman’s agenda, again disparaging the idea as a communist plot.

Frisch: Did the AMA represent the way most physicians felt?

Coates: That’s a good question. Probably not. I think the AMA was dominated by the most money-conscious members of the profession, who feared national healthcare would mean lower pay for the wealthiest doctors.

Frisch: One of the arguments against single-payer is that it can cause long waits for treatment. How do waits under Canada’s single-payer system compare with what we face in the U.S. today?

Coates: Let me tell you a story. I see many low-income patients. For example, a man may have a meniscus tear — a chronic knee injury that can be repaired with arthroscopic surgery — but he has no insurance. The elective surgery would require an exorbitant cash payment. His wait time for arthroscopic surgery is effectively infinite — or, at least, until he gets insurance that covers it. But no one is tracking those kinds of wait times in our country.

It’s true that, in Canada, wait times for elective surgeries — especially orthopedic surgeries — have sometimes been frustratingly long. A Canadian who needs arthroscopic surgery might not get into the operating room for many weeks. This has provoked public outrage in Canada, because it’s seen as a disgrace to the nation, as it should be. As a result of all this hue and cry, wait times for elective procedures are improving there. And I should emphasize that we’re talking about elective, not emergency, interventions.

Can we compare wait times in Canada and the U.S. if we don’t keep records on wait times here, while the Canadian data is public? Wait times are an ideological talking point used by people who want to privatize even more of the healthcare system.

Frisch: Are you satisfied with the sort of care people get in the U.S. when they do go to the doctor?

Coates: No. In my experience it’s too often undignified. Countless patients have been refused care or misdiagnosed or given inappropriate prescriptions. We recently discharged a man from the hospital to home hospice because he had a terminal brain tumor. During the discharge meeting, his daughter and son told us how over the previous year his insurer had refused to pay for a scan of his brain, even though his cardiologist and his primary-care physician had ordered it. The man ended up in the hospital, where the emergency-room doctor ordered a CT scan and found the brain tumor within an hour. His children were left to wonder whether their father’s life could have been extended if the insurance company had allowed the test a year earlier.

This patient had a type of Medicare called Medicare Advantage: a program through which private insurers are paid to administer Medicare benefits. Medicare Advantage plans may offer frills like a gym membership to attract patients, but in return the insurers are allowed to chisel away important benefits, things that traditional Medicare would cover without question. This is what you get when you privatize Medicare.

These days, in almost every case, there’s some way in which profiteering intervenes. I discharged a woman with a prescription for a medication that was decades old and generic. It turned out that a big pharmaceutical company had recently cornered the market on it, and a medication that a few years ago cost pennies per pill now costs more than a thousand dollars a month. She couldn’t afford it, because her insurance required her to pay a percentage of the cost of each prescription.

Sometimes an ambulance ride is not covered. I once had a clinic patient who needed to be in the hospital, but she refused to take an ambulance after having previously been billed a large amount for one. So I drove her forty miles myself. Some of my colleagues were shocked to hear this, asking, “What if something had happened while she was in your car?”

Or take hepatitis C. Medications can now cure hepatitis C. So what’s the holdup? The pharmaceutical companies charge tens of thousands of dollars for these medications. Doctors have been fighting with state Medicaid agencies to cover these drugs, but the sky-high retail price remains an obstacle.

Frisch: Are most physicians upset about the things you’ve described?

Coates: I think there’s enormous moral distress within the profession. Physicians don’t feel able to live up to their calling. They don’t have good job satisfaction. They want to spend more time with patients.

Frisch: Senator Claire McCaskill claims this isn’t a good time for the U.S. to transition to single-payer, because we’re already having trouble paying for all the baby boomers going on Medicare.

Coates: Warnings that the Medicare trust fund is going bankrupt come and go despite the fact that the system basically works. Politicians have the nerve to talk about the impending bankruptcy of Medicare when out-of-pocket spending on healthcare is bankrupting families right now. The best way to save Medicare would be to expand it to include everyone. The real reason the powerful are so opposed to single-payer is not because it won’t work but because it will.

When Canada enacted its Medicare system in the early 1970s, Canada and the U.S. were tracking even in terms of per capita healthcare costs. Today Canada is spending half of what the U.S. spends and getting better outcomes, better access to care, and better quality of life. This shows that a single-payer model absolutely will work if the goal is to cover everyone and save costs. It won’t work if the goal is to protect the interests of private insurers. It won’t work if the goal is to maximize profits.

Frisch: I’ve noticed there are no longer any independent medical practices in my county. Now they’re all under the umbrella of a single hospital.

Coates: The advent of most physicians becoming employees within a large corporate structure is something the medical profession hasn’t really come to terms with. Physicians continue to have the small-shopkeeper mentality, and we do retain a great deal of professional autonomy. But now, as employees in vast systems, we have begun to lose say over many aspects of care.

Frisch: Some opponents of healthcare reform have proposed that patients should shop around by cost for tests, drugs, and hospital stays.

Coates: With healthcare there’s no way to be a fully informed consumer, because you can’t know precisely what your future needs will be. If you develop the worst headache of your life and are in excruciating pain, you can’t know whether you’re having a migraine or a brain hemorrhage. You might need ibuprofen, or you might need a neurosurgeon. The idea of going shopping during a possible intracranial hemorrhage is just silly. The only solution that makes sense is having a healthcare infrastructure at the ready when we need it.

Frisch: How should individual physicians be paid for seeing patients?

Coates: Personally I think the full-time-salary model is the most honorable, but that may not be for everyone. There’s no perfect way to pay doctors. If you pay them a fee for service, it may encourage some to provide unnecessary services. If you pay them by the hour, it may encourage some to work too many hours. If you pay them a salary, it may encourage some to go home early. The best system would be to assume that doctors are doing the best they can for patients and let them organize themselves to decide how they want to be paid.

Frisch: Uninsured people tend to be charged more for healthcare than people who are insured. Overall who pays more under the present system: the insured or the uninsured?

Coates: The uninsured pay with their lives. For every million people without health insurance in the U.S., about a thousand deaths occur that could have been prevented. But the costs of a catastrophic illness are unpredictable even for those with insurance. I met a colleague, a senior physician, in the supermarket the other day. She told me that she had taken early retirement. I was about to congratulate her when she explained that her granddaughter had been hit by an automobile and her daughter had been fired for missing too much work, because she had to be at the hospital. The daughter was able to regain employment, but the care needs of my colleague’s granddaughter remained so significant that my colleague was taking early retirement to be there for her family. How can we measure the cost of that to society?

Studies show that the burden of providing care near the end of life falls disproportionately on women family members. The costs are great: not just financially but also to the health of the caregiver. Data also show that if your spouse dies, you have a higher likelihood of dying soon after. This often has to do with the stress of providing care: the lost sleep, the lost resources, and, many times, the lost jobs. Who pays? We all do.

Frisch: Many people don’t have the option to provide care when family members need it.

Coates: I have patients who are hospitalized but can’t afford to miss work. They fear being fired, or they simply can’t do without the income. I’ve written letters to their employers in hopes of helping them negotiate a little more time for recovery.

Frisch: Is it legal to fire people because they’re sick?

Coates: They’re not fired because they’re sick. They are fired because they’re not at work. It’s cruel.

Frisch: Is it different in other countries?

Coates: Absolutely. Other countries have not only sick-leave protections but also maternity and paternity leave.

Frisch: Let me see if I understand the basics of the system you’re pushing for: The government would provide free healthcare for everyone, paid for by taxes. You would not have to enroll; you would just have it. And I assume you’d be able to choose your physician.

Coates: Right. Physicians who participated in the system would be forbidden from having a private practice on the side, outside of the system. Doctors who wanted to have a private, for-cash practice could conceivably do so. But with the entire population covered by public healthcare, that would make little sense. With almost all doctors taking part in the system, patients could choose from a wide selection of providers. This kind of competition for the best-quality providers might turn out to be healthy for all of us.

The role of the government in this system would be to pay the costs and protect the patient-provider relationship. Medical decisions should be made privately — by the patient and the doctor — and the government should respect whatever decision they make, providing that decision is within the realm of medical science.

If we all pay a small percentage of our income into the system, we can ensure that everyone gets care. Sure, some of us, disabled by illness, will not be able to pay. But the rest of us should proudly contribute, with the understanding that we are building a system that protects us all.

Frisch: Would there be limits on allowable treatments for a given condition?

Coates: If a physician is proposing treatments that lack any credible evidence, then those treatments won’t be funded. On the other hand, if a treatment is supported by the medical evidence — and the patient and physician believe it’s worth a try — then that should be the patient’s personal decision.

Frisch: What are the chances that the system you envision will be enacted here?

Coates: I think the profound contradictions of the current system make it more likely: We have the contradiction that healthcare is so essential and yet so undignified in its delivery, with money always the underlying issue. Then there’s the contradiction that we’re paying so much more for healthcare compared with other nations but getting such inferior results. So everyone involved in the system gets progressively more frustrated and ground down. Yet we all know it doesn’t have to be this way.

I’m optimistic. Of all the social reforms that could transform the country, single-payer seems to me the most likely to happen. Still, we don’t have a mass movement of millions of people pushing for this, and that is what it will take.