Opening Scene
On the quiet morning of Saturday, November 16th, 2024, I met a retired neurosurgeon from the Carolinas ready for a healthcare revolution.
He wasn’t alone; over 300 doctors, medical students, and allied health professionals arrived at Venue Six10 in Chicago to take part in Physicians for a National Health Program (PNHP)’s annual conference. They arrived from across the country, hailing from sprawling health networks and neighborhood clinics, Ivy League academic centers and county hospitals. They were doctors at the end of storied careers and medical students who had not yet spent a full year on the wards – a dynamic group of committed professionals who deeply understood why American healthcare wasn’t working but did not entirely agree on the best next step.
Although most of the American left is familiar with Senator Bernie Sanders’ signature platform, Medicare4All, the attendees at PNHP prefer the more generic concept of “single-payer” to describe a shared idea for a national health insurance covering everyone. This is not to say attendees are not ardent supporters of current insurance plans like Medicare and Medicaid, which respectively enroll 67.7 million and 79.6 million Americans. Indeed, protecting and fortifying these two institutions represents the organization’s legislative roadmap for success. Outgoing PNHP president Dr. Paul Verhoef, a critical care physician currently working in Hawaii, summarized the organization’s vision: a “Triple Aim” that seeks to convert inertia and apathy for change into widespread confidence in a unified, government-managed program.
A single-payer system cannot be achieved without proving to voters that doctors have the political power to end healthcare profiteering and strengthen “traditional Medicare,” which includes the current benefits afforded to retirees, disabled individuals, and dialysis patients. Alongside these legislative goals, PNHP features a critical research branch to change the medical narrative on for-profit healthcare, as well as a fledgling coalition model of organizing which brings together unions, medical students, retirees, and healthcare justice activists to carry their message into the general populace.
Opposing Medicare Advantage
In the U.S., the two major political parties are equally guilty of loosening healthcare’s regulatory apparatus and allowing legalized graft to gum up the current system. Both Presidents Trump and Biden encouraged a mass transfer of patients from government-managed Medicare to Medicare Advantage, a network of privately administered insurance providers that bills the government for any retirees it accepts into its risk pool. Medicare “Disadvantage”, as conference lecturers dubbed it, represents a prime example of corporate greed impeding the group’s vision.
First, private insurance companies run aggressive advertiseing campaigns at senior citizens who are promised vision, hearing, and dental plans (which traditional Medicare does not offer) as well as free home nursing assessments if they switch from Medicare to Medicare Advantage. The government agrees to pay insurers a “per-capita” cost for every person covered. On paper, different companies are bidding to provide this insurance to large groups of patients at the lowest possible rates; in practice, insurers seek niche, carve-out populations in specific neighborhoods or with union retirement plans to avoid competition.
Once these patients have been aggregated, the company’s actuaries start calculating the risk of catastrophic health problems they might experience. For retirees, these risks represent the burdens of economic and social disparities experienced throughout life, and future costs of care can be modeled and anticipated using clinical risk factors.
For example, a college-educated grandmother who just ran a marathon is going to cost significantly less than an elderly nursing home resident struggling with multiple chronic medical conditions and a new cancer diagnosis. To balance out these varying levels of “healthiness,” the government offers higher per-capita payment plans for high-risk patients. The insurance companies have realized they can game risk pools by recategorizing the marathoning grandmother to look sicker on paper.
Cue the visiting home nurse, who documents that the grandmother actually lives on the second floor of a townhouse with enough stairs to qualify as a fall risk. Then, according to some lab work drawn during the visit, it turns out she meets the criteria for pre-diabetes and has chronically low potassium, which has never been an issue but which now appears in her medical documentation. Suddenly, she bumps over into the higher-tiered risk pool and earns the company a higher per-capita rate. From her perspective, she gets optical and dental insurance that she doesn’t have to purchase on a fixed income, but behind the scenes, she will be limited to the same narrow selection of in-network doctors’s offices and subject to many of the same insurance claim denials and prior authorizations that the average person with private insurance through their job experiences.
Finally, insurance companies can score additional rebates if they meet benchmark health criteria set by the government. These criteria, while conceptually valid, often become a system of automatic flags that prompt doctors to order repeat tests. In combination, all these perverse incentives, as well as the baseline advertising costs, shareholder dividends, and CEO payouts, add up to a significantly inflated cost of care compared to traditional Medicare.
There were numerous slides describing and predicting the rates of overpayment and abuse this kind of system permits, but during the first two hours of the conference I was so overwhelmed by the stream of high density statistics that I didn’t jot down any of the half-dozen charts meant to clinch your conviction that Medicare Advantage is a threat to all healthcare socialists. Instead, I’ll quote one slide by Dr. Adam Gaffney, a powerhouse researcher working out of Cambridge Health Justice Lab: “Medicare Advantage does not only waste money, its business model is based on care denial, and it is undermining the idea of equitable single-tier for the elderly.”
PNHP Victories
Given all the clear evidence of overpayments, PNHP National has staked out intense opposition to these corporate handouts. Since Medicare Advantage is a federal program, it represents a yearly budget fight between insurance companies and executive-branch employees at the Centers for Medicare and Medicaid Services (CMS). In 2024, PNHP won a rare budget victory by opposing the above-inflation rate increases that Medicare Advantage lobbyists demanded of the Biden administration. In a coordinated campaign across multiple chapters, activists drew the eyes of enough federal legislators to make CMS wary of continuing business as usual.
The audience applauded in catharsis when the presenter showed images of insurance company stocks dropping $95 billion after the federal government’s announcement it would limit the rate increase of Medicare Advantage payments. Presenters also told of labor organizers and PNHP allies fighting against the New York City Council, which dropped 250,000 city employees onto an inferior Medicare Advantage plan. These retirees have now won a string of lawsuits to regain their original healthcare benefits and demonstrate another spark of hope against the decades-long onslaught of privatization.
These individual stories pale in comparison to the immense task of electoral victory required to expand the welfare state. This could be most clearly seen in President Biden’s failure to pass Build Back Better, which would have included provisions that strengthened traditional Medicare in the form of adding vision, dental, and hearing insurance to every beneficiary. PNHP was a staunch supporter of Build Back Better in order to meet its Triple Aim, but obviously represented just a fraction of the progressive pressure that failed to win Senator Manchin’s vote of support. From one perspective, the structure of the U.S. Senate represents public enemy number one to members of the group seeking to achieve a single-payer system; from another, it is the only formidable barrier that has protected the Affordable Care Act (ACA) and Medicaid expansion from hostile Republicans. This could not have been clearer than when a medical student leaned over during Dr. Verhoef’s presentation to tell me “This guy has no concept of theory of change.” Among PNHP leadership, faith in electoral incrementalism remains the path for welfare expansion.
Students for a National Health Program
The relationship between Students for a National Health Program (SNaHP) and PNHP is not unlike that of YDSA to DSA. The goal is to capture vibrant student idealism for health equity and pull it into a larger political formation with progression and skill-building. PNHP believes so much in this mission that SNaHP members could attend a bonus half-day of the conference dedicated to organizing during medical training. The 151 who attended on Friday represent the far left of healthcare— future doctors who already have multiple years of experience organizing for Palestinian liberation or abolishing ICE and demand change now. Their very existence demonstrates a keen ability to jump through the hoops of high-stakes meritocratic testing while maintaining a robust bullshit detector against all the pageantry of co-opted social movements professed by medical school deans.
The Friday afternoon SNaHP Summit at nearby Roosevelt University included breakout groups teaching students how to write testimony, build campaigns, and organize medical school events to teach fellow classmates about single-payer policies. I appreciated how these organizers had deeply analyzed the structure of medical school curricula to maximize impact. “Spreading propaganda is super-important to us,” said one presenter while discussing essential rules to prevent the message from falling flat; for example, never host an event on the week of an exam, host events after mandatory lectures when classmates are already on campus, always offer food for students, and give every member who commits to organizing an event a named position in that SNaHP chapter for their résumé. “Your medical school, as a rule, wants you to do their work for free,” noted another presenter while pulling up a slide with the national curricular requirements for what medical schools must teach students about health policy. It’s an open secret that if you design a lecture that meets a teaching requirement, your professor will probably use it to cut costs even if it contains a pro single-payer message.
The most well-attended SNaHP breakout session was a packed room of over 40 students who wanted a chance to hear from labor organizers. For doctors, clinical training includes a mandatory 3-7 years after medical school in a hospital-based program called residency. These programs are notoriously exploitative, often expecting trainees to work 24- to 28-hour call shifts and up to 80 hours a week without overtime pay. Since 1957, several waves of resident unionization have occurred in response to these conditions, first at public hospitals in New York City, Los Angeles, and Chicago, and followed by other cities predominantly across the West Coast, Midwest, Mid-Atlantic, and New England.
Currently, the SEIU (Service Employees International Union)-affiliated Committee of Interns and Residents (CIR) represents the nation’s largest physician union with over 33,000 residents, and it’s estimated up to 25% of the resident trainee sector are now unionized. In recent years, CIR members passed resolutions in support of a national single-payer program and a ceasefire in Gaza. Recently unionized members spoke highly of their relationship to the Emergency Workplace Organizing Committee (EWOC), a joint venture between the United Electrical, Radio and Machine Workers of America and DSA as a way to build up organizing capacity before CIR took on their case. I met several doctors familiar with or members of DSA which speaks to the growing networks between health justice projects and labor organizing.
The union organizing session had been held at previous SNaHP summits, and this year’s version was attended by current CIR president Dr. Taylor Walker. Dr. Walker made a clear pitch that medical students should join the labor movement to propel health justice projects like abortion care, medical debt relief, and Palestinian liberation into a democratic debate at the workplace. This vision would serve both medical workers and their patients, and the rising leadership who will pilot PNHP in the coming years agreed. Talking to both current CIR members and doctors who have completed residency, a SNaHP-to-CIR-to-PNHP pipeline represents a promising model for maintaining an organized formation of progressive physicians. Each organization would contribute to a doctor’s organizing skills parallel to the steps of their medical education.
Dr. Arya Zandvakili, an infectious disease physician in Iowa who is now approaching the final hurdle of his sub-specialist training, is one such representative of this new batch of mid-career doctors who remains motivated to show up for PNHP. “People are going into financial ruin and debt,” he told me when I asked him what draws him to the organization. “Single-payer is a way to get universal healthcare that’s economically efficient.” However, even if we count on a burgeoning labor movement and a rising generation of radical doctor organizers, it’s still unclear how to translate power into politics.
State or Federal
Though all PNHP members have made the same conclusions as Dr. Zandvakili given the data at hand, the conference did not clarify a best path forward. One flyer being passed around called for organizing state-managed single-payer insurance plans. This would allow progressive states to bypass federal roadblocks and roll out a one-size-fits-all plan for their populations. This is far from perfect. Some fear a small state like Vermont or Rhode Island would go bankrupt under such legislation and set a bad example for the national project (full disclosure: I have previously testified at the Rhode Island Statehouse in favor of a Medicare4All-style bill). For the New York Metro chapter of PNHP, which has its own staff organizer supporting their campaign for the New York Health Act, it would mean leading the country with an exemplary model of universal coverage. Even this project requires federal backing, however, as the CMS would have to be granted permission to deliver its federal insurance money as a lump sum payout to New York, which would then dispense care.
Debate within PNHP chapters about state-based programs remains contentious. Dr. Cheryl Kunis, a nephrologist from New York, told me she’s skeptical of state-based single-payer legislation. “It’s unethical for New York to have it, but the rest of the country does not have it.” No one knows if a single state could bear the burden of a democratic experiment, or how citizens in neighboring states would respond to the free care next door. Nothing from the lecture about PNHP’s triple aim— stop profiteering, improve traditional Medicare, and win single-payer— supports or disavows an alternative state-managed path to victory. By side-stepping the all-important question of implementation, it feels like PNHP has held off from the big unknown at the center of the project: who is actually going to wield the democratic power that commands private insurance companies to get lost?
At the end of the day, it seems doctors who’ve stuck it out the longest have seen enough suffering that they’ll take any win they can find. Former PNHP president Dr. Johnathon Ross recalled being snubbed by then-Governor Bill Clinton alongside several thousand activists in Little Rock, Arkansas while trying to pressure him to support single-payer. Back then, he told me, PNHP was much smaller, without formal elections, an active national board, or a SNaHP wing. The organization’s growth over one professional lifetime has been tremendous, but it still doesn’t seem like we’re any closer to a national project succeeding before a state project passes. As we were filing out of a conference room breakout session and back to the main auditorium, Dr. Ross confided in me: “When you look at the history of doing hard things in America, a state always does it first.”
Joey DiZoglio, MD, is a practicing OB/GYN in Wisconsin. He was a former leader of his medical school’s SNaHP chapter and a current dues-paying member of PNHP and DSA.
