left: Debra Street, right: Andrew Coates

Thirty years ago, soon after she arrived in Fort Walton Beach, Florida, from her native Canada, Debra Street found herself in a hospital emergency room with a painful kidney stone problem. This unpleasant situation quickly became more unpleasant, and something of a cultural shock.

She was asked how she would pay by an intake interviewer. Street, currently the chair of the sociology department at the University at Buffalo, had no insurance, or job. Her husband had both, but his insurance hadn’t kicked in yet during a probationary period. She had no checks with her name printed on them since the bank hadn’t yet sent them. She had no credit card. “It was a perfect storm” of misfortune, she told a meeting of the League of Women Voters at an Amherst restaurant last Friday. She was told to seek treatment at a “charity hospital” 40 miles away. “I hadn’t thought of this before,” she said. “I’m a Canadian. We get healthcare.”

And they get it without this kind of scrutiny. The Canadian government is billed for service. Canadians pay for it through premiums or taxes, depending on which province they live in.

Street might encounter a different response today because of a federal law that mandates emergency room treatment without regard for a patient’s fiscal resources. But maybe not. As she pointed out in a telephone interview this week, she might be turned down because hospitals are only required to stabilize emergencies and they judge whether a case is one. They also need not give preventive or longer-term service. (This is true despite the blithe assurance of the Buffalo News’ editors several years ago that everyone is protected by a care “safety net” because of access to emergency rooms. The News was engaging in a long-running opposition to President Barack Obama’s healthcare proposal and its limited insurance mandate.) None of this would have mattered to Street in Canada. As she said, Canadians get healthcare, in a single-payer system, where treatment isn’t approved or disallowed by private interests, as in this country.

“In Canada,” she told League members, “corporations don’t make the important decisions about health; public officials do.”

The night before Street spoke, more than 80 people crowded into a basement meeting room at Buffalo’s Lafayette Presbyterian Church for a community forum on “Poverty, Disparities and Healthcare,” organized by the Community Health Worker Network of Buffalo. At least a third of the attendees were young people, a result of outreach to medical students and undergraduates, according to Jessica Bauer Walker, the Network’s director. The lead speaker was Andrew D. Coates, the newly elected president of Physicians for a National Health Program. Coates is an assistant professor at Albany Medical College and the medical director at an Albany County-owned nursing home. The PHNP is a 19,000-member organization dedicated to the institution of a single-payer system in this country, rather than what it regards as the unwieldy, piecemeal, and inadequate Obamacare program.

Thursday night, in his talk, Coates effectively functioned not only as a physician but also as a political economist, a historian, and a sociologist. For about an hour he deftly sped through data compilations and comparisons, succinctly and sometimes aphoristically commenting on the dismal state of American healthcare. The poor results of the American system haven’t been a secret for years, although a large portion of the American public has seemed confused about or unaware of the situation, an ignorance created at least in part by powerful political and private interests.

The US ranks at or near the bottom of a list of 20 of the most advanced nations around the world in such categories as infant mortality, incidence of serious illness, and life expectancy. It is at the top in the cost of its system. “Our health delivery systems have created the dismal results and ill-health,” Coates said.

The two central themes of the Coates presentation—and of two co-speakers—were “the social determinants” of health, and the probable failures of Obamacare. There are at least 50 million uninsured Americans, and millions more of the underinsured. This glaring lack accounts for much of the bad outcomes, Coates said. He noted a recent finding by a Harvard economist that there were 45,000 “excess deaths” each year because of a lack of access to medical services. The National Institute of Medicine, part of the National Academy of Sciences, estimated the number at about 25,000, using another methodology. (Either figure should be appalling.)

As to state Medicaid programs, a crucial element of the Obama plan that is supposed to provide for those unable to pay for the insurance policies offered by private companies on the Internet “exchanges” that are to be established, Coates expressed biting skepticism: “Medicaid may be indefensible, but it’s better than nothing.”

It may also prove unavailable. (Dis)qualifying standards are usually stringent and a large number of the 50 states will apparently opt out of Obamacare’s expanded Medicaid with liberalized requirements despite a federal subsidy to them, according to William P. Keefer, a health law practitioner at the Buffalo law firm Phillips, Lytle LLP.

Coates dismissed the prospects of Obamacare insuring a majority of the uninsured. In an interview before the event, he cited a recent Congressional Budget Office projection that there will be 30 million people left out of the program, a number increasing to 36 million by the end of 2016. The cost of policies offered will be too great for many people, he said. The sector of the population that will benefit the most from Obamacare are corporate interests: insurance, managed care, medical device and pharmaceutical companies. (Last June, USA Today quoted insurance executives who were relieved that the US Supreme Court had sustained the program because it would create an expanded market for them.)

Coates scoffed at so-called market-driven reforms, quoting Harvard professor David Himmelfarb: “Consumer-driven plans are driven like cattle are driven.” High co-pays and deductibles cause people with meager resources to deny themselves care, he said. “People delay care, even for heart attacks, one-fifth more if they’re underinsured,” he reported.

Sam Magavern, co-director of the Partnership for the Public Good, told the audience that for all the talk of Buffalo’s extreme poverty, the problem isn’t really the city’s poverty rate: “It’s not poverty, it’s inequality,” he said. The metropolitan area around Buffalo has a poverty rate at the national median. The national healthcare crisis isn’t due to “lack of resources. It’s the politics of who is willing to pay for what.”

Dr. Myron Glick, founder and chief executive at the non-profit Jericho Road Family Practice in Buffalo, pointedly recalled how he has marvelled at the new and lavish suburban offices of insurance companies and medical groups he has visited for meetings. And he remembered a prominent cardiologist who declined a referral from Glick because the patient had only Medicaid. “It was the first question he asked,” Glick said. “He said I should send him to the county hospital. ‘They need patients to practice on.’”

Glick said he later saw the doctor at a medical conference. “I hold it against him,” he went on, “but it’s really the system. But the system won’t be changed by altruism.”

“I’m an incrementalist,” Coates said. “I’m not asking for a social revolution, but to get rid of a private-profit health system.” A single payer system, he said a few minutes later, would “eliminate the most parasitical portion of finance capital” from healthcare.