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How Obamacare Is Unsustainable: Why We Need a Single-Payer Solution for All Americans

John Geyman

Friday Harbor, WA, Copernicus Healthcare, 2015, 315 pp., $18.95, paperback

From early 2009, when President Obama called for legislation implementing universal access to health care, to the signing of the Patient Protection and Affordable Care Act (ACA) in March 2010, and continuing to the time of this review (mid-2015), “Obamacare” has been sharply criticized by the political right as excessive government interference with our market-based system.

John Geyman, MD, professor emeritus at the University of Washington School of Medicine, makes exactly the opposite case in How Obamacare is Unsustainable. He argues that American health care has been plagued by an excess of unregulated profit-making, to the serious detriment of affordable quality health care. In his view, the ACA did little to address this fundamental problem. He calls instead for the implementation of a comprehensive, national health insurance system (NHI). He has written this book, published in January 2015, as a three-part argument, backed by numerous tables, statistical reports, and analyses.

Part One provides a history of health care reform efforts in the United States, from 1917 to the present. Dr Geyman documents five efforts, prior to the ACA, to implement significant health care reform. He notes that only one push led to a solid success: the passage of Medicare legislation in 1965. Dr Geyman holds up Medicare as an NHI prototype. But rather than finding a path to universal access, Dr Geyman argues, organized medicine over the last century has allowed “transformation from a service-oriented cottage industry into big business,” with health care access a marketplace commodity, rather than a right.

Part Two contains Dr Geyman’s critique of the ACA, identifying not only inherent flaws, but also multiple problems the ACA doesn’t attempt to address. He does concede: “To be fair, ACA has accomplished some good things for many Americans” (p. 164), including, he reports, newly insuring at least 10 million Americans. But he concludes that ACA was doomed to failure from the start: “Health care ‘reform’ through the ACA was framed and hijacked by corporate stakeholders . . . The interests of insurers, the drug and medical device industries, hospitals, and organized medicine took precedence over the needs of patients for broad access to affordable quality health care.” (pp.166-167).

Dr Geyman sees very little value in attempting incremental reform and argues in Part Three for a sweeping health care system overhaul: financing, access, and delivery. He asserts that a well-crafted national insurance program would: (1) reduce the total cost of health care, (2) provide better population-wide health outcomes, and (3) address a moral inequity by giving health care access to all, not just those whose insurance or personal wealth allows it. He advocates financing a single-
payer plan through a payroll tax. He argues that, over time, this would be more than offset by cost reduction. He maintains that excess profits would gradually be squeezed out, and unneeded procedures diminished in frequency, with quality evidence-based care incentivized in the national health plan.

How Obamacare is Unsustainable can be criticized from a number of perspectives. Libertarians are unlikely to be persuaded. Polling data exists to challenge Dr Geyman’s contention that a single-payer system enjoys strong majority public support; public endorsement of government-based health funding varies greatly over time.1 Those of us who see ACA as the maximum reform obtainable in the current political climate may find Dr Geyman’s assertions too harsh that ACA has accomplished little.2 Having weathered two Supreme Court reviews, Obamacare, incomplete a reform as it is, will likely be the last reform effort for some time.

With US per capita health care spending wildly exceeding that of other democracies, and health outcome measures registering quite poorly,3 the burden of proof for the future rests on those finding value in maintaining free enterprise as the dominant mechanism of the health care system.

Dr Geyman’s thesis poses at least two moral questions: (1) Is it acceptable to leave millions of Americans uninsured and unable to afford needed medical care? and (2) Have we as health care providers/professionals, with incomes high relative to our counterparts abroad, acquiesced to a badly structured system, one limiting our ability to provide beneficence to our patients?

This thoroughly researched and passionately articulated work deserves a careful reading by all of us in the health care system. John Geyman, MD, deserves immense respect for his tireless advocacy on behalf of a vision for a better and fairer health care system for all.

Ronald L. Malzer, PhD

La Crosse-Mayo Family Medicine Residency

La Crosse, WI



  2. For a considerably more positive review of ACA and its success with increasing access, see Blumenthal DB, Collins ST. Health care coverage under the Affordable Care Act—A progress report. N Engl J Med 2014;371(3):275-81.
  3. US health in international perspective: shorter lives, poorer health. National Academies of Science Press, 2013. http//

Copyright 2018 by Society of Teachers of Family Medicine