David Himmelstein and Steffie Woolhandler: advocates for an equitable US health system.

www.thelancet.com Vol 389 April 8, 2017 1389 Back in 1979, Steffie Woolhandler interviewed for a residency position in Oakland, CA, USA, and was guided around the hospital by a resident called David Himmelstein. This turned out to be not only a moment of providence for both doctors, but also for advocacy efforts to promote an equitable US health system, which they have championed for the past three decades. “Within a few days of that first meeting, David and I realised we were kindred spirits, and wanted to spend the rest of our lives together”, Woolhandler says. Both were deeply influenced by their parents. Woolhandler grew up in Shreveport, LA, where her father was a radiologist, amid a backdrop of racial segregation. “My parents were prointegration, and from an early age fostered in me the values of social justice and equality”, Woolhandler says, who studied medicine at Louisiana State University. Himmelstein’s family lived in New York City, and his cardiac surgeon father and psycho analyst mother hoped he would follow the family traditions of medicine and progressive politics. He obliged by studying at Columbia College of Physicians and Surgeons. Today, Woolhandler and Himmelstein, who have led and are co-authors of The Lancet’s America: Equity and Equality in Health Series, are professors of public health and health policy in the City University of New York School of Urban Public Health at Hunter College, New York City. Their contact with patients these days may be less than it used to be—they spend a few hours a week at a community clinic in the south Bronx—but for more than 30 years they have been first and foremost clinicians, always working in the public sector, both specialising in internal medicine in Cambridge, MA, and in academic medicine at nearby Harvard Medical School. Early in her career, when treating a patient, Woolhandler had her eyes opened to the inequities of the US health system. “The woman had just given birth, but had overwhelming tuberculosis with a whiteout of her lungs, which could have been diagnosed a year earlier. She had not sought treatment, having no insurance coverage. I was unable to save her life”, she says. Himmelstein’s name became prominent in the mid-1980s after writing in the American Journal of Public Health (with Woolhandler) about the uninsured patients being refused treatment in hospital. This phenomenon, known as “patient dumping”, led to the 1986 Emergency Medical Treatment and Labor Act (EMTALA), which made it illegal for hospital emergency departments to turn away patients, irrespective of insurance coverage or ability to pay. Soon after the arrival of EMTALA, they attended a meeting in New Hampshire that galvanised their thinking and advocacy efforts in the arena of health equity, and in making the case for the USA to one day adopt a single-payer health system. “This was an important gathering, as it became clear that non-existent or poor coverage was also affecting middle-income people, not just the poorest people in our communities”, Himmelstein says. Woolhandler adds: “There was a clear consensus of the 200 or so doctors at the meeting that we needed an evidence-based advocacy organisation for physicians who believed in the vision and values of a singlepayer system”. From this meeting, Physicians for a National Health Programme was born and now has 20 000 members, with Woolhandler and Himmelstein still among its leaders. Surveys suggest that the US public is broadly persuaded by the idea of a single-payer health system. “So much of the problem lies in language”, says Woolhandler. “Medicare-forall is always enthusiastically greeted in surveys, but when the language changes to a nationalised health programme, people become confused, and more suspicious. Our job is to better explain what it is, which usually leads to increased support”. The couple’s forensic knowledge and extensive writing about health-care administration costs is prolific. They have shown how single-payer health care could reduce administration fees nationwide by US$400–500 billion. This couple have barely been separated since their first meeting back in Oakland. “Our children hate being around us when we are working, usually at a long desk with a computer screen in front of us, bickering over every word of the papers that we are embroiled in”, says Woolhandler. As longstanding colleague David Bor, Chief Academic Officer at Cambridge Health Alliance and Associate Professor of Medicine at Harvard Medical School, says: “It has been a remarkable collaboration for David and Steffie as life partners—we call them the Himmelhandlers—researchers, clinicians, teachers, advocates, and parents. They felt that their authenticity as advocates for just health and social policies derived from practising primary care at a public hospital, and maintaining the deepest fund of medical knowledge, which they have sustained for more than three decades.” With President Donald Trump’s failure to get the American Health Care Act (AHCA) as far as a vote in Congress, are they optimistic for the future? “The AHCA’s defeat has certainly buoyed our spirits. Obamacare expanded coverage, but its adherence to a market-based approach hobbled the reform, leaving it open to Trump’s attacks”, says Woolhandler. “The surging opposition that triggered the collapse of the Republican plan signals the broad support for a non-market alternative that can create a new opening for single payer, so yes, we have some grounds for optimism”, Himmelstein says.