OPinion Articles

An Introduction to Single Payer for Pharmacists and Pharmacy Technicians

By Shannon M. Rotolo, PharmD, BCPS; Founder of Pharmacists for Single Payer ; Clinical Pharmacy Specialist; U Chicago Medicine and Randall W. Knoebel, PharmD, BCOP; Senior Manager, Pharmacy Health Analytics, Drug Policy & High Reliability; U Chicago Medicine

Illinois Council of Health-System Pharmacists, KeePosted, May 1, 2020


What is single-payer?

Single-payer national health insurance describes a system in which one public agency is responsible for health care coverage, but the delivery of health care services continue to be provided by mostly private businesses.1 This means all payments health care services would come from one agency, but physicians’ offices, hospitals, and pharmacies would continue to be owned and operated by organizations or individuals, as they are in the current system. The two proposed bills for single-payer in the United States are commonly known as Medicare for All. While there are differences between the House bill2 and the Senate bill3, both endeavor to provide robust health care coverage – medical, pharmacy, dental, vision, etc. – for everyone living in the US and to eliminate the private insurance industry’s role in covering health care services included in this legislation. Projected costs vary between analyses4, but most show the overall cost of health care services remaining about the same or decreasing, due to minor increases in utilization as more uninsured or underinsured people can afford to seek the care they need, coupled with major decreases in overhead – Medicare spends about 2% on administrative costs compared to private insurers spending up to 18%5 – and decreased cost of health care services, including drug pricing.

How would it impact pharmacy?

Perhaps the most obvious change that would impact pharmacy is in drug pricing. Brand name drug prices have increased dramatically in the last decade.6 Based on data from Australia and New Zealand, some experts estimate the cost of brand name drugs would drop as much as 50%. While the generic market is less likely to see dramatic price changes, there is greater opportunity for rapid intervention and improved access during drug shortages and for negotiation on prices with both brand and generic manufacturers of “me too” drugs if there is one national formulary.7 This is a role some argue pharmacy benefit managers (PBMs) can play, but again, drug prices continue to climb. In scenarios where savings are achieved by a PBM this is often to the benefit of their shareholders or partnering businesses, rather than to taxpayers or patients.8 By consolidating negotiating power with a single-payer, there would be greater leverage over drug companies’ asking prices.

Additionally, with a single-payer and the eradication of the PBM model, the idea of “preferred pharmacies” would no longer exist. Patients would be free to fill their prescriptions at the pharmacy that best meets their needs, at no cost. This would mean simplified billing and predictable reimbursement. What would you do with the time you previously spent on the phone trying to understand why an override wasn’t working, or trying to help a patient or physician determine the covered “preferred formulary alternative” when you get a rejection? What if you could spend more time focusing on ensuring therapy is safe and effective, instead of on whether or not your patient could afford it? Would you expand clinical pharmacy services? Would you open your own independent pharmacy, perhaps in an underserved rural area, or in the pharmacy deserts on the south or west sides of Chicago?

We have plenty of evidence from other countries to suggest how patients would respond to a single-payer system. The United States currently has the highest rates of cost-related medication non-adherence (CRMN).9 In places where patients don’t need to worry about copays and deductibles, the overall rate of cost-related medication non-adherence is < 3%. Even in Canada, which does not fully cover prescriptions with their single-payer system, rates of CRMN are about half of what they are in the United States. This example highlights the importance of thoughtful inclusion of pharmacy benefits in a single-payer health care coverage plan.

Why do pharmacists need to be involved?

Currently proposed Medicare for All bills in the House and Senate differ in their plans for prescription coverage. The House bill calls for no deductibles and no copays at any point. The Senate bill would allow for up to $200 per year in out-of-pocket prescription costs. This may sound like a small distinction, but has the potential to disproportionately impact low income patients.10 Pharmacists who have worked with patients with high-deductible prescription plans will immediately recognize this issue. Physicians may not, but they are the primary health care professionals advocating for Medicare for All.11 Most physicians have a limited understanding of the intricacies of pharmacy billing and reimbursement.12 We don’t know if single-payer will move forward in the next few years, or if it will take several decades, but we do know pharmacists will need to have a seat at the table when the time comes to ensure the changes made are appropriate and sustainable. The best way to guarantee that seat at the table is to get involved in the conversations happening around single-payer now.

To our knowledge, there are less than a dozen pharmacists actively involved in the single-payer movement right now, as compared to the over 23,000 physicians and 1,200 medical students who are members of Physicians for a National Health Plan (PNHP). We know pharmacists are extraordinarily effective advocates when we work for change to improve the lives of our patients and to advance our profession.13 We continue to rank among the top professions year after year for honesty and ethical standards.14 We are trusted experts, and we have the authority to speak on issues facing our broken health care system, particularly when it comes to medications. It’s time to put our expertise to use in advocating for structural change, and to make sure the plans behind it support our patients and align with our goals as a profession.

For those looking to get involved, two Illinois based organizations that focus on this issue are IL Single Payer Coalition (http://ilsinglepayer.org) and PNHP Illinois (https://pnhp.org/chapter/illinois). Other ways to take action include contacting your state and federal legislators to ask them to support single payer legislation, writing op-eds or letters to the editor in local newspapers, public speaking, lobbying, and organizing.


  1. Physicians for a National Health Program. About Single Payer. https://pnhp.org/what-is-single-payer (accessed 2019 Nov 22).

  2. Medicare for All Act of 2019, H.R.1384, 116th Cong. (2019). https://www.congress.gov… (accessed 2019 Nov 22).

  3. Medicare for All Act of 2019, D.1129, 116th Cong. (2019). https://www.congress.gov… (accessed 2019 Nov 22).

  4. The New York Times. Would ‘Medicare for All’ Save Billions or Cost Billions? https://www.nytimes.com… (accessed 2019 Nov 22).

  5. Center for Economic and Policy Research. Overhead Costs for Private Health Insurance Keep Rising, Even as Costs Fall for Other Types of Insurance. http://cepr.net… (accessed 2019 Nov 22).

  6. Wineinger NE, Zhang Y, Topol EJ. Trends in Prices of Popular Brand-Name Prescription Drugs in the United States. JAMA Netw Open. 2019 May 3;2(5):e194791.

  7. Gaffney A, Lexchin J; US; Canadian Pharmaceutical Policy Reform Working Group. Healing an ailing pharmaceutical system: prescription for reform for United States and Canada. BMJ. 2018 May 17;361:k1039.

  8. The Commonwealth Fund. Pharmacy Benefit Managers and Their Role in Drug Spending. https://www.commonwealthfund.org… (accessed 2019 Nov 22).

  9. Heidari P, Cross W, Weller C, Nazarinia M, Crawford K. Medication adherence and cost-related medication non-adherence in patients with rheumatoid arthritis: A cross-sectional study. Int J Rheum Dis. 2019 Apr;22(4):555-566.

  10. Kaiser Family Fund. Medicaid. The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings. https://www.kff.org… (accessed 2019 Nov 22).

  11. TIME. A New Generation of Activist Doctors Is Fighting for Medicare for All. https://time.com… (accessed 2019 Nov 22).

  12. Tseng, C., Lin, G.A., Davis, J. et al. Giving formulary and drug cost information to providers and impact on medication cost and use: a longitudinal non-randomized study. BMC Health Serv Res. 2016 Sep 21;16(1):499.

  13. Little J, Ortega M, Powell M, Hamm M. ASHP Statement on Advocacy as a Professional Obligation. Am J Health Syst Pharm. 2019 Feb 1;76(4):251-253.

  14. Forbes. America’s Most & Least Trusted Professions. https://www.forbes.com… (accessed 2019 Nov 22).

Letters: ‘Medicare for All’ would drive down drug costs

By Shannon M. Rotolo, PharmD, BCPS; Founder of Pharmacists for Single Payer ; Clinical Pharmacy Specialist; U Chicago Medicine and Randall W. Knoebel, PharmD, BCOP; Senior Manager, Pharmacy Health Analytics, Drug Policy & High Reliability; UChicago Medicine



In 2017, a study found that more than 15% of people living in the United States went without a needed medication because of its cost. This is significantly higher than the nonadherence in a majority of European countries. While there are multiple bills at the state and federal level aimed at reducing drug prices for single classes of drugs, such as insulin, or targeting high-cost drugs as a category, none of these bills has the potential to make the same impact as a switch to a single-payer system, commonly known as “Medicare for All.”

Creation of a single-payer system has the ability to drive down drug prices by consolidating negotiating power. This is something we’ve been told pharmacy benefit managers (PBMs), middlemen in our current system, could achieve. But despite their presence, drug costs have continued to skyrocket. A single-payer system, on the other hand, is projected to reduce brand name drug prices by about 50%. These changes in average wholesale price (AWP) or any other price measures used by the industry or in retail pharmacies aren’t necessarily tied to the copay you see at the pharmacy counter, though. Medicare for All would address that piece as well, with no copays or deductibles in one proposed version, and a maximum of $200 per year on prescriptions in the other.

Another unique advantage of Medicare for All is that it would restore patient choice in pharmacy. Private insurance and PBMs ensure greater profits for themselves by restricting choice, driving prescriptions to the chains they own. When they do permit patients to use alternative pharmacies, the reimbursement to those small businesses can be so low that prescriptions are often filled at a loss. The end result is the pharmacy deserts we see on the South and West sides of Chicago, and closing of independent pharmacies in the Chicago area in general.

Medication only helps if you can take it, and you can only take it if you can afford it. Everyone deserves to get the medication they need from a pharmacy they trust. I encourage everyone who takes medication or loves someone who takes medication to learn more about Medicare for All and to support the candidates who will fight for it.

COVID-19 Reveals the Dark Side of US Health Care Coverage

By Shannon M. Rotolo, PharmD, BCPS; Founder of Pharmacists for Single Payer ; Clinical Pharmacy Specialist; U Chicago Medicine and Randall W. Knoebel, PharmD, BCOP; Senior Manager, PHarmacy Health Analytics, Drug Policy & High Reliability; UChicago Medicine

IMPACT | DEC 3, 2020


Within the first three to four months of the COVID-19 pandemic, an estimated 186,000 workers in Illinois and their families lost their health insurance coverage due to job losses. Nationwide estimates in June 2020 suggest as many as 7.7 million workers and 6.9 million of their dependents lost employer-sponsored insurance (ESI) when they lost their jobs during the pandemic-induced recession. And while Illinois has more state-run programs and support available than many other states, many individuals and families losing coverage do not qualify for Medicaid, and many can’t afford other so-called low-cost plans. Even those who are able to obtain alternate health insurance may be left with gaps in their coverage. We know from pre-pandemic data that having a gap in coverage more than doubles the likelihood that someone will forego filling a prescription. Additionally, for individuals or families that have not lost their ESI, but for whom a meaningful portion of their household income was variable – for example restaurant servers, bartenders, hair stylists, or nail technicians who earnings may be dramatically impacted by tips – the same ESI plan that was previously sufficient may now leave them underinsured. The definition of underinsurance varies somewhat between studies, but generally this refers to an insured person or family facing out-of-pocket costs (ex. premiums, deductibles, and / or copayments) at such a high proportion of total household income that health care is not affordable, or is only able to be procured at the expense of other basic necessities.

Pharmacists have been observing the impact of this health insurance crisis from the front lines. Other health care professionals may not know the reason why a patient cancels an appointment or delays care. It could be cost, fear of COVID-19, a scheduling conflict, difficulty securing transportation, or one of so many other variables or barriers. But pharmacists, and in particular community pharmacists, often talk to patients who are struggling with tough decisions between a basket of groceries and a prescription refill. The pandemic has increased the frequency of these interactions in a country that was already leading our peer nations in numbers of uninsured and underinsured residents. And people make these difficult decisions between medications and other necessities monthly. Perhaps an annual screening or well check-up can be deferred without major issues in some situations, but delaying a prescription refill has a clear, visible consequence: running out of medication. And while missing only a few days of a medication for high blood pressure, for example, may not directly and immediately lead to a stroke for everyone, there are certain medications that do have serious, predictable consequences. A person with Type I diabetes can develop life-threatening complications within hours to days of running out of insulin.

Earlier in the pandemic, roughly May to June, I remember a scramble as many of the patients I worked with at the specialty pharmacy were no longer able to afford their high-cost medications. The pharmacy technicians and I were frantically filling out patient assistance program applications or grant fund applications to try and obtain medication for patients via limited free drug programs offered by drug manufacturers or charitable organizations whose funds were vanishing as quickly as they could be repleted by donors. I struggled to answer questions with no good answers for my patients: What should I do if the monthly cost of COBRA coverage for my family is the same as our total budget for the month, that is meant to include groceries and gas to get to the few shifts of work that are still available? Should I consider getting legally divorced so either my spouse or I might qualify for health coverage based on our individual income? What happens if I miss a week of this medication, if I know I have nothing in my debit account today, but I’m expecting a deposit on the 1st or the 15th of the next month? What will happen to me?

While the economic impacts of the COVID-19 pandemic have been felt globally, the idea of losing health insurance and prescription drug coverage as a consequence of this pandemic-induced economic downturn is almost uniquely American. Other high-income countries have single-payer systems that guarantee health care as a human right to their citizens. People there may be fearful of contracting COVID-19, but not because the cost of care will bankrupt them, as it could here in the United States.

We know controlling the spread of the virus will be crucial to getting our economy back on track. We should also consider the impact of our health care system on our ability to fight this virus. Now is the time to tell our elected representatives that we demand at a minimum universal coverage of a COVID-19 vaccine, and also universal health care coverage, period. It has never been more important to protect each other.

OPen Letter: What about the "war on bugs"

By Daniel Salas, PharmD, infectious diseases pharmacist, Los Angeles, California

The notion that the “free market” is the most efficient way to spur biomedical innovation has been largely undermined by the COVID-19 pandemic, particularly with regards to the new antiviral remdesivir. First, the government has always played a major role in financing drug discovery through taxpayer dollars. Remdesivir (formerly, GS-5734), a compound originally identified in the wake of the 2014 Ebola virus outbreak, emerged from a collaborative research effort between Gilead Sciences and public institutions, costing tens of millions in taxpayer dollars. Despite significant public financing, patent law effectively grants Gilead a monopoly on remdesivir, inflating its price far above what would be expected in a true “free market”. Thus, remdesivir is priced at over $3,000 for a five-day treatment course, despite production costs estimated to be as low as $1 per vial. Reliance on the free market is particularly problematic for anti-infective drugs when research is undertaken in response to an outbreak or pandemic. The SARS and MERS coronavirus outbreaks of 2002 and 2012, respectively, demonstrate how reliance on the market has led to a predictable surge in research and funding at the start of an outbreak, which inevitably fades as infections wane. This leaves researchers playing catch-up when the next outbreak comes, as is the case with the current SARS-CoV-2 outbreak. The above points highlight the need for an alternative mechanism of financing anti-infective drug research and development. Hundreds of billions of taxpayer dollars are dedicated to the “war on terror” and the “war on drugs''. What about the “war on bugs”?

Medicare for all town hall

from June 17, 2021. Founding member, Thomas J. Cook, PhD, RPh, was a panelist at the virtual town hall and focused on the small business/pharmacy perspective for a single-payer healthcare system.

Link: https://fb.watch/6ruJvzD99K/

Mental health awareness is vital year-round

By founding member, Tashrique Rahman PharmD, MBA. Dr. Rahman discussed the mental health crisis in the US, highlighted the important role of pharmacy professionals in addressing the crisis, and emphasized how a single-payer system would help resolve major issues driving the crisis.

Link to article on Pharmacy Times: https://www.pharmacytimes.com/view/mental-health-awareness-is-vital-year-round

Why Pharmacists Should Advocate for a Single-Payer Healthcare System

Writing on The Grassroots Pharmacist blog, founding members, Thomas J. Cook, PhD, RPh, and Tashrique Rahman PharmD, MBA, summarize the pharmacist's case for a single-payer healthcare system.

Link to the blog post on The Grassroots Pharmacist