Wednesday, February 28, 2018

Are doctors ready to embrace single payer health care?


Single payer health care is enjoying a boomlet in public opinion. 

A Pew Research Center poll released in June 2017 found that, “Overall, 33 percent of the public now favors such a ‘single payer’ approach to health insurance, up 5 percentage points since January and 12 points since 2014.”  58 percent of those surveyed by Pew said that the government has a responsibility to ensure health for all, with a third saying it should be through a single national government program and 25 percent through a mix of government and private programs.  Another 33 percent said the government is not responsible to ensure health care for all but agreed that Medicare and Medicaid should be continued, while 5 percent said the government should not be involved at all. The poll also showed that a majority of Democrats now favor single payer; support was also stronger among younger persons than older ones.  However, most Republicans and older voters oppose single payer.
Source: Pew Research Center

The Kaiser Family Foundation’s June 2017 tracking poll found even higher levels of support for single payer, with 53 percent in favor and 43 percent opposed.  However, it also described support for single payer as being “malleable” and subject to change when presented with arguments for or against: “While a slim majority favors the idea of a national health plan at the outset, a prolonged national debate over making such a dramatic change to the U.S. health care system would likely result in the public being exposed to multiple messages for and against such a plan. The poll finds the public’s attitudes on single-payer are quite malleable, and some people could be convinced to change their position after hearing typical pro and con arguments that might come up in a national debate.”

A Harvard-Harris poll conducted in September 2017 found even higher levels of support for single payer, with a narrow majority (52 percent) supporting it while 48 percent opposed. 

Doctors also appear to be warming to single payer, according to some recent polls.  And, as I have traveled around the country in recent months to visit ACP chapter meetings, I’ve found more and more ACP members are advocating that the College come out strongly in favor of single payer health care, and not just in so-called liberal leaning “blue” states.  I’ve explained that a 2008 ACP paper, which I co-authored on behalf of our Health and Public Policy Committee, examined what the United States could learn from other countries’ health systems.  We recommended “that the federal and state governments consider adopting one or the other of the following pathways to achieving universal coverage:

  1. Single-payer financing models, in which one government entity is the sole third-party payer of health care costs, can achieve universal access to health care without barriers based on ability to pay. Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access. They may require a higher tax burden to support and maintain such systems, particularly as demographic changes reduce the number of younger workers paying into the system. Such systems typically rely on global budgets and price negotiation to help restrain health care expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals' freedom to make their own health care choices.
  2. Pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs (Australia and New Zealand). Pluralistic financing models must provide 1) a legal guarantee that all individuals have access to coverage and 2) sufficient government subsidies and funded coverage for those who cannot afford to purchase coverage through the private sector.”

(Note that this paper was written a year before the Affordable Care Act (ACA) became law; the ACA is an example of the second option, although it has fallen short of assuring universal access).

Recognizing the growing interest in single payer, and in other models that may still involve multiple payers but with the government having a much large role in financing and ensuring coverage (most European countries are not truly single payer, because they still allow some role for private insurance), ACP’s Health and Public Policy Committee will over the next several months begin examining different alternatives to advance universal coverage.   As it does, I think there are several important questions that will need to be asked, particularly of single payer:

  1. Will all Americans be required to get their coverage through a single, government-financed system (compulsory coverage), meaning that they would have to give up their employer-based or individual coverage?  (If not, it really isn’t single payer; if so, will Americans react favorably to being compelled to get their coverage from the new program?)
  2. Related, will Americans conclude that the coverage under the new program is better or worse than what they have now?  Will deductibles and co-payments be higher or lower?  Many single payer advocates assume that deductibles will be lower under single payer than most Americans typically now pay, but that is in no way a given; one could imagine a single payer plan based on the ACA’s silver plans, for instance.  Will the covered benefits be more or less generous?  Will premiums—or if funded solely through taxes, the taxes they pay—cost them more or less compared to what they and their employers now contribute?  Will taxes be progressive, meaning the wealthier pay more, or regressive, as is the case with Social Security taxes?  Will they have limited networks of physicians and hospitals, like Medicare Advantage plans, or complete choice of physician and hospital, like traditional Medicare?  Will they and their physicians be able to have access to any FDA-approved prescription drugs, or will there be a limited formulary to choose from?
  3. Will the government contract with insurance companies to run the new system, like is the case today with Medicaid managed care, Medicare Advantage, and even Medicare Part B (administered by private insurance carriers) and Part D (pharmacy benefit managers)?  It would be so typically American to create a single payer system, and then pay insurers to administer it.
  4. How will costs be controlled?  With global budgets, price controls, limits on capacity, and/or limiting access to care based on determinations of quality-adjusted life years like in other countries? How will physicians, hospitals, drug companies, and medical device manufacturers be paid?

This may seem like I am arguing against single payer; I’m not.  The same questions might be asked of other approaches.  And models that continue to rely on multiple payers, as is the case with the ACA, may never be as effective and efficient as a single payer system in ensuring that everyone has affordable coverage. Single payer almost certainly would have lower administrative costs and be more egalitarian.

Rather, what I am suggesting is that as ACP, and the country, considers different approaches to achieve universal coverage and access (not the same things), the questions that will need to be considered are far more complex than the snapshot (do you favor or oppose Medicare for All) questions asked in polls.  How those questions are answered will likely determine if the public, and physicians, are truly ready to embrace single payer health care.

Today’s question: What is your view of single payer (Medicare for All) health care?

Thursday, January 4, 2018

What did ACP advocacy achieve in a year of unparalleled challenge?

What did ACP advocacy achieve in a year of unparalleled challenge?

2017 was the most challenging year that I have experienced in my 38 years of advocating for internists.

To put things in perspective, I joined the governmental affairs staff of the American Society of Internal Medicine in January 1979, during the presidency of Jimmy Carter.  I had the privilege of helping ASIM advocate for internists for 19 years, until ASIM merged with ACP on July 1, 1998, and then continuing after the merger as Senior Vice President for ACP’s Division of Governmental Affairs and Public Policy.  From Jimmy Carter to Ronald Reagan, to George H.W. Bush, to Bill Clinton, to George W. Bush, to Barack Obama, I have seen both ASIM and ACP skillfully navigate the challenges associated whenever there is a new occupant in the White House, and also, changes in which party controls the House and Senate. 

If you choose to participate in advocacy in Washington, or in state capitals for that matter, change and disruption are par for the course. For instance, it is hard to overstate how big a change Ronald Reagan’s policy agenda was from the policies pursued by Jimmy Carter, or Barack Obama’s compared to George W. Bush’s.

Yet there has never been a more challenging, and disruptive shift in policies and priorities than since President Trump was elected and became president, just shy of one year ago. After all, he ran on a platform of ending as much of President Obama’s legacy as possible, including a promise to repeal Obama’s signature achievement, the Affordable Care Act (ACA), “on day one” of his presidency.  With the Republicans controlling both chambers of Congress, there was reason to believe he would succeed, if not on day one, during the first year of his administration.

As a result, ACP spent much of last year playing defense on the ACA, which we support, and also on several other priorities, where the current administration's and congressional leadership's priorities were at odds with long-standing ACP policy.  This was not our choice: as a strictly non-partisan organization, our hope is always to find common ground with a new president and Congress wherever possible, to compromise when needed, and to resist only when necessary.  And in some cases, we have been able to find common ground with President Trump and Congress.  Yet we have also had to defend repeated attacks on programs, policies and priorities that we believe are essential to the health and well-being of patients.

So how did we do, in such a year of unparalleled challenges to our advocacy agenda?  Pretty darn well, I’d say:

  • On Coverage and Access:  While many Americans believe otherwise, the ACA was not repealed.  Except for repeal of the ACA’s requirement that individuals purchase insurance, all the rest of the ACA remains the law of the land, including coverage of essential benefits, preexisting condition protections, no lifetime limits on coverage, and premium and cost-sharing subsidies.  Medicaid was not capped and cut.  ACP specifically helped derail the Graham-Cassidy bill, which would have radically devolved responsibility for funding and regulating coverage from the federal government to the states, causing tens of millions to lose coverage and benefits.  Repeal of the individual mandate, which was included in the tax bill, is of concern to the ACP, because it likely will further destabilize insurance markets.  Nonetheless, the fact that the rest of the ACA has survived, despite President Trump’s repeated calls for repeal followed by repeated (failed) votes in Congress to repeal it, is a huge win for ACP advocacy.
  • On women’s access to health care: Planned Parenthood was not defunded.  And the administration's interim final rule to allow employers to opt out of contraceptive coverage, which ACP opposes, has been blocked by two recent court decisions, at least for now.
  • On health care expense and tuition interest deductions:  ACP achieved several big wins in the tax legislation that passed Congress in late December:  the deductibility of student loans and medical expenses was preserved, even though an earlier version of the bill passed by the House of Representatives would have repealed both.    
  • On insurer mergers: The courts blocked two mega insurer mergers that would have reduced competition and harmed physicians and patients.
  • On non-discrimination against transgender persons: The courts stepped in to block the administration's ban on transgender persons serving in the military, consistent with ACP’s opposition to the ban
  • On immigration and health: Court decisions have also resulted in the administration substantially modifying its original executive order on immigration in a way that, while still concerning, is less damaging to the ability of physicians trained in the affected countries to enter and remain in the United States under legal visas. 
  • On reducing paperwork: We were able to advance our policy agenda as it relates to Patients Before Paperwork to the point where the administration has launched a similar initiative, called Patients Over Paperwork. 
  • On improving quality payments: We achieved substantial wins in improving the Medicare Quality Payment Program and payment for internists' services, particularly by easing the burden on smaller practices. Dr. Louis Friedman, an ACP member, was asked to testify on his experiences with the CPC+ APM model before the Energy and Commerce health subcommittee, invited by both the majority (R) and minority (D) leadership of the committee—a testament to the high regard that both parties hold of ACP when it comes to payment and delivery system reforms. 
  • On addressing the opioids crisis: The President’s Commission on Opioids issued a report that is largely consistent with ACP’s recommendations, including a recommendation to establish drug courts in all jurisdictions.
  • On prescription drug pricing: The National Academy of Medicine issued a report on prescription drug pricing that also closely reflected ACP’s recommendations; several ACP-supported bills were introduced in Congress to address the high cost of prescription drugs.
  • On climate change: While the administration's approach to climate change remains very concerning, states, localities, and businesses have stepped up to adopt measures to mitigate climate change. 
  • On firearms: ACP and its Florida chapter had a big win when a federal appeals court overturned a Florida law that prohibited physicians from discussing gun safety with patients. Many states and localities have stepped in to adopt policies consistent with ACP's recommendations, by expanding background checks and other common-sense regulations while beating back the gun lobbies' efforts to make guns even more available.  

Of course, ACP didn’t achieve all of these wins completely on our own. Advocacy is never won through the efforts of only one engaged actor; rather, it is the result of many with shared interests joining together to combine their efforts to achieve a common end.  2017 was the year that 6 physician professional organizations—ACP, the American Academy of Pediatrics, American Academy of Family Physicians, American Osteopathic Association, American Congress of Obstetricians and Gynecologists, and the American Psychiatric Association came together to form the “Group of 6” coalition, representing a combined membership of over half a million doctors and medical student members.  The Group of 6 has now become one of the most influential (and largest!) health care coalitions in Washington, with 6 leadership fly-ins to Capitol Hill in 2017 and another scheduled for next week.

Particularly in challenging times, determined advocacy is what is most needed to make a difference for the better.  In 2017, ACP passed the test, with flying colors.

Today’s question: what is your take on ACP’s advocacy in 2017?

Thursday, November 30, 2017

Warning: Congress’ tax reform bill is bad for your health



If legislation harmful to health was required to carry a Surgeon’s General warning like tobacco, the tax bill being voted on today by the Senate would surely qualify.  It will harm health care for many millions of Americans, leading to more uninsured persons and higher premiums.  It also will lead to automatic scheduled cuts to Medicare and many other programs that are vital to health care.  Yet despite all of this, the Senate is poised to vote later today on the Tax Cuts and Jobs Act, and right now, it looks more likely than not it will pass the chamber by a party-line, Republican only majority vote (all Democrats are expected to vote against it).

Here are 2 things you need to know about the bill and how it will hurt patients and their doctors:

1.  By repealing the Affordable Care Act (ACA) requirement that people purchase a qualified health insurance plan or pay a penalty to the government, people who buy coverage in the individual insurance market will see double-digit premium increases, many insurers will bolt from the markets resulting in less competition and choice, and 13 million people will become uninsured. The individual insurance requirement is needed because without it, many people will wait until they get sick to enroll in coverage, knowing that the ACA prohibits insurers from charging sick people more.  With more sick people and fewer healthy people in the insurance pool, insurers will have no choice but to jack up premiums for everyone, or simply, decide not to see insurance at all in the individual market.  The American Academy of Actuaries has warned that repeal of the individual mandate would lead to premium increases, weaken insurer solvency, cause an increase in insurer withdrawals from the market, and "lead to severe market disruption and loss of coverage among individual market enrollees." According to a report by the non-partisan Congressional Budget Office, repealing the individual mandate would increase the number of uninsured by four million in 2019 and 13 million in 2027 and "average premiums in the non-group market would increase by about 10 percent in most years of the decade."

2.  Medicare and other vital health care programs will be cut by billions of dollars to pay for the tax cuts that go mainly to corporations.  Under a 2010 law called Statutory Pay-As-You-Go Act (SPAYGO), any law that will add to the federal deficit must be paid for with spending cuts, increases in revenue or other offsets.  Automatic cuts are imposed, through budget sequestration, if Congress does not enact the required offsets.  The Senate tax bill is projected to increase the federal deficit by $1.5 trillion over the next 10 years, so automatic across-the-board cuts will be triggered next year unless Congress passes separate bills to offset the cost in some other way.  Medicare would be automatically cut by $25 billion in 2018, which will result in an average cut of 4 percent in Medicare payments for health care services provided by  doctors, hospitals, clinical laboratories, graduate medical education programs, and other "providers."  For doctors, this cut will be on top of a near 3 percent cut that Congress previously imposed on them in 2013, 14, 15, 16, and 17—combined, Medicare payments to physicians will have been cut 7 percent less as a result.   Many other vital health programs, like the Centers for Disease Control and Prevention (which we all count on to help prevent infectious diseases, whether it is this year’ seasonal flu, or global pandemics that could sicken millions worldwide), will also be subjected to deep, across-the-board spending cuts to pay for the tax bill; some will be completely eliminated.  The New York Times has a very useful list and graphic of what will be cut, and by how much.

Is it any wonder then that the American College of Physicians, the nation’s largest physician specialty society, and second largest physician membership organization, came out today in opposition to the Senate bill? 

Should the Senator ignore ACP’s advice and pass the bill, it doesn’t mean that the fight is over, since the Senate would have reach an agreement on a identical tax bill that both chambers could support (the House passed its own, but different version, several weeks ago).  But any Senator who votes for Tax Cuts and Jobs Act must be held accountable by their constituents for  voting for a bill that is bad for their health, while disregarding doctors’ warnings about the harm it will do.