Wednesday, February 26, 2020

Where does ACP stand on Medicare-for-All?

When ACP released its Better is Possible: ACP’s Vision for the U.S. Health Care System, the College knew it would be provocative.  By proposing comprehensive reforms to expand coverage and lower costs, improve care delivery, and overcome other barriers to care, ACP is challenging a status quo that leaves too many Americans behind without accessible and affordable health care.

ACP’s recommendations to achieve universal coverage have gotten the most attention, support, and controversy:

“The American College of Physicians recommends that the United States transition to a system that achieves universal coverage with essential benefits and lower administrative costs.

Coverage should not be dependent on a person's place of residence, employment, health status, or income.

Coverage should ensure sufficient access to clinicians, hospitals, and other sources of care.

Two options could achieve these objectives: a single-payer financing approach, or a publicly financed coverage option to be offered along with regulated private insurance.”

Much of the news coverage, commentary, and social media discussion of ACP’s recommendations have focused on ACP’s support for a single-payer financing approach.  This is not surprising, since ACP is the first major national medical specialty society to say that a single payer system could achieve the goals of universal coverage that is not dependent on residence, employment, health status or income. Mentioned less often is that ACP also said a publicly-financed coverage option to be offered along with regulated private insurance could achieve the same objectives.  ACP’s paper on coverage and cost discusses that each approach has significant advantages and disadvantages.
ACP’s support for single payer has often been reported as being in support for “Medicare for All”—creating a good deal of confusion over whether ACP is endorsing the idea of enrolling everyone in a plan modeled on Medicare with better benefits, or a particular bill by that name authored and championed by Senator Bernie Sanders, a leading candidate for the Democratic nomination for president.

Let me clear things up.
1.   ACP does not use the phrase “Medicare for All” in its policy paper to describe our recommended approaches to coverage.  Yet, we’ve found that reporters often describe ACP’s support for single payer (as one of the two ways to achieve universal coverage recommended by us, the other being a public option) as supporting “Medicare for All” in the stories they file.  

2.   This is because “Medicare for All” is the shorthand used by many reporters, headline writers, non-partisan think tanks, pollsters, researchers, and advocates to describe any plan to (1) enroll everyone in a publicly-funded and administered plan, modeled on Medicare (with expanded benefits) and (2) eliminate or greatly limit private insurance.  When they use this phrase, they are not usually referring to Senator Sanders’ bill by this name unless they specifically say so, but rather, the idea of enrolling everyone in a public plan modeled on Medicare. 

3.   ACP has been consistent in saying that we have not endorsed or recommended any particular bill, whether called Medicare for All or something else, or any political candidate’s health care plans.

4.  ACP has been consistent in stating that ACP cannot, will not, and does not endorse candidates for federal office, or attempt to influence its members on who they might choose to vote for.  Rather, ACP hopes that its policy recommendations will help inform the debate over ways to achieve universal coverage, lower costs, improve payment and delivery, and reduce other barriers to care—from an evidence-based policy perspective of what’s best for patients, not from a political orientation or agenda.  

5. While ACP does not endorse any specific bill or plan put forth by a candidate, ACP policy supports the idea of a single payer plan (whether called Medicare for All or something else), that would 1) enroll everyone in a publicly-funded and administered plan, potentially modeled on Medicare but with better benefits and (2) eliminate or largely eliminate private insurance, if it meets our detailed policy recommendations. 

6.  ACP policy also supports the idea of public choice/public option that would (1) give everyone the choice of enrolling in a publicly-funded and administered plan, which potentially could be modeled on Medicare but with better benefits, or (2) in a qualified private insurance plan that has comparable benefits as the public plan, if it meets our detailed policy recommendations.  

7.  ACP’s detailed policy recommendations, among other things, say that under a single payer or a public choice model, cost-sharing should be eliminated for high value services and for patients with certain chronic conditions, payments to physicians must be sufficient to ensure access and not be limited by the current Medicare rates, and payments should not continue the disparities between complex cognitive and comprehensive care and procedures that existing in the current Medicare physician fee schedule.

8. Such detailed policy recommendations can help inform discussion of how closely a particular plan or bill meets ACP’s objectives, without leading to ACP endorsement or opposition to them.

In the current hyper-polarized political environment, it’s unfortunate that the names that people give to proposals can add to controversy, if misinterpreted as ACP supporting a particular candidate, plan or bill rather than offering our own ideas to make health care better. 

Yet, in my view what’s most important is to get back to the substance of what ACP recommends and why.  ACP believes, and the evidence shows, that no matter what one chooses to call it

Enrolling everyone in a publicly financed and administered plan

Or, alternatively, giving everyone the choice of enrolling in publicly-financed and administered plan or in private insurance with comparable benefits

If designed and implemented as ACP recommends

Would be a vast improvement over the status quo.

Because, as ACP wrote in  Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians,  “U.S. health care costs too much; leaves too many behind without affordable coverage; creates incentives that are misaligned with patients' interests; undervalues primary care and public health; spends too much on administration at the expense of patient care; fails to invest and support public health approaches to reduce preventable injuries, deaths, diseases, and suffering; and fosters barriers to care for and discrimination against vulnerable individuals.”

Better is possible.

Tuesday, January 21, 2020

ACP has proposed a bold new plan to fix American health care. It’s about time someone did.

The American health care system is broken.
Patients know it. Physicians know it. People who study health care know it. You know it. I know it. 

Yet instead of doing something about it, we are told to accept the unacceptable because changing it will be too hard and the politics too difficult.

But isn’t time for someone with influence to speak out and say enough is enough, we can and must do better?

Yes, and that someone is the American College of Physicians. Today, ACP issued a bold call to action challenging the U.S. to implement systematic reform of the health care system in a series of policy papers published as a supplement in Annals of Internal Medicine.

“Better is Possible: The American College of Physicians Vision for the U.S. Health Care System” is a comprehensive, interconnected set of policies to guide the way to a better U.S. health care system for all. It includes a call to action, of which I am the corresponding author, which presents ACP’s vision of a better health care system for all, summarizes ACP’s key recommendation to achieve it, and challenges the U.S. not to settle for the status quo. The additional set of ACP policy papers in the supplement address issues related to coverage and cost of care, health care payment and delivery systems, and barriers to care and social determinants of health, and offer specific recommendations supported by evidence about ways the U.S. can change the status quo and achieve a better healthcare system for all. The papers are:

 “Envisioning a Better Health Care System for All: The American College of Physicians’ Call to Action

“Envisioning a Better Health Care System for All: Coverage and Cost of Care

 “Envisioning a Better Health Care System for All: Reducing Barriers to Care and Addressing Social Determinants of Health”

 “Envisioning a Better Health Care System for All: Health Care Delivery and Payment System Reform

One of the 10 vision statements in the Call to Action states that “ACP envisions a health care system where everyone has coverage for and access to the care they need, at a cost they and the country can afford.” To achieve this, ACP recommends that the U.S. adopt either a single payer system or a public choice plan. 

Under single payer, everyone would be enrolled in the same publicly-financed and administered plan, with little or no role for private insurance. In a public choice model, everyone would have the option of enrolling in a publicly-financed program or keeping private insurance that would be required to have comparable benefits as the public option. 

This is the first time that ACP has expressly recommended either a single payer plan, or a public choice plan that would be made available to everyone. To our knowledge, we are the first national medical specialty society to do so; we are also the largest, representing 159,000 internal specialist physician and medical student members.

We offered both approaches as ones we can recommend because our examination of other countries with universal coverage found that there are some that have a single payer system, while others have systems where there is a mix of public and private coverage strongly regulated by the government and where coverage is guaranteed. In other words, there is more than one way to achieve universal coverage.

Single payer has the advantage of much lower administrative costs and associated administrative requirements on clinicians but is more disruptive because it would largely eliminate private insurance, while a public choice models is less disruptive and would achieve administrative savings compared to our current system, as more people choose the public choice option, but less than from single payer.

Also new and notable is that ACP recommends eliminating cost-sharing that creates barriers to high value care; including for patients with certain chronic conditions. We also proposed ways to control costs, including expanding global budgets and all payer rate setting, prioritizing spending, increasing investment in primary care, and considering comparative effectiveness in cost.

ACP didn’t just focus on coverage and cost. We propose major reforms in payment and delivery systems to center them on patients’ needs, including redesigning value-based payment programs that largely have not been effective in improving outcomes or lowering costs. Specifically, we call for

Eliminating “check the box” performance measurement reporting that take physicians’ time away from patients without resulting in better care,

Realigning incentives to support physician-led clinical care teams,

Eliminating disparities in payment between physicians’ cognitive services and procedures,

Redesigning Electronic Health Records to help physicians deliver patient-centered care.

Finally, we advocate for policies to reduce barriers to care based on where people live (social determinants), eliminate discrimination against and disparities in care based on personal characteristics, and devote more resources to the public health crises of firearms-related injuries and deaths, maternal mortality, tobacco and nicotine use, substance use disorders, and climate change.

ACP understands that our recommendations are provocative and controversial. We know that some of them will be fiercely opposed by those who financially benefit from our broken system. We know that politics will be hard. And, while we are confident that most ACP members support us in offering a bold vision for change, we also know that not every one of them will agree with everything we propose, and their concerns need to be respectfully addressed.

But the alternative is accepting the unacceptable: a broken U.S. health care system that, as we wrote in the Call to Action, “costs too much; leaves too many behind without affordable coverage; creates incentives that are misaligned with patients’ interests; undervalues primary care and public health; spends too much on administration at the expense of patient care; fails to invest and support public health approaches to reduce preventable injuries, deaths, diseases and suffering; and fosters barriers to care and discrimination against vulnerable individuals.’

I am so proud that ACP is offering a vision for better health care system for all and of my contributions to making this happen.

Friday, September 13, 2019

Trump’s health care plan is hiding in plain sight

As the Democratic candidates for president continue to beat up each other on how best to achieve universal coverage (Medicare-for-All, a public option, closing the ACA’s coverage gaps), health care journalists keep wondering when President Trump will release his long promised “phenomenal” plan to position the GOP as “the party of health care” for the 2020 election.

Skepticism is warranted over when or even if the administration will actually offer such plan (never mind whether it will be “phenomenal”) since it never did during the two years when the White House and then GOP-controlled Congress unsuccessfully sought to “repeal and replace” the ACA. The Trump administration currently is urging a federal appeals court to uphold a ruling by a Texas judge that the entire ACA is unconstitutional, without explaining what should replace it—repeal without a replacement. Polling also shows that President Trump starts with a very substantial disadvantage on health care: a recent ABC/Washington Post poll found that “Americans, by a 17-point margin, say his handling of health care makes them more likely to oppose than support him for a second term.” 
Yet even without a formal plan, the administration’s approach is readily discernible from the things it has announced and is implementing. Democrats and their progressive allies might discover to their surprise that it may have more appeal to voters than they now anticipate. A Trump health care plan likely would look like this:

1. A promise to let individual Americans decide for themselves what kind of health care coverage they need and how much they want to spend on it, instead of “government bureaucrats” imposing an expensive plan on them. The administration can point to the changes it has made to offer people so-called short-term duration and association health plans, both of which are exempted from the “Obamacare’s” benefit mandates—which it will spin as Washington no longer forcing you to pay for coverage you don’t want or need.

2. It will promise that no one will be turned down for coverage for a pre-existing condition. But unlike the ACA, or Medicare for All, the administration will argue that government won’t dictate what the plans available to people with pre-existing conditions will cover—a 60 year man with Type 2 diabetes won’t be required to buy coverage for maternity care, for instance.

3. It will say that the Trump administration is doing more to reduce paperwork burdens on physicians and patients, through its Patients Over Paperwork initiative.

4. It will say that the President is leading the effort to drive down prescription drug prices and require hospitals to be transparent in their pricing of health care services.

5. It will point to its commitment to protect patients from the harms of tobacco and e-cigarettes, calling for much greater regulation than is usual for Republican administrations.

6. It will contrast its approach of trusting Americans to make their own choices over what it will say is the Democrat’s support for a complete government take-over. It will argue that whether the Democratic nominee supports Medicare for All plan with no private insurance, or a Medicare Choice/public option approach that keeps a role for private insurance, the result will be a government “take-over” of health care, higher taxes, fewer choices, longer waits, and poorer outcomes. (No matter that countries with publicly-funded care generally have better outcomes and lower costs than in the United States). Health insurers, drug manufacturers, and hospitals will eagerly reinforce such misleading scare tactics.

Critics will argue, correctly in my view, that the administration’s weakening of essential benefit and pre-existing protections, efforts to get a federal court to overturn the entire ACA, “conscience protections” that allow employers to opt-out of offering contraception and other needed services, treatment of immigrants, and it’s wholesale assault on women’s reproductive rights and health, denial of climate change, and unwillingness to confront the epidemic of gun violence, are anti-health and anti-patient. At the same time, the administration deserves credit for addressing the administrative burden on physicians, increasing regulation of tobacco, addressing high prescription drug costs, and increasing price transparency. Progressives and Democrats will make the case that Medicare for All, or a public option, will make care more affordable and accessible for most Americans, and they have plenty of evidence on their side.

Yet they would be foolish to underestimate the potential appeal of a “Trump Health Plan” that is framed, accurately or not, as a choice between you deciding what’s best for your health, or the government deciding for you.