The ACP Advocate Blog

by Bob Doherty

Thursday, December 18, 2008

Is Obama's health reform plan a back door to single payer?

The health plan touted by President-elect Obama during his campaign is not a single payer, Canadian-style, national health insurance plan. Yet, there are some who worry - and others fervently hope - that it will end up being the back door entry way to a single payer system.

Let's begin by recounting all of the reasons why the Obama proposal is not a single payer plan.

It doesn't eliminate private insurance, it subsidizes it. People who don't have access to affordable coverage through their employer would receive federal subsidies to buy coverage through a "National Health Insurance Exchange." The Exchange would allow people to choose from hundreds of different private health insurance plans, just like federal employees do. No one has to switch plans though; anyone who has private insurance through an employer, and likes it, could keep it.

Obama proposes to mandate that people buy coverage for their children, opening up more business growth opportunities for the insurance industry. America's Health Insurance Plans (AHIP) has proposed to expand this to an "enforceable individual coverage mandate" for everyone, not just kids, to buy coverage.

But the Obama plan also grows government's role. Obama proposes to expand enrollment in government-run (public) plans like Medicaid and the State Children's Health Insurance Program.

And, in addition to giving subsidies to individuals to choose from hundreds of private insurers, he would give them the choice of enrolling in a public plan, similar to Medicare. Robert Pear reports in yesterday's New York Times that the public plan, according to HHS Secretary-designee Tom Daschle, would be "modeled after Medicare" and would have "tremendous clout to bargain for the lowest prices" from health care providers.

AHIP argues that because of cost-shifting, the new proposed new public program could lead to higher costs for people who already had private insurance.

The insurance industry's biggest concern is that the government plan will undercut private insurance. As a result, enrollment in the public plan would grow over time, while private insurance enrollment would contract.

This - coupled with the planned expansion of Medicaid, SCHIP, and the inevitable growth of Medicare associated with an aging population - could get the country to a single payer system, or something close to it.

It wouldn't be a single payer system created by legislative fiat, but one that comes from "competition" (fair or unfair as it may be) between private insurance and public coverage.

ACP members who favor single payer will be encouraged by this scenario. Others, who distrust giving government so much control over health care, will view it with dismay and trepidation.

What is certain is the creation of a "public plan" option will be among the most controversial elements of the Obama plan.

Today's question: Do you believe that people should have the option of choosing between a subsidized private insurance plan and a public plan like Medicare?

3 Comments :

Blogger Steve Lucas said...

In the PBS Frontline special Sick Around The World they highlight a number of countries who have insurance mandates. None of these countries have the convoluted system we do in the US, but they do have lower cost and better outcomes.

My personal belief is we need to choose A system. As long as there is a government subsidized system employers will default in favor of this to save cost. The most recent example is Hawaii and it's children's health insurance initiative.

One interesting point of the program, and something my wife and I have noticed as we travel, is people in other countries view medical care as a personal cost. Since everyone pays, and see this bill monthly, they are less likely to over use medical resources. Medicine is also viewed as a service. This promotes the concept that those involved are compensated, but the industry as a whole is not to make a profit.

In order to promote nationwide coverage and standard policy coverage we will need a government run system, Medicare for all. While I would prefer a private system, I do not see it able to be put in place with all of the various state agencies trying to justify their existence.

A government run system would also allow for government negotiated drug pricing, elimination of DTC ads, and the review of medical standards with an eye to controlling cost. Many find this concept contrary to the American way of free choice but the simple reality is we over prescribe and over test creating a cost structure we cannot support as a country.

Steve Lucas

December 19, 2008 at 9:45 AM  
Blogger T said...

I am among those physicians who hope Obama's plan is a back door to single payer. Medicare+Medicaid+SCHIP already insures the neediest and sickest members of our society. I think it is definitely fair to have a public insurance program compete with private insurance, for profit company. The public insurance premiums would be much lower because of the lower administrative costs(90% lower on average).

December 19, 2008 at 12:42 PM  
Blogger Discover What You Think said...

The following are facts that are believed to exist regarding the present U.S. Health Care System. This may be why about 80 percent of U.S. citizens understandably want our health care system overhauled:
The U.S. is ranked number 42 related to life expectancy and infant mortality, which is rather low.
However, the U.S. is ranked number one in the world for spending the most for health care- as well as being number one for those with chronic diseases. About 125 million people have such diseases. This is about 70 percent of the Medicare budget that is spent treating these terrible illnesses. Health Care cost presently is over 2 trillion dollars of our gross domestic product. One third of that amount is nothing more than administrative toxic waste that does not involve the restoration of the health of others. This illustrates how absurd the U.S. Health Care System is presently. Nearly 7000 dollars is spent on every citizen for health care every year, and that, too, is more than anyone else in the world.
We have around 50 million citizens without any health insurance, which may cause about 20 thousand deaths per year. This includes millions of children without health care, which is added to the planned or implemented cuts in the government SCHIP program for children, which alone covers about 7 million kids.
Our children
Nearly half of the states in the U.S. are planning on or have made cuts to Medicaid, which covers about 60 million people, and those on Medicaid are in need of this coverage is largely due to unemployment. With these Medicaid cuts, over a million people will lose their health care coverage and benefits to a damaging degree.
About 70 percent of citizens have some form of health insurance, and the premiums for their insurance have increased nearly 90 percent in the past 8 years. About 45 percent of health care is provided by our government- which is predicted to experience a severe financial crisis in the near future with some government health care programs, it has been reported. Most doctors want a single payer health care system, which would save about 400 billion dollars a year- about 20 percent less than what we are paying now. The American College of Physicians, second in size only to the American Medical Association, supports a single payer health care system. The AMA, historically opposed to a single payer health care system, has close to half of its members in favor of this system. Less than a third of all physicians are members of the AMA, according to others.
Our health care we offer citizens is the present system is sort of a hybrid of a national and private health care system that has obviously mutated to a degree that is incapable of being fully functional due to perhaps copious amounts and levels of individual and legal entities.
Health Care must be the priority immediately by the new administration and congress. Challenges include the 700 billion dollars that have been pledged with the financial bailout that will occur, since the proposed health care plan of the next administration is projected to cost over a trillion dollars within the first year or so of the proposed plan to recalibrate health care for all of us in the U.S. Yet considering the hundreds of billions of dollars that are speculated to be saved with a reform of the country’s health care system, health policy analysts should not be greatly concerned on the steakholders who may be affected by this reform of our health care system that is desperately needed. Tom Daschle leads this Transition’s Health Policy Team. And we also have Ed Kennedy, the committee chair and a prolific legislator. So if the right people have been selected for this reforming team, the urgency and priority regarding our nation’s health care needs should be rather overt to the country’s citizens.
Half of all patients do not receive proper treatment to restore their health, it has been stated. Medical errors desperately need to be reduced as well, it has been reported, which should be addressed as well.
It is estimated that the U.S. needs presently tens of thousands more primary care physicians to fully satisfy the necessities of those members of the public health. This specialty makes nearly 100 thousand less in income compared with other physician specialties, yet they are and have been the backbone of the U.S. health care system. PCPs manage the chronically ill patients, who would benefit the most from the much needed coordination and continuity of care that PCPs historically have strived to provide for them. Nearly have of the population has at least one chronic illness- with many of those having more than one of these types of illnesses. A good portion of these very ill patients have numerous illnesses that are chronic, and this is responsible for well over 50 percent of the entire Medicare budget. .
The shortage of primary care physicians is due to numerous variables, such as administrative hassles that are quite vexing for these doctors, along with ever increasing patient loads complicated by the progressively increasing cost to provide care for their patients. Many PCPs are retiring early, and most medical school graduates do not strive to become this specialty for obvious reasons. In fact, the number entering family practice residencies has decreased by half over the past decade or so. PCPs also have extensive student loans from their training to complicate their rather excessive workloads as caregivers.
Yet if primary care physicians were increased in number with the populations they serve and are dedicated to their welfare. Studies have shown that mortality rates would decrease due to increased patient outcomes if this increase were to occur. This specialty would also optimize preventative care more for their patients. Studies have also shown that, if enough PCPs are practicing in a given geographical area, hospital admissions are decreased, as well as visits to emergency rooms. This is due to the ideal continuity in health care these PCPs provide if numbered correctly to serve more, the quality improves, as well as the outcomes for their patients. Most importantly, the quality of life for their patients is much improved if there are enough PCPs to handle the overwhelming load of responsibility they presently have due to this shortage of their specialty that is suppose to increase in the years to come. The American College of Physicians believes that a patient centered national health care workforce policy is needed to address these issues that would ideally restructure the payment policies that exist presently with primary care physicians.
Further vexing is that it is quite apparent that we have some greedy health care corporations that take advantage of our health care system. Over a billion dollars was recovered for Medicare and Medicaid fraud last year through settlements paid to the department of Justice because some organizations who deliberately ripped off taxpayers. These are the taxpayers in the U.S. who have a fragmented health care system with substantial components and different levels of government- composed of several legal entities and individuals, which has resulted in medical anarchy, so it seems.
Health 2.0, a new healthcare social networking innovation, is informing patients about their symptoms and potential if not possessing various disease states- largely based on the testimonies of other people on various websites. This may be an example of how so many others rely now on health concerns from those who likely are not medical specialists, instead of becoming a participant, if not victim, of the U.S. Health Care System.
Thanks to various corporations infecting our Health Care System in the United States, the following variables sum up this system as it exists today, which is why the United States National Health Insurance Act (H.R. 676) is the best solution to meet our health care needs as citizens, it appears. We would finally have, as with most other countries, a Universal Health Care system that will allow free choice of doctors and hospitals, potentially. It should be and likely will be funded by a combination of payroll taxes and general tax revenue:
Access- citizens do not have the right or ability to make use of this system as we should.
Efficiency- this system strives on creating much waste and expense as it possibly can.
Quality- the standard of excellence we deserve as citizens with our health care is missing in action.
Sustainability- We as citizens cannot continue to keep our health care system in as it is designed at this time- as it exists today.
http://www.mckinsey.com/mgi/publications/US_healthcare/index.asp
Dan Abshear

December 23, 2008 at 3:58 PM  

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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