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.