Wednesday, November 11, 2020

President-elect Biden wants to make health care better, but it won’t come easy

 When ACP released its Vision for a Better US Health Care System in January, we could not have anticipated that a global pandemic would soon reach our country, and 10 months later, be responsible for deaths of more than 240,000 Americans, many millions more being sickened, and hospital beds and clinical staff again in short supply because of another dangerous surge in cases.

But it turns out that ACP’s vision was prescient in identifying fundamental deficiencies in US health that have worsened the toll from COVID-19.  Losing your insurance because you lost your job.  Living in a state that has not expanded Medicaid.  Being faced with high deductibles and excessive prices even if insured. Discrimination and racism that contributes to poor health. Living in communities that are underserved, neglected, and poor.  A failure by the US to invest and support public health and primary care.  These are all risk factors for getting sick and dying from COVID-19, just like being old and having chronic conditions like diabetes and heart disease. 

You might even say that the United States itself has multiple chronic diseases of its health care system, making it far more vulnerable to COVID-19 than many other countries.

While many issues influenced how Americans cast their votes on November 3, the performance of President Trump and his administration on COVID-19 certainly was one of them. By electing Joseph R. Biden as the next president, and Kamala D. Harris as the next Vice President, voters elected the candidates who promised a major shift in how the US government addresses health care. Voters may have hedged their bets, though, by maintaining GOP control of the Senate, depending on the outcome of two special elections in Georgia.  Democrats have to win both Senate seats up for grab in Georgia on January 5 to split the Senate 50-50, with Vice President Harris being available to cast tie-breaking votes. Should the Republican candidate win either or both, Senator Mitch McConnell (R-KY) will remain the Senate’s Majority Leader and be able to impede much of a Biden administration’s legislative agenda.  The filibuster will still require 60 Senate votes on most legislation. The House of Representatives will remain under Democratic control, but with a smaller majority.

The Biden transition website, Build Back Better, lists COVID-19, racial equity, and climate change, and economic recovery, as the top 4 initial priorities for the new administration. Getting Congress to enact legislation to advance policies in these and other areas will be difficult.  Still, there is a lot a Biden administration can do to make health care better, even without Congress:

COVID-19: President-elect Biden already is charting a different course on COVID-19 than President Trump, announcing a COVID-19 Task Force composed of physicians and other health experts, co-chaired by former Surgeon General and ACP member Vivek Murthy.  He is expected to seek a national mandate to wear masks, using the administration’s regulatory authorities to require it in federal facilities and contractors and in public transportation, while seeking support from the states’ governors for a broader mandate.  He pledges to have science and scientists lead the public health response, rejoin the World Health Organization as recommended by ACP, address lack of supply of personal protective equipment, and expand testing and tracing.

Coverage and cost:   A Biden administration can use its executive authority to expand coverage under the ACA, in ways recommended by ACP in its New Vision papers and other policy statements. It can begin to reverse Trump administration rules that allow sale of plans that do not cover the 10 categories of essential benefits required of other ACA-compliant plans. It can increase funding and support for ACA outreach and enrollment and stop states from imposing work requirements as a condition for Medicaid coverage. 

President-elect Biden’s more ambitious plans to move the country closer to universal coverage will face an uphill battle. Congress would need to enact legislation to expand Medicare to persons aged 50 through 64, create a public option available to everyone, automatically enroll people in non-Medicaid expansion states in the public option, and lift the income caps on federal subsidies to buy health insurance coverage.  Of these, lifting the income caps might be more likely to command bipartisan support, because it would extend subsidies to people with incomes over 400% of the Federal Poverty Level, many of whom have been priced out of coverage.  A Biden administration will seek to rein in prescription drug prices, but Congress is unlikely to allow the federal government to negotiate Medicare Rx prices, or eliminate the tax deductibility for direct-to-consumer advertising.

Immigration: As President Trump has shown, presidents have a lot of power to shape immigration policy, without needing to go through Congress, and the courts generally defer to the executive branch.  The Biden administration will begin reversing immigration policies that have an adverse impact on health, one of ACP’s top priorities.  President-elect Biden has promised that on the first day of his administration, he will terminate the Trump administration’s ban on travel from 7 majority-Muslim countries, restore the DACA program to protect “Dreamers” from deportation, end the practice of separating children from their parents at the border, and appoint a federal task force to re-unite immigrant children who were separated—all actions strongly supported by ACP.

The new administration can take action to address the backlog in visas for international medical graduates (IMGs) seeking permanent residency status, and to ensure the effective and efficient processing of visas for IMGs seeking to enter the United States.  It can also begin the process of reversing the public charge rule, which denies residency to legal immigrants if they are likely to use public programs like Medicaid, which ACP has said is a major barrier to legal immigrants getting the health care they need.

Women and LGBQT health: The Biden administration is expected to begin to reverse restrictions on federal funding for Planned Parenthood and on physicians who counsel women on abortion or provide abortion services themselves—as called for by ACP.  It may seek to expand the ACA’s essential benefit requirements to ensure coverage for the full range of women’s health, and roll back so-called employer conscience exemptions that allow them to exclude contraception from coverage, although a Supreme Court decision may stand in their way.  President-elect Biden pledged to codify Roe v. Wade into federal law, as a hedge against future Supreme Court decisions to overturn or curtail the constitutional right to abortion; this though would require that such legislation pass both the House and Senate, which is very unlikely.  Similarly, the Senate would likely reject his call for Congress to end the Hyde rule, with prohibits federal funding for abortion.  As ACP and other organizations representing frontline physicians have advocated, the new administration is expected to reverse federal regulations and executive actions that weaken protections for LGBQT persons

Climate change: As called for by ACP, President-elect Biden has promised to rejoin the Paris Accord on the first day of his administration, which would recommit the United States to specified targets for reducing carbon emissions.  He can begin the process of reversing Trump administration regulations that eased restrictions on carbon emissions and opened up more federal lands to drilling for oil.  His more ambitious plans to promote green technologies and achieve a carbon-free power sector by 2035 likely will be stymied by the Senate, although the new administration can be aggressive in using its executive authority to achieve as much of this agenda as it can. 

Racism and health:  There are many things a Biden administration can do to address racism, discrimination, and related health disparities, only some of which require legislation from Congress.  It can reverse a Trump administration Executive Order that prohibits implicit bias training for federal employees and contractors as called for by ACP and AAMC, redirect federal funding and priorities to addressing social drivers of health, prioritize persons that are at the greatest risk of COVID-19 because of where they live and their race or ethnicity, have the Department of Justice address inequities in sentencing and legal representation particularly for capital offenses, and seek bipartisan solutions to system racism in law enforcement, although much of the latter likely will require legislation at the state and federal levels.   As important as specific policies are, President Biden and Vice President Harris can speak to the need for the United States to extend justice, fairness, diversity, equity, and inclusion to all and support Black Lives Matter, rather than seeking to undermine such goals. ACP welcomes the opportunity to advocate for policies to address the impact of racism and discrimination on health care.

Rolling back regulations that have been finalized by the previous administration won’t happen overnight, since by law they have to go through an entirely new round of agency rulemaking with public comment; many could remain in effect in the meantime.  The Biden team, to be sure, will be exploring ways to halt, delay or modify implementation of rules it seeks to reverse or modify, as quickly as possible.  Executive orders that have not been finalized as regulations likely can be reversed with the stroke of a pen of the new president, and new policy directions for federal agencies can be created by new Biden executive orders.

There are initiatives from the Trump administration that ACP will urge the Biden administration to continue, or even expand, including implementing higher Medicare payments for office visits, putting patients over paperwork, easing documentation and reporting requirements, and expanding coverage and payment for telehealth visits and phone calls.

In Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians, we wrote that “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.”  [Disclosure, I was the lead author for this Call to Action].  COVID-19 has shown us how true this is.  President-elect Biden now has the opportunity to advance polices to make health care better, and ACP stands ready to assist him, no matter how difficult it may seem.

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.