Now that the Obamacare replacement bill has passed the House and is moving on to the more centrist Senate, the real debate begins. What is the true purpose of health insurance, and what is our government’s goal in ensuring we have it?
I learn from my patients every day about the benefits, limitations and contradictions of their health insurance. One charming 60-year-old with severe seasonal allergies insists on seeing his primary care physician every few weeks this time of year, even though their office tells her she doesn’t need to — her antihistamines and nasal spray treatment rarely changes. But she worries that her allergies could be hiding an infection, so their office investigates her sinuses, throat, lungs and ears. She is reassured, and her insurance (which she buys through Maryland’s Obamacare exchange) covers the bill.
If she was responsible for more than a small co-payment for these visits, I’m sure her doctor would see her less often.
We pride ourselves on being a compassionate society, and insurance companies use this to manipulate us into sharing the costs of other people’s excessive health care. Meanwhile, 5 percent of Americans generate more than 50 percent of health care expenses. Why shouldn’t a patient who continues to see me unnecessarily pay more?
The government’s job is to maintain public health and safety. It should ensure that insurance plans include mandatory benefits like emergency, epidemic, vaccine and addiction coverage. The Republican bill would let states apply for waivers to define these benefits differently; it would be a big mistake to drop such coverage entirely. But Obamacare went well beyond these essentials, by mandating an overstuffed prix fixe meal filled with benefits like maternity and mental health coverage that drove smaller insurers with fewer options out of the market. The few that remain often have a monopoly, and premiums rise.
Speaking of compassion, how about some for the 20-something construction worker who can’t afford to pay his rent because his premiums help subsidize overusers like my allergy sufferer? Why shouldn’t a patient who is risk-averse pay more for coverage she might never need, while that construction worker be allowed to choose a cheaper insurance plan that might cover only the essentials?
In addition to limiting the menu of essential benefits, the House bill would let states create high-risk pools for patients with pre-existing conditions who had let their insurance coverage lapse, and who could then be charged premiums more in keeping with their health care needs. This is the only way to make insurance affordable for most consumers; pre-existing conditions will continue to drive up premiums if everyone is compelled to pay the same price.
These risk-pool premiums can and should be subsidized by the government. A recent report from the Kaiser Family Foundation found that high-risk pools can work, but have been historically underfunded. Trumpcare should change that — though it will cost more than the House bill’s $8 billion in additional funding. Drastic cuts to Medicaid should also be reversed, which could help the bill pass the Senate.
But the bill is on the right track. Americans believe that insurance provides access to care, when in fact it is the gatekeeper that often denies care. Many think Obamacare is generous, and yet I often have to fight for essential care for my patients. We need to be more pragmatic, and less emotional, about this issue.
Jimmy Kimmel’s contention this week that a child like his would not receive lifesaving surgery for his congenital heart problem without Obamacare may tug at the heartstrings, but it is neither fair nor accurate. Employer-based health insurance, which covers 170 million Americans, including, no doubt, Mr. Kimmel, would have paid for this infant’s needs with or without Obamacare. Even if the Republican plan replaced Obamacare, and even if the infant didn’t have employer-provided insurance, the treatment would still be covered, either through a traditional plan or a high-risk pool. And at the end of the day, a federal law, the Emergency Medical Treatment and Labor Act, guarantees this kind of treatment, whether we have Obamacare or Trumpcare.
The final question concerns the skyrocketing costs of innovation, and how one-size-fits-all insurance can possibly continue to pay for it. My 93-year-old father, a retired engineer, just received a $50,000 catheter-inserted aortic valve, which was covered by Medicare. But if all such high-tech devices are covered, it will be practically impossible for any insurance company not to go belly-up. The tax-free savings accounts that the House bill would expand and make more flexible are a far better way to pay for this kind of care. Shouldn’t my father and those like him be asked to save their own money for just this sort of rainy day?
Or should we continue to overload health insurance with all our fears and expectations? Julie Henry wrote last May that, more than 2,200 physicians announced their support for a proposal for a single-payer national health program (NHP); a related editorial was published in the American Journal of Public Health.
And consider my point last week where the CEO of Aetna as he was announcing the pull out of Aetna from the last two states The CEO of health insurer Aetna told employees in a private meeting that the U.S. should consider a single-payer healthcare system, Vox reported Friday.
“Single-payer, I think we should have that debate as a nation,” Mark Bertolini reportedly said after being asked about the possibility of the GOP’s ObamaCare repeal plan paving the way for a single-payer system.
Earlier last week, Aetna announced it would pull out of the last two states where it was participating in ObamaCare’s markets, meaning it wouldn’t sell any plans for next year on the health exchanges.
In a private meeting where Bertolini faced employee questions, one reportedly asked: “In the news media, it is reporting that the Republican health plan is paving the way to a single-payer system. What are your thoughts on that, and how would it impact Aetna?”
“If the government wants to pay all the bills, and employers want to stop offering coverage, and we can be there in a public private partnership to do the work we do today with Medicare, and with Medicaid at every state level, we run the Medicaid programs for them, then let’s have that conversation,” Bertolini responded.
The CEO “was certainly not advocating for a single-payer system,” Aetna spokesperson T.J. Crawford wrote in an email.
Instead, he was indicating his openness to debating it “while pointing out that public-private partnerships have been the backbone of the more successful government health care programs (examples include administering Medicare Advantage or Medicaid managed care). In other words, partnering works when done the right way,” Crawford wrote.
Sen. Bernie Sanders (I-Vt.) staunchly advocated for a single-payer healthcare system during his Democratic presidential campaign last year, frequently referring to it as “Medicare for all.”
The doctors appear to be fed up with the current healthcare system. “Caring relationships are increasingly taking a back seat to the financial prerogatives of insurance firms, corporate providers, and Big Pharma,” Dr. Adam Gaffney, a Boston-based pulmonary disease and critical care specialist and lead author of the editorial, said in a press release. “Our patients are suffering and our profession is being degraded and disfigured by these mercenary interests.”
Combining current government health expenditures into a single fund would fund the NHP; it would also require a tax increase, which the doctors say will “be fully offset by reductions in premiums and out-of-pocket spending.”
The proposal estimates that the NHP would save around $15 billion annually by cutting administrative costs.
Details of the NHP
Highlights of the NHP proposal include the following:
- All residents of the U.S. would be covered for all necessary medical care, regardless of immigration status.
- Coverage would include inpatient and outpatient care, rehabilitation services, mental health services, long-term care, dental care and prescription drugs.
- Patients could choose to go to any hospital or doctor.
- Premiums, co-pays, deductibles, and co-insurance would be eliminated.
- Medical bills for covered services would be eliminated for U.S. residents.
- Most hospitals and clinics would remain privately owned and operated; they would receive a budget from the NHP to cover all operating costs.
- Physicians could continue to practice on a fee-for-service basis, or receive salaries from group practices, hospitals, or clinics.
Medicare for All
Democratic presidential candidate Bernie Sanders (I-VT) has also developed a proposal for a single-payer plan, which has been dubbed Medicare for All. Under this system, all US citizens would be automatically enrolled into Medicare.
Various tax revenues, credits and subsidies would finance the program.
According to the Medicare for All website, the plan will cost more than $6 trillion less than the current healthcare system over the next 10 years.
Under the plan:
- Patients could choose to go to any hospital or doctor.
- Premiums, co-pays and deductibles would be eliminated.
- Coverage would include inpatient and outpatient care; preventive care; emergency care; primary care; long-term and palliative care; vision, hearing and oral health care; mental health and substance abuse services, prescription medications and medical equipment, supplies, diagnostics and treatments.
However, a new report from Urban Institute’s Health Policy Center from this week estimated Sanders’ (I-VT) single-payer plan would increase federal spending $32 trillion over the next 10 years – much more than the $13.8 trillion he said his plan would cost and the $15.3 trillion in new revenue he estimated it would raise. This would leave a $16.6 trillion hole the government would need to pay for the single-payer plan, according to the study.
Possible hurdles to a single-payer system
In an article for Vox, Harold Pollack, a liberal healthcare policy expert at the University of Chicago, said: “Single-payer would require a serious rewrite of state and federal relations in Medicaid and in many other matters.” Pollack also said converting to a single-payer system would require complex negotiations to transition people from employer-based coverage.
Additionally, most of the healthcare industry would undoubtedly put up a fight against any single-payer proposal. “The entire supply side of the medical economy would be opposed to efforts to increase the bargaining power of the government and to set prices and terms of care,” Pollack, told Modern Healthcare.
Will Colorado lead the way for the rest of the US?
In November, voters in Colorado considered a ballot measure to implement a single-payer system called ColoradoCare. However, Colorado voters dealt a blow to the idea of a single-payer health insurance, a controversial ballot initiative that would have provided medical coverage to all state residents through a payroll tax.
The idea was backed by progressives, but opposed by the business community, health insurers, Democratic Gov. John Hickenlooper and members of Congress from both parties. About 80% of voters cast ballots against the measure.
It’s the latest blow to the Medicare-for-all approach to healthcare that is supported by liberals like Sen. Bernie Sanders, the Vermont Democrat, who was runner-up to Hillary Clinton for the Democratic Party’s presidential nomination.
The Senate is negotiating its own legislation to repeal and replace much of the Affordable Care Act in secret talks with senators hand-picked by party leaders and with no plans for committee hearings to publicly vet the bill.
“I am encouraged by what we are seeing in the Senate. We’re seeing senators leading,” said Sen. Ted Cruz, R-Texas, one of the 13 Republicans involved in the private talks. “We’re seeing senators working together in good faith. We’re not seeing senators throwing rocks at each other, either in private or in the press.”
Senate Democrats have a different take. “Your morning reminder that under the cloud cover of the FBI story, 13 GOP Senators are still secretly writing a bill to destroy the ACA,” Sen. Chris Murphy, D-Conn., tweeted Monday morning.
Why should America have a Single-Payer System?
Donald Berwick, MD, who helped launch the Affordable Care Act,(ACA), considered it to be the only health reform this country would need, when he was administrator of the Centers for Medicare & Medicaid Services (CMS) in 2010 to 2011.But 5 years later, Dr. Berwick and millions of other Americans are calling for a new round of reform that would involve much deeper changes: a single-payer system. Dr. Berwick says he still supports the ACA—”It’s been a step forward for the country,” he says—but adds, “The ACA does not deal with problem of waste and complexity in the system.”
Other single-payer advocates are less forgiving. They think that the ACA has pampered the commercial insurance industry, providing it with millions more customers and allowing it to jack up charges to levels that fewer Americans can afford.
The proposed single payer would be the US government.
Consider that the single-payer reform would take an audacious step. It would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a work force of 470,000—and replace it with one unified payer. A small vestige of the industry would remain to cover nonessential services, such as LASIK surgery.
Advocates often envision a single-payer system as an expansion of Medicare, as I have mentioned, or “Medicare for all.” Single-payer systems in Canada, Australia, Denmark, Norway, and Sweden—as well as other types of centrally run systems—have much lower per capita health spending and generally better health outcomes than the United States. However, this is also true for non–single-payer systems outside of the United States. The United States simply has the highest healthcare costs, regardless of the system.
Sasha Savisky reported the newly crowned Miss USA is already under fire. Kara McCullough, of the District of Columbia, was asked during Sunday night’s pageant whether she thinks that affordable health care for all U.S. citizens is a right or a privilege. She said it is a privilege. “As a government employee, I’m granted health care and I see firsthand that for one to have health care, you need to have jobs,” the 25-year-old shared. The U.S. Nuclear Regulatory Commission scientist’s answers did not sit well with some viewers, who took to social media to slam her remarks.
I bring this up because the single-payer approach has a moral argument—that everyone should have a right to healthcare—but it also has a practical argument, says James Burdick, MD, a transplant surgeon at Johns Hopkins University School of Medicine and author of Talking About SINGLE PAYER, which will be published later this year. “It’s a more economical way to use healthcare resources,” Dr. Burdick says. “You could reduce expenses and still improve quality. That’s a tremendous opportunity that you don’t have in many other fields.”
But who would manage the single-payer system and if “run” by the government just look at the history of government run health care system here if the U.S.- the Veterans Association Health Care System and the continued problems and frustrations. Even considering these relative failures I am convinced that we will have a single-payer health care system here in this country.