The Time For Single-Payer Is Now! Maybe, Maybe Not!

pelosi008When presented with an unexpected up-or-down vote on single-payer health insurance, not a single Democrat supported it. Joe Newman, via the Public Citizen, reported that little more than a week ago the Democrats not only looked a gift horse in the mouth, they gave it back, too. The gift? An up-or-down vote on single-payer health insurance, under which the federal government would provide health insurance for all Americans and covering the more than 20 million Americans still uninsured under the Affordable Care Act. Not a single member of the Democratic caucus supported it. This seems so obviously a mistake that it bears to ask the question: Why didn’t they vote for it? The short answer is, congressional Democrats are afraid.

This past week an unexpected champion took up the cause of single-payer health insurance: Republican Senator Steve Daines of Montana. His amendment to the Republican health care plan would replace the bill and cover all Americans. It was plainly a tactic to get Democrats on the record in support of single payer. The Democrats didn’t go for it; 43 members of the Democratic caucus voted “present” and five members voted “no.”

Until now, the Democratic Party has been largely occupied with pushing back against the Trump administration’s agenda: seeking to block unqualified and ultra-right judicial nominees, insisting on investigations into Trump’s collusion with Russia, mobilizing against efforts to repeal the Affordable Care Act. This has been somewhat successful on a policy level, as the administration has yet to achieve a single significant victory in Congress. But in terms of politics, it is not enough for Democrats to be the not-Republicans — a lesson learned in 2004 and again in 2016. The Democrats must not only propose an affirmative agenda, something toward which they recently took steps, but show they are willing to fight for it. The single-payer amendment presented an opportunity to do that by showing leadership and mettle.

We elect people we trust to lead us, not to blindly follow popular opinion. It is no surprise, then, that the endorsement of prominent politicians can actually increase support for the policy. Marriage equality provides a good example. Prior to Obama’s announcement in May 2012 of his support for same-sex marriage, only a handful of politicians on the national stage had done so. At that point, support stood at a bare 50 percent in favor and had only recently emerged from the mid- to low-forties. Within months, support jumped to 53 percent and by a year later it had climbed to the high fifties. Though this is not conclusive alone, it stands to reason that as more and more national politicians—nearly the entire Democratic caucus in both the House and Senate—announced and explained their support, they convinced their constituents of the policy’s legitimacy.

We can see the beginnings of this with single-payer health insurance. In March 2014, a mere 21 percent of Americans supported single-payer health insurance, and only 47 percent said the government has a responsibility to make sure all Americans have health insurance coverage. After Bernie Sanders made this one of his key issues in his 2016 presidential run, it grew to 28 percent support for single-payer in January of this year, and then 33 percent as of a month ago. Support is particularly strong, nearly half, among Millennials, regardless of party affiliation. Likewise, around 60 percent of Americans now believe that it is the government’s responsibility to ensure that all Americans are covered by health insurance. Democrats should have seized on the chance to make this an issue, going out and working with progressive groups to convince Americans to finally insure all of us, rather than running scared

Skeptics might note that support for single-payer is currently substantially lower than support for marriage equality was, the stakes are likewise far lower: this is merely an amendment in the midst of an extremely complex health care debate, with the mid-term election over a year away. These conditions actually make support for the amendment more valuable, not less. Given the effects of national politicians endorsing policy and seeking to convince their constituents, support for single-payer could grow substantially over the next 16 months.

Moreover, though unlikely, it could have passed. Cynics might scoff, but historical precedent demonstrates the possibility. Originally, the Civil Rights Act of 1964 did not prohibit sex discrimination. That change was due to the effort of segregationist Southerners who sought to delay the vote on the Act and fracture the fragile coalition seeking to pass the bill. Many proponents of the Civil Rights Act opposed the amendment, concerned that it would doom the legislation—but it passed regardless. Ironically, many of the “yea” votes were Southern Democrats who believed it would sink the law entirely. When the dust settled, women suddenly found themselves, at last, protected by federal anti-discrimination legislation.

Though the facts are not precisely parallel now, the miscalculation by segregationists shows that a simple amendment—the sex amendment was a one-word addition to the bill—designed to implode a more moderate effort, or to embarrass those who support it, can change history. The same could have happened here if only the Democrats had gathered their courage.

Finally, Americans deserve to know where their representatives stand on single-payer health insurance. A majority of Democrats—52 percent—now support single-payer health care, and it is a priority for many of us. If we are supposed to make educated decisions in the voting booth, if we want to send representatives to Washington who share our values, the fact that congressional Democrats are so shy to discuss, let alone vote, on single-payer militates against our ability to do just that. It is disingenuous at its very best.

As Democrats, we need to get our act together. It is not enough to reveal the Trump administration to be an omnishambles populated by cretins; we must go further. We must present an agenda that speaks to the problems they face daily; whether the administration has colluded with Russia is of no import to a family worrying about how to afford their medical bills. It is time to say: 22 million uninsured Americans is 22 million too many. Campaign on that. Vote on that. The moment for milquetoast liberalism is over.

The big question- Is the U.S. Ready for a Single-Payer Health Care System? Sandro Galea reviewed this issue and noted that ironically, as congressional Republicans have been trying to replace the Affordable Care Act, the ACA’s popularity is at an all-time high, and the majority of Americans now believe that it is the federal government’s responsibility to provide health care for all Americans. This shift in sentiment suggests that a single-payer system — a “Medicare for all” — may soon be a politically viable solution to America’s health care woes.

This system has long been an aspiration of the far left, yet even the right now seems to acknowledge its growing likelihood. Following his decision not to support the Better Care Reconciliation Act (BCRA), the Senate Republican leadership’s latest attempt to replace the ACA, Senator Jerry Moran, Republican of Kansas, warned in a statement: “If we leave the federal government in control of everyday health care decisions, it is more likely that our health care system will devolve into a single-payer system, which would require a massive federal spending increase.” (The BCRA, which failed in the Senate, would have kept the basic contours of the ACA but greatly reduced its ability to provide care.)

Although congressional Republicans remain uncomfortable with universal coverage as a concept, some seem to understand that the American people are coming to see health care as a right. It is very difficult to imagine how universal coverage could be sustainable over the long run without a central payment system.

While there may be openings for bipartisan compromise to address the weaknesses of the ACA,  the core of the ACA framework is unstable — a hostage to the market and political fortune. By contrast, a single-payer model stands to be much more durable and provides a chance to build a health care system around the well-being of patients rather than the profits of providers and insurers. Thirty-three percent of the American public now supports a single-payer system — a 5% increase since January.

To be sure, some important players remain opposed to a single-payer system. One is the American Medical Association. It favors an ACA-like structure that subsidizes insurance for low-income individuals and families and argues that a single-payer system would stymie private-sector innovation, create long waiting periods, and offer less patient choice. However, the AMA is far from a disinterested party. Indeed, it was an early resister of alternatives to our current fee-for-service system, fearing a more progressive model could diminish the independence and entrepreneurial capacity of its members.

Not surprisingly, insurance and pharmaceutical industries, which have a strong economic self-interest in maintaining the status quo, are also against the single-payer model. Opponents warn that a single-payer model could lead to a wholesale bureaucratization of the health care system by the federal government, or even to socialized medicine.

But are these concerns warranted? Doctors who fear losing their autonomy need only look north to see how a single-payer system can work without encroaching on the independence of physicians. Canada has had a single-payer model for decades, and there’s no government takeover of its health care system in sight. Most services are still provided by the private sector, and most physicians are still self-employed. While health expenditures remain high, Canadians nevertheless enjoy better health outcomes at lower cost than the United States, whose population’s health is mediocre despite ever-higher spending on medical care.

Canada’s success stems from a few basic tenets. Its system is structured around a federal requirement to provide coverage for necessary services such as doctor and hospital visits. While the cost of this care is covered by the taxpayer, the task of providing it is decentralized to each of the country’s 13 provinces and territories. Each region has wide latitude to innovate — as long as it honors the basic guarantee of providing free point-of-care treatment to all citizens for certain essential services, funded through a central payer. This is an important point. The single-payer approach is often characterized as a gateway to Byzantine regulation. Yet the reality is it is a fundamentally simple, even elegant, concept: Everybody gets the coverage that everybody pays for. Within this framework, there is much room for maneuver.

If implemented correctly, a centralized payment structure can create a health care system that is genuinely organized around health. It may seem counterintuitive to suggest that the U.S. system is not organized around health, but this truth has long been obvious to anyone who follows this issue or to anyone who has ever had to seek care in a time of need. Over and over, we have seen how the U.S. health care system produces a vast array of increasingly expensive drugs and treatments that few can access without high-quality insurance.

A single-payer model could change this — not by nationalizing health care outright but by incentivizing new payment structures such as bundled payments, accountable care organizations, and other population-based models. Unlike a fee-for-service arrangement, these models do not tether provider compensation to the frequency and expense of care. Bundled payments — which provide a fixed-dollar amount for a particular type of care (e.g., replacing a knee) delivered over a set period of time — would encourage greater efficiency in care by having providers compete on the basis of quality and price.  And capitation, by compensating providers per assigned patient, would open the door to an increased focus on prevention, which would save time and resources.

While such innovative payment models are possible within the current fragmented payer system — indeed, the Centers for Medicare and Medicaid Services has been a leader in innovating — a single-payer system immediately creates an opportunity for wide-scale adoption of new approaches that can transform health in the United States. With a health system reoriented toward stopping disease before it starts, rather than treating it once it strikes, we may even start to see more health investments go beyond health care, targeting the social, economic, and environmental factors that create the conditions for disease in society.

Decades of opposition have tinted Americans’ view of a single-payer system’s potential. But there is no reason to think that the status quo is immutable. It did not, after all, come about organically; it is the product of years of influence strategically wielded by powerful stakeholders in business, medicine, and politics. These stakeholders were able to advance their agenda in large part because Americans had not come to view health care as an essential collective right. This is changing. Turning this growing view into policy will require a national agreement that health care is a value worth paying for. The country is not there yet, but it no longer feels that far off.

Have also questioned Bernie Sanders Medicare for all goal. Is this what we want?

Thankfully, the GOP did not pass Paul Ryan’s repeal and replace bill for Obamacare.  Immediately after, we see a headline hopefully concluding, “Medicare for all may be next.”  Shannon Tapia in her article “Single payer: Yes! Medicare for all: No! noted that in Medicare’s current form, this would be devastating for the health of America.  I treat many Medicare patients; I know a heck of a lot about Medicare.  Most people don’t.  They just see it as a great perk of turning 65 in America and the social health care we offer to elderly and disabled.  I did too until I became a physician who sees many Medicare patients.

Medicare originated in 1966 in recognition that we needed to do a better job as a nation at caring for our aging and disabled who could not get employer-provided insurance.  In 1989 the Omnibus Budget Reconciliation Act established a fee schedule for Medicare payments.  This assigns “relative value units” or RVUs to everything we do for our patients in medicine.  The formula that determines RVUs disproportionately favors procedural care to time-based care.  Essentially, Medicare pays and incentivizes medical providers to do things to patients and actually disincentivizes physicians from taking their time with patients.

If you wonder why the doctor-patient relationship is not doing well right now, wonder no more.  Trust takes time.  Even family doctors who take Medicare have to turn their practice into a patient or low-risk procedure mill to make ends meat.  Medicare will pay a physician between $70 to $80 to freeze off a wart, a procedure that takes about 2 minutes to do, and 1 minute to document in an EMR.In contrast, I can spend an hour with an elderly patient with multiple complicated issues, addressing their concerns, reviewing and adjusting their many medications, and coming up with a plan and then having to take 30 minutes later to document what happened and get paid essentially the same amount (about $80) had I just spent 3 minutes removing a wart and sending them out the door.  Is it any wonder that geriatrics is a dying field?

In contrast, I can spend an hour with an elderly patient with multiple complicated issues, addressing their concerns, reviewing and adjusting their many medications, and coming up with a plan and then having to take 30 minutes later to document what happened and get paid essentially the same amount (about $80) had I just spent 3 minutes removing a wart and sending them out the door.  Is it any wonder that geriatrics is a dying field?

There was a time, however, when despite the RVU working against physicians who primarily use their time and knowledge to diagnose and care for patients, physicians still did it because they could make a decent living while being fulfilled in the solace they were helping.  But times have changed.  My father was a general practitioner.  He went to medical school in St. Louis, on the Army’s “scholarship.”  No loans needed.  Students today get out of medical school with roughly $200,000 -$340,000 in debt at anywhere from 7 to 15 percent interest that accrues quarterly.

The physicians today in their fifties to seventies truly cannot comprehend the financial sacrifice new physicians make when committing to primary care today.  But, it’s not all about the money.  There is far more paperwork, tracking of useless data, nonpatient care related work that we are forced to do that merely detracts from the already limited time we have to see patients and develop a relationship.  And we have to deal with this burden from day 1 of our practicing lives.  Many of the older docs have moved into administrative roles yet still remember clinical practice how they experienced it.  In turn, they create detrimental policies and regulations to feed metrics in the name of “quality” all while being clueless as to what it is like to actually treat patients in the modern era.

Some might argue that by expanding Medicare for all, it would cover less complicated patients so the current model shouldn’t be a problem.  I’d also beg to differ on that one.  Doing things to people, even prescribing medications, is dangerous and should not be taken for granted.  Medicare still incentivizes doing more invasive things for the least complicated patients.  Say we expand it to everyone, and a 22-year-old comes in with a cough she’s had for five days.  It’s viral.  Viruses are the worst.  There is no treatment other than time and support.  But convincing patients of this when they know I have the power to prescribe a Z-pak and they always get better on the Z-pak (20 percent of the effect of any treatment is placebo) takes a long empathetic conversation.

You know what is quick and easier?  You got it, just writing the darn script and moving on to the next person so I can get paid more.  And then we have massive bacterial resistance to azithromycin (the Z-pak) and C. diff is on the rise.

The numbers on all accounts point to the reality that Medicare’s RVU system of paying providers is causing worse outcomes, is unsustainable in cost and is not attracting young talented physicians to the most needed primary care fields.  I wonder how many of the new family docs will inevitably succumb to 10-minute visits with high procedures and more referrals to costly specialists or ultimately opt-out of Medicare and insurance for direct primary care?  Medicare spent 650 billion dollars in 2015.  An underestimate suggests 200 billion dollars (or 30 percent) was spent on beneficiaries in their final year of life.  That means we as a medical community, despite probably knowing the patients were dying, kept doing procedures and tests and more treatments to people because that is what we are paid to do.

American culture indoctrinates us that death is optional.  It’s really not.  But why would a physician take the time explain to a patient and family the reality of their situation, a conversation that is exhausting and challenging for everyone involved, when they are paid about 5x more to just offer another procedure or test and move on?  And then we spend billions of dollars doing things while ignoring the essentials that require time, and we get the worst outcomes.   The current Medicare, if expanded to all, will only exacerbate the costly failures of our current system.

A single-payer universal coverage system?  Yes, please, maybe!  But not Medicare as we know it.  Heed the geriatricians now while you still can.  We’re the most needed physician endangered species.

Where do we want to go from here? It was just a standard congressional committee statement: “This committee will hold hearings beginning the week of September 4th on the actions Congress should take to stabilize and strengthen the individual health insurance market so that Americans will be able to buy insurance at affordable prices in the year 2018.”

But that joint statement Tuesday from senators Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), the chairman and ranking member, respectively, of the Senate Health, Education, Labor, and Pensions (HELP) Committee, was met with great interest on Capitol Hill and elsewhere, with many media outlets running stories about the announcement.

In the wake of the Senate Republicans’ failure last Friday to pass a “skinny repeal” of the Affordable Care Act (ACA), President Trump expressed his disappointment in Congress, tweeting, “3 Republicans and 48 Democrats let the American people down. As I said from the beginning, let ObamaCare implode, then deal. Watch!”

But the HELP Committee leaders had other ideas. “Unless Congress acts by September 27, when insurance companies must sign contracts with the federal government to sell insurance on the federal exchange next year, millions of Americans with government subsidies in up to half our states may find themselves with zero options for buying health insurance on the exchanges in 2018,” Alexander said in a statement. “Many others without government subsidies will find themselves unable to afford health insurance because of rising premiums, co-pays and deductibles.”

“There are a number of issues with the American healthcare system, but if your house is on fire, you want to put out the fire, and the fire, in this case, is the individual health insurance market,” he continued. “Both Republicans and Democrats agree on this. Our committee had one hearing on February 1 on this subject, and we’ll work intensively between now and the end of September to finish our work in time to have an effect on the health insurance policies sold in 2018.”

Alexander said he had urged the Trump administration to continue paying cost sharing reduction (CSR) subsidies — payments to insurers that help low-income enrollees on the ACA’s insurance exchanges pay their out-of-pocket costs — until late September to give Congress time to work out its own deal to continue them. The president had threatened to stop making the payments if a new healthcare bill was not approved quickly.

Legislation to shore up the markets also should include “greater flexibility for states in approving health insurance policies,” Alexander said. Although he didn’t specify what he meant by greater flexibility, some Senate Republicans have urged that insurers be allowed to issue policies that do not cover all of the “essential health benefits” required under the ACA, as well as policies that charge older enrollees higher premiums than currently permitted.

Any solution that is passed by Congress to help the markets should be “small, bipartisan, and balanced,” Alexander added.

Alexander also praised a recent move by the state of Alaska, which received a waiver from the U.S. Department of Health and Human Services for its plan to “reinsure” health insurers that have high-cost patients. “This waiver ought to be a big help for Alaska as it works to stabilize the state’s individual insurance market,” he said in a July 11th statement.

Will anything happen in the Senate by the Sept. 27 deadline? “Senator Alexander’s committee is not likely to enact legislation by late September, but they will help to set the tone for the debate going forward,” Michael Sparer, Ph.D., JD, chair of the department of health policy and management at Columbia University in New York City, said in an email.

While Alexander and Murray make their plans for the HELP Committee, a group of about 40 House Democrats and Republicans have unveiled their own proposal. The group, known as the Problem Solvers Caucus, has a five-point plan for rejuvenating the ACA’s insurance markets:

  • Create a “stability fund” to help states reduce premium costs for those with pre-existing conditions
  • Repeal a medical device tax
  • Loosen the employer mandate by applying it to businesses with 500 or more employees, as opposed to 50 or more under current law
  • Encourage state experimentation to reduce costs and increase coverage
  • Guarantee the CSR payments

Congress and the White House don’t have much time to lose. In addition to the insurers’ Sept. 27 deadline, the next CSR payment is due on Aug. 21, so “if the administration intends not to make the August payment, it must announce its decision soon,” wrote Timothy Jost, JD, professor of law emeritus at Washington & Lee University, in Lexington, Va., in a blog post for Health Affairs.

There is also another fly in the ointment when it comes to the CSR payments: a federal court on Tuesday granted a motion to allow 16 Democratic state attorneys general to participate in any actions related to the CSRs. Specifically, the order allows them to file briefs and to block any settlements or appeal rulings in favor of blocking the payments. The ruling involved a lawsuit known as House v. Price that was filed in 2014 by Republican members of Congress who objected to the White House being able to make the CSR payments.

This new wrinkle “will complicate any effort by the president to quickly end the subsidies,” Sparer noted.

What Congress should do about the ACA “depends on who they are trying to help,” Edmund Haislmaier, senior research fellow at the Heritage Foundation, a right-leaning think tank here, said in a phone interview. “It’s not clear that the Republicans and the Democrats are trying to solve the same problem. For example, [making] the CSR [payments] would affect people getting coverage through the exchange, but it doesn’t do anything for people who are off the exchange and seeing their premiums go up and have no subsidies. Those are the people that Republicans were trying to address with regulatory relief in the legislation that failed.”

He noted that even if the CSR payments were to stop, the people in the exchanges who receive subsidies — those making 250% or less of the federal poverty level — wouldn’t really be affected because if the insurers raised their premiums to compensate, the government would simply increase the number of the subsidies, which are given as tax credits.

“Are you trying to salvage the exchanges and the ACA subsidy structure, or are you trying to provide a benefit to people outside the exchange — the middle class who don’t see subsidy relief and want this thing repealed, which is what the Republicans want to do?” Haislmaier said. Allowing insurers to sell less comprehensive policies and varying premiums more by age are examples of provisions that could help these consumers through lower premiums, he contended.

But, maybe this latest turn of events will continue the discussion between both parties, a true bipartisan effort, so that we/they can actually get things done to improve health care delivery for all.

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