Single Payer Here We Come, But What Does It Look Like and What do the Insurers Think?

15439960_1053735618089430_7095899501210775916_nBob Doherty of the American College of Physicians stated that the idea of a single-payer healthcare is enjoying a boom in public opinion and he went on to list the important questions.

A Pew Research Center poll released in June 2017 found that “Overall, 33 percent of the public now favors such a ‘single payer’ approach to health insurance, up 5 percentage points since January and 12 points since 2014.” Fifty-eight percent of those surveyed by Pew said that the government has a responsibility to ensure health for all, with a third saying it should be through a single national government program and 25% through a mix of government and private programs. Another 33% said the government is not responsible to ensure healthcare for all but agreed that Medicare and Medicaid should be continued, while 5% said the government should not be involved at all. The poll also showed that a majority of Democrats now favor single payer; support was also stronger among younger persons than older ones. However, most Republicans and older voters oppose single payer.

The Kaiser Family Foundation’s June 2017 tracking poll found even higher levels of support for single payer, with 53% in favor and 43% opposed. However, it also described support for single payer as being “malleable” and subject to change when presented with arguments for or against: “While a slim majority favors the idea of a national health plan at the outset, a prolonged national debate over making such a dramatic change to the U.S. healthcare system would likely result in the public being exposed to multiple messages for and against such a plan. The poll finds the public’s attitudes on single-payer are quite malleable, and some people could be convinced to change their position after hearing typical pro and con arguments that might come up in a national debate.”

A Harvard-Harris poll conducted in September 2017 found even higher levels of support for single payer, with a narrow majority (52%) supporting it while 48% opposed.

Doctors also appear to be warming to single payer, according to some recent polls. And, as I have traveled around the country in recent months to visit ACP chapter meetings, I’ve found more and more ACP members are advocating that the College come out strongly in favor of single-payer healthcare, and not just in so-called liberal-leaning “blue” states. I’ve explained that a 2008 ACP paper, which I co-authored on behalf of our Health and Public Policy Committee, examined what the United States could learn from other countries’ health systems. We recommended, “that the federal and state governments consider adopting one or the other of the following pathways to achieving universal coverage:

Single-payer financing models, in which one government entity is the sole third-party payer of healthcare costs, can achieve universal access to healthcare without barriers based on ability to pay. Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than systems using private health insurance, lower per capita healthcare expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access. They may require a higher tax burden to support and maintain such systems, particularly as demographic changes reduce the number of younger workers paying into the system. Such systems typically rely on global budgets and price negotiation to help restrain healthcare expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals’ freedom to make their own healthcare choices.

Pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs (Australia and New Zealand). Pluralistic financing models must provide 1) a legal guarantee that all individuals have access to coverage and 2) sufficient government subsidies and funded coverage for those who cannot afford to purchase coverage through the private sector.”

(Note that this paper was written a year before the Affordable Care Act (ACA) became law; the ACA is an example of the second option, although it has fallen short of assuring universal access).

Recognizing the growing interest in single payer, and in other models that may still involve multiple payers but with the government having a much large role in financing and ensuring coverage (most European countries are not truly single payer, because they still allow some role for private insurance), ACP’s Health and Public Policy Committee will over the next several months begin examining different alternatives to advance universal coverage. As it does, I think there are several important questions that will need to be asked, particularly of single payer:

Will all Americans be required to get their coverage through a single, government-financed system (compulsory coverage), meaning that they would have to give up their employer-based or individual coverage? (If not, it really isn’t single payer; if so, will Americans react favorably to being compelled to get their coverage from the new program?)

Related, will Americans conclude that the coverage under the new program is better or worse than what they have now? Will deductibles and co-payments be higher or lower? Many single-payer advocates assume that deductibles will be lower under single payer than most Americans typically now pay, but that is in no way a given; one could imagine a single payer plan based on the ACA’s silver plans, for instance. Will the covered benefits be more or less generous? Will premiums — or if funded solely through taxes, the taxes they pay — cost them more or less compared to what they and their employers now contribute? Will taxes be progressive, meaning the wealthier pay more, or regressive, as is the case with Social Security taxes? Will they have limited networks of physicians and hospitals, like Medicare Advantage plans, or complete choice of physician and hospital, like traditional Medicare? Will they and their physicians be able to have access to any FDA-approved prescription drugs, or will there be a limited formulary to choose from?

Will the government contract with insurance companies to run the new system, like is the case today with Medicaid managed care, Medicare Advantage, and even Medicare Part B (administered by private insurance carriers) and Part D (pharmacy benefit managers)? It would be so typically American to create a single payer system, and then pay insurers to administer it.

How will costs be controlled? With global budgets, price controls, limits on capacity, and/or limiting access to care based on determinations of quality-adjusted life years like in other countries? How will physicians, hospitals, drug companies, and medical device manufacturers be paid?

This may seem like I am arguing against single payer; I’m not. The same questions might be asked of other approaches. And models that continue to rely on multiple payers, as is the case with the ACA, may never be as effective and efficient as a single payer system in ensuring that everyone has affordable coverage. Single payer almost certainly would have lower administrative costs and be more egalitarian.

Rather, what I am suggesting is that as ACP, and the country, considers different approaches to achieve universal coverage and access (not the same things), the questions that will need to be considered are far more complex than the snapshot (do you favor or oppose Medicare for All) questions asked in polls. How those questions are answered will likely determine if the public, and physicians, are truly ready to embrace single-payer healthcare.

Today’s question: What is your view of single payer (Medicare for All) healthcare?

Bob Doherty is senior vice president of Government Affairs and Public Policy at the American College of Physicians and author of the ACP Advocate Blog, where a version of this post originally appeared.

How exactly would a Single Payer System Work?

Whether you call it single payer or Medicare for all, the idea of a government-sponsored universal health care system, no matter how contentiously debated, continues to infiltrate the health care discussion.

The idea of universal health care reemerged during the 2016 presidential primary campaign as one of Bernie Sanders’ main platforms. In September, Sanders, I-Vermont, introduced a “Medicare for All” bill into the Senate with the full knowledge it would likely go nowhere — for now. In August, Rep. John Conyers, D-Michigan, reintroduced an expanded and improved Medicare for All bill in the House.

Both bills would convert the current many-payer system — insurance companies, states, the federal government — into a government-sponsored, tax-supported health care system. As in many other countries, every US citizen would receive health care, and it would essentially be paid for by one source, the government.

In addition to these national legislative moves, which may be more symbolic than realistic, at least three states have been working toward a single-payer system, and those efforts can also help consumers understand how such a plan would work.

The most recent effort toward that goal came from the Massachusetts Senate early in November. Already known for its progressive health care policies, the state approved a broad health care reform bill that seeks to lessen price disparities between hospitals, address rising drug costs and lower the number of patients readmitted for hospital care within 30 days of a discharge.

An important amendment to the bill called for a study of what it would cost Massachusetts to implement a government single-payer health care system. The amendment, introduced by Sen. Julian Cyr, a freshman Democrat, passed by a surprising 33 to 6 vote. “When you consider every other developed nation has single-payer health care, we’ve just got to look at this,” said Cyr.

In addition, he pointed out that Massachusetts is a state that spends one of the highest amounts per capita on health care. Thus, it only makes sense to find out if that money could be spent more equitably and efficiently with a single-payer system.

Other states grappling with this issue haven’t been entirely successful. Back in 2011, Vermont was the first state to implement a universal health care system of its own, in which all citizens were insured under Green Mountain Care. But by 2014, the state abandoned its efforts, citing unmanageable higher taxes.

Now Vermont is moving toward an alternative system that offers healthcare providers lump sum payments that are designed to reward doctors for keeping patients healthy instead of solely treating illness.

California, however, may have had the country’s most ambitious plan for single-payer health care. Such a plan passed the Senate in June but was then stalled in the summer because of the potential increase in taxes and the lack of analysis on how the bill would be funded. The debate continues.

When asked in a recent interview on NPR if state efforts are the shortest way to get to a single-payer system, Linda Blumberg, senior fellow in the Health Policy Center at the Urban Institute, said implementing single-payer health care state-by-state may be far more difficult than a federal system. “High-income states that have a lot of private health care spending … are most likely to be able to do something like this,” she said. But other states without resources can’t just shift costs from one side of the ledger to the other, she added.

In the meantime, pundits such as Drew Altman, president, and CEO of the Kaiser Family Foundation, have other warnings about a national single-payer system. Most people worry about the increase in taxes a single-payer system would cause, Altman has written. But also, most people don’t realize they would need to change providers under a single-payer system, something that has always been complicated and uncomfortable for consumers.

For the moment, how single-payer would work is anyone’s guess. It may take months or years to answer these questions. But the earlier consumers can be aware of the issues involved in a big change like this, the better.

Health insurers are “very mindful” of brewing single-payer battle

Sarah Kliff reviewed this battle and suggested that on June 1, Matt Eyles will take over as the chief executive of America’s Health Insurance Plans (AHIP), the lobbying group that represents insurers. Between a brewing single-payer debate and Obamacare’s unknown future, he has a lot on his plate stepping into this new role.

Eyles currently serves as AHIP’s vice president for public policy. Earlier this week, Dylan Scott and I had the chance to sit down with him to chat about what the health care landscape looks like from his vantage point. Today, I wanted to share some of the parts of our discussion that I found most interesting.

Insurers are “very mindful” of the Democrats’ single-payer discussion.

One question the author had for Eyles was how a group like his will weather the single-payer debate that is brewing within the Democratic Party. There are lots of plans floating around Capitol Hill right now that would have the government play a more significant role in running the health care system — and less of a role for the plans Eyles represents.

”We’re very mindful of that trend within that wing of the party that is focused on moving toward what might be a more single-payer type approach,” Eyles says.

He gave me a bit of what felt like a preview of the arguments you’ll hear from the industry as this debate continues. “We see obviously a lot of risk with that,” he says. “If you think of 180 million people who are covered by the employer market today, that would be enormously disruptive. If you think of all the people that are in Medicare, are they just going to be cut out of that, or what will happen to those in Medicaid?

”There are so many different elements that need to be addressed across so many different problems. We want to focus on making what we have work a lot better rather than fundamentally disrupt what is going on.”

One comment Eyles made that I found especially interesting was how he thought about the origins of this single-payer push — why it’s being discussed at this particular moment.

”We’re very mindful that this has been brewing for quite a while, and a lot of it has to do with costs within the system, and what has happened within the individual market,” he says. “That’s still such a small part of the system, but it feels like, from a bigger-picture debate perspective, we’ve spent so much time on the individual market. … I think it’s the instability that we’ve seen there that has fed into this.”

Obamacare repeal doesn’t seem to be on the table for 2018

There have been rumors here and there about a renewed push toward Obamacare repeal from congressional Republicans.

Eyles, for his part, doesn’t expect to see that happen this year.

”I think it’s very, very small [the odds of a repeal push]. There’s not a lot of hunger, I think, to address that right now,” he says. “Certainly there are, in some corners, people who will say we need to come back and do it. … But I think to come in at this point, as we head into the summer and as we start focusing on the midterms, I think it’s just … really hard to say that we want to come back to that big discussion right now.”

Insurers aren’t that jazzed about auto-enrollment ideas

There’s this one policy idea that has quietly been gaining bipartisan support among health care wonks: automatic enrollment. The idea is to sign up uninsured Americans for a bare-bones health insurance plan to get them into the market.

I thought insurers would be pretty into this idea, as it would mean more consumers enrolled in their products. But Eyles definitely had a measured reaction to the idea.

”It’s an attractive idea but very difficult to actually administer,” he says. “There’s a way it could be workable, but would people feel differently about auto-enrollment and would it create some sort of political challenge? People don’t like a mandate. Would they like auto-enrollment? I don’t know that we’ve actually gone out and asked people that question.”

Next, let’s look at the California plan and Medicare for all.

Happy Memorial Day to all, especially our sincere thanks to all those that had protected us in the past and those that continue to protect us all!!

Also, Father’s Day is approaching and a gift of our new book on process improvement may be a great gift: The Search for Excellence in Clinical Practice: A Handbook for Clinical Process Improvement for Providers, Sentia Publishing Company. A great read for all!!

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