By Scott Simon
NPR Weekend Edition, July 8, 2017

Doctors Julie Gunter, Rob Stone and Gary Sobelson talk with Scott Simon about the problems with American health care and what they think of the current Republican health care plan.

TRANSCRIPT

SCOTT SIMON, HOST: The United States spends about $9,000 per person per year on health care, the highest in the world. But our life expectancy is still lower than France, Switzerland, Japan, the United Kingdom, all of which spend less. With the Republican health care bill still on the Senate docket, we thought it would be a good time to hear from U.S. doctors. We have three with us now, Dr. Julie Gunther, a family doctor in Idaho, Rob Stone, an ER turned palliative care doctor in Indiana, and Dr. Gary Sobelson, a primary care doctor in New Hampshire. Thanks so much for being with us.

GARY SOBELSON: Thank you.

ROB STONE: Thank you.

JULIE GUNTHER: Thank you.

SIMON: Let me begin, if we can, with you, Dr. Gary Sobelson there in New Hampshire. Seven years since the Affordable Care Act – three since most of the changes went into effect. How is health care different? Is it better, worse?

SOBELSON: Much better coverage for our patients, particularly, in my case as a family doctor, for the working poor. I have people coming in for preventive services, for hypertension management, for cardiovascular disease prevention, for cancer screening who really had not been coming in except for the most acute needs. And that’s been meaningfully different.

SIMON: Dr. Rob Stone in Indiana, you were an ER doctor. You must have seen patients who who came to the ER because they didn’t have insurance to cover primary care visits. Has that changed under the Affordable Care Act for you?

STONE: It’s changed very noticeably. And a far smaller percentage of people are coming in uninsured, although we still continue to take care of those folks, too. Our hospital’s also affiliated with some very small-town hospitals in Bedford, Ind., Paoli, Ind. And in those areas in particular, I think the Medicaid expansion part of the Affordable Care Act has helped to solidify the financial standing of those hospitals, which was somewhat questionable earlier.

So I would say that’s all good. The downside – and this started before the Affordable Care Act – before Obamacare – is that co-pays and deductibles and premiums keep going up for the people who aren’t on Medicaid. And so people coming into the ER find themselves underinsured too often when they realize they can’t afford their co-pays or their deductibles.

SIMON: Dr. Julie Gunther, you’re a family doctor in Idaho. And I gather you’ve kind of opted out of the typical model and you have your own direct primary care practice.

GUNTHER: Yes, I have. I was a system-employed outpatient physician until 2014. And then I left and started a solo, independent, cash-based practice. So I no longer bill insurance.

SIMON: And why did you take that step?

GUNTHER: The simple answer is I had to leave the system to save myself to be the doctor I wanted to be. It’s valuable for me to hear Dr. Sobelson and Dr. Stone’s experiences. My experience was very, very different. Even before the Affordable Care Act – but especially after – the progressive amount of regulations made it almost impossible for me to serve people the way I was originally called to serve them as an outpatient family doctor.

And so I have built a rather successful cash-based practice that charges very, very little per month. The majority of my patients are either uninsured, underinsured or so frustrated with the current system and its barriers that they would rather pay a small amount out of pocket every month for more direct care.

SIMON: Well – and so I’m going to bring Dr. Rob Stone into this conversation because I’ve been told you’re an advocate for a single-payer system. Is Dr. Gunther onto something?

STONE: Well, I don’t know how generalizable it is widely – and particularly not to very poor areas like the inner city. But my feeling is that we have a good model for how to take care of everybody, which some people still think is kind of a pie-in-the-sky dream. But I’m still going to push for it. And I think that is expanding Medicare, which already takes care of everybody over 65. And I happened to turn 65 a couple months ago. And I’m on Medicare now. And I’m pretty happy with that.

SIMON: Dr. Gary Sobelson, are the high costs of health care unavoidable? Can’t we, after all, just do more for people – a lot more – than we could even 10 and 20 years ago?

SOBELSON: While there are many things that we can do, the high costs are things that the system itself brings about. We’ve designed a system that rewards high-reimbursement procedures, surgeries and undervalues the things that are cost-effective. And it doesn’t really matter how much we research this or prove this to ourselves within our profession. We don’t seem to move in that direction. We don’t have the political will.

Dr. Stone’s comments about Medicare for all are not isolated to small groups of the population. We’ve studied this in New Hampshire, and over 80 percent of our primary care physicians are in favor of a system that some would call single-payer – and the majority of our overall doctors, even including specialists. And that’s been replicated across the country, too. We as Americans seem to value our independent decision-making over collective wisdom, though I would argue that when simple procedures like common arthroscopic knee surgery, something that takes 15 to 30 minutes, is costing $15,000 to $25,000 in community hospitals around our country – that no one has the freedom to make that decision.

GUNTHER: I was just going to say I normally talk about a single payer system. And we use Medicare as a model. My patients who have Medicare say that it works. My mother and father who are economically well off pay $150 a month towards their health care. My Americans who are age 30 to 60 are dropping their health care plans. And they come in, and they tell me, I can choose between putting food on the table, paying for my kid to go to college or getting a health plan that I can’t afford.

So it’s not that I oppose a broader solution. But I would contend we have a system that is completely crumbling and unsustainable. And in my opinion and experience, I don’t think Medicare is working all that well, especially not in a way that we could roll it out to our whole country in any sort of sustainable way. And the heart of it in my opinion is we talk a lot about who’s going to pay for health care. But what we should be talking about is the price of health care.

SIMON: Do we have an unrealistic expectation that health care costs can be reduced when we expect health care to do more and more?

GUNTHER: I think there’s great examples that current health care prices are upwards of a thousand times more than anywhere close to true cost. My patients can get a CAT scan – cash price for $300. If they go into the local ER, it’ll bill out at $2,400. So I think we need to start asking why. Because we keep talking about who should pay or how we should pay for health care.

But if we allow free market forces and competition to create price transparency, then we start to have the opportunity for price control, cost control. And then I think we can completely change the dialogue from who should pay and how should we pay too to what parts of health care do people need help paying for.

SOBELSON: I think Dr. Gunther is describing the problems that we’ve created by more or less – and this is a failing of the ACA – allowing corporate profitability to be the driving force of how we set these so. So, again, if you’re not under Medicare or Medicaid in this country, you’re depending on a private insurance industry to somehow control costs, when, in fact, it’s not really in their interest. They don’t have skin in the game here.

They make their profitability based on how much they collect in revenue. And, in fact, it’s written into the law. So, again, it’s not surprising that we’ve created a model where, in fact, more spending will be encouraged, not discouraged because the only people who really would care about it would be the consumers. And they don’t seem to believe that they can control it.

SIMON: Let me ask this finally, if I could. The Senate bill that’s under consideration right now may or may not be going anywhere. Could each of you give us one idea that you would like to see the government adopt that could improve health care in this country? – or not just the government. What can we do?

STONE: Well, I would say first that the Senate bill is a terrible thing that would set us back and would cost lives. And the people who would be hurt the worst would be children, the disabled and the elderly and nursing homes because of the ravages to Medicaid. So the first thing I would do would be, say, save Medicaid and continue to expand it. And then the second biggest problem in the Senate bill is that it would make health care very expensive for people ages 50 to 65 or 55 to 65 – would be to think about lowering the age of Medicare eligibility to, say, 55 and not cut those people out into the cold.

SIMON: That’s Dr. Rob Stone in Indiana. Dr. Julie Gunther, what would you suggest?

GUNTHER: I would agree with Dr. Stone. I don’t think the Senate bill provides the improvements to the Affordable Care Act or some of our biggest health care problems that we need. If I had one ask it would be that we allow consumers – we allow patients who do have health savings accounts to use those health savings dollars to pay their physician, whether it’s a periodic fee or a direct payment.

And one of my favorite quotes about health care in our country is that we continue to tape wings on a car and call it an airplane. I think we have to radically transform the system at its core if we hope to end up in a different place.

SIMON: And Dr. Gary Sobelson.

SOBELSON: Yeah. From my perspective in New Hampshire, I think the damages to Medicaid that the Senate bill would bring about would be devastating to us and take back so much positive progress we’ve had in terms of access and cost containment.

And if I had to add one thing to it, I think Dr. Stone’s idea of expanding Medicare to populations that traditionally have a hard time buying insurance could be extended into the whole idea of the ability of a public option, the ability of the Medicare and Medicaid programs to work out ways to compete with private insurers so that the public could become more comfortable with them.

SIMON: Doctors Rob Stone, Julie Gunther and Gary Sobelson, thanks so much for joining us.

GUNTHER: Thank you.

STONE: Thank you.

SOBELSON: Thank you.

http://www.npr.org…

By Robert H. Frank
The New York Times, July 7, 2017

Lingering uncertainty about the fate of the Affordable Care Act has spurred the California legislature to consider adoption of a statewide single-payer health care system.

Sometimes described as Medicare for all, single-payer is a system in which a public agency handles health care financing while the delivery of care remains largely in private hands.

Discussions of the California measure have stalled, however, in the wake of preliminary estimates pegging the cost of the program as greater than the entire state government budget. Similar cost concerns derailed single-payer proposals in Colorado and Vermont.

Voters need to understand that this cost objection is specious. That’s because, as experience in many countries has demonstrated, the total cost of providing health coverage under the single-payer approach is actually substantially lower than under the current system in the United States. It is a bedrock economic principle that if we can find a way to do something more efficiently, it’s possible for everyone to come out ahead.

By analogy, suppose that your state’s government took over road maintenance from the county governments within it, in the process reducing total maintenance costs by 30 percent. Your state taxes would obviously have to go up under this arrangement.

But if roads would be as well maintained as before, would that be a reason to oppose the move? Clearly not, since the resulting cost savings would reduce your county taxes by more than your state taxes went up. Likewise, it makes no sense to oppose single-payer on the grounds that it would require additional tax revenue. In each case, the resulting gains in efficiency would leave you with greater effective purchasing power than before.

Total costs are lower under single-payer systems for several reasons. One is that administrative costs average only about 2 percent of total expenses under a single-payer program like Medicare, less than one-sixth the corresponding percentage for many private insurers. Single-payer systems also spend virtually nothing on competitive advertising, which can account for more than 15 percent of total expenses for private insurers.

The most important source of cost savings under single-payer is that large government entities are able to negotiate much more favorable terms with service providers. In 2012, for example, the average cost of coronary bypass surgery was more than $73,000 in the United States but less than $23,000 in France.

Despite this evidence, respected commentators continue to cite costs as a reason to doubt that single-payer can succeed in the United States. A recent Washington Post editorial, for example, ominously predicted that budget realities would dampen enthusiasm for single-payer, noting that the per capita expenditures under existing single-payer programs in the United States were much higher than those in other countries.

But this comparison is misleading. In most other countries, single-payer covers the whole population, most of which has only minimal health needs. In contrast, single-payer components of the United States system disproportionately cover population subgroups with the heaviest medical needs: older people (Medicare), the poor and disabled (Medicaid) and returned service personnel (Department of Veterans Affairs).

In short, the evidence is clear that single-payer delivers quality care at significantly lower cost than the current American hybrid system. It thus makes no sense to reject single-payer on the grounds that it would require higher tax revenues. That’s true, of course, but it’s an irrelevant objection.

In addition to being far cheaper, single-payer would also defuse the powerful political objections to the Affordable Care Act’s participation mandate. Polls consistently show that large majorities want people with pre-existing conditions to be able to obtain health coverage at affordable rates. But that goal cannot be achieved unless healthy people are required to join the insured pool. Officials in the Obama administration tried, largely in vain, to explain why the program’s insurance exchanges would collapse in the absence of the participation mandate.

But the logic of the underlying argument is actually very simple. Most people seem able to grasp it if you ask them what would happen if the government required companies to sell fire insurance at affordable rates to people whose houses had already burned down.

No home insurer could remain in business if each policy it sold required it to replace a house costing several hundred thousand dollars. Similarly, no health insurer could remain in business if each of its policy holders generated many thousands of dollars in health care reimbursements each month.

That’s why the lack of a mandate in the alternative plans under consideration means that millions of people with pre-existing conditions will become uninsurable if repeal efforts are successful. An underappreciated advantage of the single-payer approach is that it sidesteps the mandate objection by paying to cover everyone out of tax revenue.

Of course, having to pay taxes is itself a mandate of a sort, but it’s one the electorate has largely come to terms with. Apart from fringe groups that denounce all taxation as theft, most people understand that our entire system would collapse if tax payments were purely voluntary.

The Affordable Care Act is an inefficient system that was adopted only because its architects believed, plausibly, that the more efficient single-payer approach would not be politically achievable in 2009. But single-payer now enjoys significantly higher support than it did then, and is actually strongly favored by voters in some states.

Solid majorities nationwide now favor expansion of the existing single-payer elements of our current system, such as Medicare and Medicaid. Medicaid cuts proposed in Congress have been roundly criticized. Perhaps it’s time to go further: Individual states and, eventually, the entire country, can save money and improve services by embracing single-payer health care.

https://www.nytimes.com…

By Robert H. Frank
The New York Times, July 7, 2017

Lingering uncertainty about the fate of the Affordable Care Act has spurred the California legislature to consider adoption of a statewide single-payer health care system.

Sometimes described as Medicare for all, single-payer is a system in which a public agency handles health care financing while the delivery of care remains largely in private hands.

Discussions of the California measure have stalled, however, in the wake of preliminary estimates pegging the cost of the program as greater than the entire state government budget. Similar cost concerns derailed single-payer proposals in Colorado and Vermont.

Voters need to understand that this cost objection is specious. That’s because, as experience in many countries has demonstrated, the total cost of providing health coverage under the single-payer approach is actually substantially lower than under the current system in the United States. It is a bedrock economic principle that if we can find a way to do something more efficiently, it’s possible for everyone to come out ahead.

By analogy, suppose that your state’s government took over road maintenance from the county governments within it, in the process reducing total maintenance costs by 30 percent. Your state taxes would obviously have to go up under this arrangement.

But if roads would be as well maintained as before, would that be a reason to oppose the move? Clearly not, since the resulting cost savings would reduce your county taxes by more than your state taxes went up. Likewise, it makes no sense to oppose single-payer on the grounds that it would require additional tax revenue. In each case, the resulting gains in efficiency would leave you with greater effective purchasing power than before.

Total costs are lower under single-payer systems for several reasons. One is that administrative costs average only about 2 percent of total expenses under a single-payer program like Medicare, less than one-sixth the corresponding percentage for many private insurers. Single-payer systems also spend virtually nothing on competitive advertising, which can account for more than 15 percent of total expenses for private insurers.

The most important source of cost savings under single-payer is that large government entities are able to negotiate much more favorable terms with service providers. In 2012, for example, the average cost of coronary bypass surgery was more than $73,000 in the United States but less than $23,000 in France.

Despite this evidence, respected commentators continue to cite costs as a reason to doubt that single-payer can succeed in the United States. A recent Washington Post editorial, for example, ominously predicted that budget realities would dampen enthusiasm for single-payer, noting that the per capita expenditures under existing single-payer programs in the United States were much higher than those in other countries.

But this comparison is misleading. In most other countries, single-payer covers the whole population, most of which has only minimal health needs. In contrast, single-payer components of the United States system disproportionately cover population subgroups with the heaviest medical needs: older people (Medicare), the poor and disabled (Medicaid) and returned service personnel (Department of Veterans Affairs).

In short, the evidence is clear that single-payer delivers quality care at significantly lower cost than the current American hybrid system. It thus makes no sense to reject single-payer on the grounds that it would require higher tax revenues. That’s true, of course, but it’s an irrelevant objection.

In addition to being far cheaper, single-payer would also defuse the powerful political objections to the Affordable Care Act’s participation mandate. Polls consistently show that large majorities want people with pre-existing conditions to be able to obtain health coverage at affordable rates. But that goal cannot be achieved unless healthy people are required to join the insured pool. Officials in the Obama administration tried, largely in vain, to explain why the program’s insurance exchanges would collapse in the absence of the participation mandate.

But the logic of the underlying argument is actually very simple. Most people seem able to grasp it if you ask them what would happen if the government required companies to sell fire insurance at affordable rates to people whose houses had already burned down.

No home insurer could remain in business if each policy it sold required it to replace a house costing several hundred thousand dollars. Similarly, no health insurer could remain in business if each of its policy holders generated many thousands of dollars in health care reimbursements each month.

That’s why the lack of a mandate in the alternative plans under consideration means that millions of people with pre-existing conditions will become uninsurable if repeal efforts are successful. An underappreciated advantage of the single-payer approach is that it sidesteps the mandate objection by paying to cover everyone out of tax revenue.

Of course, having to pay taxes is itself a mandate of a sort, but it’s one the electorate has largely come to terms with. Apart from fringe groups that denounce all taxation as theft, most people understand that our entire system would collapse if tax payments were purely voluntary.

The Affordable Care Act is an inefficient system that was adopted only because its architects believed, plausibly, that the more efficient single-payer approach would not be politically achievable in 2009. But single-payer now enjoys significantly higher support than it did then, and is actually strongly favored by voters in some states.

Solid majorities nationwide now favor expansion of the existing single-payer elements of our current system, such as Medicare and Medicaid. Medicaid cuts proposed in Congress have been roundly criticized. Perhaps it’s time to go further: Individual states and, eventually, the entire country, can save money and improve services by embracing single-payer health care.

https://www.nytimes.com…