By Dylan Scott
Vox, August 10, 2018
The muscle of the health industry lobby — pharma, health plans, doctors, and hospitals — is gathering to stop single payer.
The Hill’s Peter Sullivan had the report on Friday morning. The industry’s influence can’t be underestimated: It stopped Clintoncare. And, for better or worse, it was a boon for passing Obamacare that the industry mostly supported the legislation.
The industry’s disparate interests fight over a lot of issues, but Medicare-for-all unites them. That is going to be a factor if we get to 2021 with a Democratic Congress and president, and they decide to pursue single-payer health care.
That moment really might come. A sign times are changing: A Republican health care lobbyist called me recently to ask whether all-payer rate setting would be a better alternative to single payer, by causing less disruption. (I quibbled that you would need some kind of coverage component, given the moral urgency that is animating the left on health care.)
Still, a Republican almost endorsing price controls. That is a pretty strong indicator of where our health care debate seems to be heading.
Payment cuts for health care providers, if we eliminate private insurance and move everybody to Medicare rates, are going to come up a lot in this debate.
Those cuts are an easy thing for industry lobbyists to target and for Republicans to run ads on. Cuts could be overstated, depending on how much legitimate waste single payer can actually eliminate by consolidating the administration of health care, but the projections for Medicare for All plans are going to anticipate big cuts.
That explains the industry’s lobbying position. But reality on the ground is more complicated than that. There are absolutely health care providers who support single payer. Quite a few of them sent me emails after I asked for their thoughts last week.
Here are some of the most interesting responses. From a registered Republican working at a next-gen gene sequencing company:
Medicare is, without question, the most reliable, most predictable payer that we deal with. And for somebody like me it would be a dream to only have to deal with them. Yes, they are pretty heavily regulated. And yes, they have pretty strict guidelines for who to cover. But unlike other payers, who make life virtually impossible for smaller providers because they’re in the for-profit game (the not paying for care game), Medicare at least adheres to a clear set of rules. Other payers put up an endless set of traps against reimbursement, contracting, and other parts of the revenue life cycle that add substantial cost to services and thus increase cost to the consumer. I can say with near certainty that parties in my industry would provide services at a materially lower price and with more predictable out of pocket costs if every payer was as reliable and consistent as Medicare.
As such, I’m now, despite growing up a conservative afraid of such government largesse as “Medicare for all,” convinced that a single public payer, either as rate setter or as a true single payer, is needed. In contrast, I remain a staunch defender of private medical care, where companies such as my own and our competition do battle to increase quality and lower patient cost.
So I guess you could count me as pro-Medicare for all, a sentence I never thought I’d write 15 years ago.
From a retired neurosurgeon, who had also thought of himself as a Republican:
I practiced neurosurgery in Texas and retired 20 years ago. I started out as a pretty solid, but non-thinking, Republican, opposing perceived intrusions of Medicare into my practice. I read Himmelstein and Woolhandler’s NEJM articles and thought they were Harvard hippie Communists. Over time, I came to see that they were right, that we really need a universal health care system, as so many of my patients weren’t getting needed care. I was a bit embarrassed making as much money as I did, and would have done it for half of that.
From a radiation oncologist of more than 20 years, in Chicago and for the military:
I left full-time medicine a few years ago after getting fed up with continuously fighting insurance companies for pre-authorization and for the right to practice medicine the way I was trained within the standard published guidelines. I now work part-time seeing primarily uninsured and Medicaid patients.
A 2011 Health Affairs study found that the average US physician spends nearly $83,000 a year interacting with insurance plans. And a 2010 American Medical Association Study found the average doctor spent 20 hours a week on pre-authorization activities. This has only gotten more expensive and much worse. Under a single payer plan, this would be much easier and far less expensive.
In addition, we know that the major cost of malpractice coverage is for the continued medical care of the patient that was harmed. A single payer system would insure that any such patient would be covered for the rest of their lives and as a result, malpractice coverage would also be dramatically lower.
While reimbursement under a single payer plan most likely would be less, so would the headaches and administrative hassles and costs. And I would be able to see far more patients instead of being on the phone fighting with a case manager, while my office and malpractice coverage costs would be far less.
From a Texas oncologist still early in their career:
My general view of Medicare-for-all is that it would moderately contribute to remedying our health care spending problem, but by no means fix it.
My understanding is that the biggest savings would come from getting rid of the huge administrative dead weight in our private insurance system. However, that in and of itself would not fix the fact that billing rates are through the roof here in the US. Saving a few percent on overhead would be great, but MRIs and appendectomies are still going to cost 2x-4x here than in other OECD countries.
I am definitely heterodox among physicians in believing that our salaries (mainly among specialists such as myself) ought to be significantly lower. The greater bargaining power that a single, government payer might have could potentially rein in some of that.
On the other side, from an anesthesiologist intern in Chicago, fiscally liberal but socially conservative, who has some concerns about how single payer would handle Catholic hospitals:
The one part of a more single-payer system that worries me relates to the socially conservative opinions I have. I’m sure you have seen the series FiveThirtyEight has had the past week on the effects of Catholic hospitals coming to predominate more rural areas and even some cities. (As someone who grew up in a small town, I can say the main health care provider in the area is a Catholic hospital.) I don’t fear a single-payer system would result in individual providers being required to provide services they individually oppose for religious beliefs.
However, I do worry about whether or not there would be requirements for Catholic hospitals to provide services contrary to Catholic teaching, generally surrounding abortion or end of life care, in order to be eligible for billing Medicare. I do presume a Medicare-for-All system would pass on a party-line vote with only Democrat support and could see them trying to expand abortion coverage–either directly in a law or through regulation like many abortion coverage issues have been changed–at the same time since that issue has also grown much more partisan in the past decade.