By Jonathan Cohn
HuffPost, January 20, 2020
The campaign to create a government-managed, truly universal health care system may have just picked up an important new ally: the nation’s second-largest physician organization.
The American College of Physicians, which represents 159,000 doctors with training in internal medicine, on Monday said the federal government should assert more control over national health spending and guarantee insurance for all Americans, either by covering everybody directly (through what advocates call “Medicare for All”) or by creating a new public program that can compete with private plans (through what’s come to be known as a “public option”).
ACP’s announcement could prove to be a milestone in the century-long quest to make health care a universal right, considering how frequently and effectively physicians have resisted ambitious reforms. And it comes at a time when such reforms are once again a focus of national debate, because so many Americans are still struggling with the cost of medical care and because the two political parties are calling for such radically different responses.
Republicans, led by President Donald Trump, are still trying to repeal or roll back the Affordable Care Act, which dramatically reduced the number of uninsured people and established key principles of universal coverage such as guaranteed insurance for people with preexisting conditions. Insofar as Republicans support new initiatives, they have in mind reforms that would relax or eliminate these regulations on insurance companies and shrink government insurance programs on which tens of millions rely.
Democrats want government to do more than it does today ― by reaching the remaining uninsured, providing everybody with more protection from medical bills, and addressing health care spending more aggressively. Inside the party, the debate is all about whether Medicare for All or the public option is the best way to achieve those goals.
What They Are Saying About Government And Health Care
After more than a year of study and internal deliberations, ACP’s governing boards and policy committees have concluded that either Medicare for All or a strong public option could work, though it doesn’t use those terms. The overriding goal, the organization says, should be to give the government much more sway over health care, like other developed countries have long done, rather than to rely on some combination of patchwork reforms and the free market.
And in a series of articles that appear in the new Annals of Internal Medicine, ACP officials and affiliates make a detailed case for why. The package includes a thorough review of national health systems abroad, along with summaries of what American politicians are now proposing.
“The U.S. health care system is like a chronically ill patient, and ACP is proposing a new prescription,” three of the group’s officials say in the lead essay. “Simple market solutions have been unsuccessful elsewhere, and we do not believe that health care is a commodity.”
ACP, which supported the Affordable Care Act and has fought efforts to repeal it, has always been among the most liberal physician organizations. But this is the first time the organization has formally called for the government to create a new insurance program, be it mandatory or optional, and to exert so much more power over health care spending, according to Robert McLean, an internist and the group’s president.
“We have said in the past, ‘Hey, maybe we need to consider or look at single-payer financing as an option,’ but we didn’t fully come out and boldly endorse it,” McLean told HuffPost. “We are doing that now. This is a really assertive endorsement with much more detail on how this approach has been shown to be effective for these various reasons. … That is new for us.”
What It Means For The 2020 Election
The ACP articles assiduously avoid endorsing any politician or party. But ACP’s positions line up with some well-known advocates.
Sen. Bernie Sanders (I-Vt.) is Medicare for All’s most visible champion, having written the damn bill, as he likes to say, and endorsed it for nearly his entire life in politics. Sen. Elizabeth Warren (D-Mass.) has also endorsed Medicare for All, though she has said she would seek to get there through a two-step process, starting with a law to create a public option.
Other 2020 Democratic presidential candidates ― including former Vice President Joe Biden; former South Bend, Indiana, Mayor Pete Buttigieg; and Sen. Amy Klobuchar (D-Minn.) ― have warned that Medicare for All represents too dramatic a change. They have said they would prefer simply to pass public option reforms, at least for now, although the specific initiatives those candidates have put forward would appear to be less ambitious than what ACP has in mind.
In its review of public option proposals, ACP cited plans from the Center for American Progress and Yale political scientist Jacob Hacker. The closest analogue to those plans is proposed ”Medicare for America” legislation from Reps. Rosa DeLauro (D-Conn.) and Jan Schakowsky (D-Ill.) that would envision, among other things, more federal intervention to control prices.
And that element of the ACP endorsement, the interest in letting government get more involved with the price of health care through either Medicare for All or a public option, may ultimately be the most important part of its endorsement.
How And Why Physician Opinion May Be Shifting
Physicians, like most providers of health care, have a long history of fighting ambitious reforms, going back to the Progressive Era when state medical societies fought the first, embryonic efforts at “compulsory health insurance.” Thirty years later, the American Medical Association, which was and remains the largest U.S. organization representing doctors, led the fight to defeat Harry Truman’s universal coverage plan.
Since that time, however, physician opposition to sweeping health reforms has softened.
The AMA, like the ACP, supported the Affordable Care Act and has opposed efforts to repeal it. Last year, the AMA’s House of Delegates came within a few percentage points of voting to rescind its historic opposition to single-payer schemes like Medicare for All. It also withdrew from the Partnership for America’s Health Care Future, a health industry group that has fought both Medicare for All and the public option.
The evolution of physician sentiment likely reflects a variety of factors, including a generational shift. Older physicians came into the profession with expectations of operating in solo practices or as small groups, with minimal outside interference.
Younger doctors are more accustomed to working in large organizations and in many cases see government as a necessary, even welcome force to counter the influence of insurance companies and guarantee access in a way that private plans do not.
“First, there is widespread recognition of the harm that our health care financing system inflicts on our patients’ health,” said Adam Gaffney, a pulmonology specialist who is president of Physicians for a National Health Program. “But second, there’s also growing recognition of the ways that the system fails physicians too — endless hours glued to the electronic medical record, enormous amounts of time, energy, and resources expended on billing, documentation, and other onerous clerical tasks. We’re recognizing more and more that patients and doctors are in this together.”
What The Endorsement Doesn’t Say
PNHP is a longtime champion of Medicare for All and recruited more than 2,000 doctors to sign an open letter, set to run as an advertisement in The New York Times on Tuesday, endorsing the idea. Together with ACP’s announcement, the letter suggests that Medicare for All is gaining mainstream credibility.
“The fact that the largest medical specialty society in the country explicitly and officially endorsed Medicare for All is a huge deal — even if they also endorsed another option,” Gaffney said.
ACP’s support of both Medicare for All and strong public option reforms comes with warnings that limiting provider payments too aggressively could hurt doctors and hospitals that operate with low margins, ultimately hurting patients. This is no small thing.
Actual legislation to create either a Medicare for All or ambitious public option system could entail limits on provider income that many physicians would find objectionable. Yet without enough control over health spending, the math of reform gets tricky and it’s difficult to deliver the benefits advocates promise.
But though it’s a tough problem to solve, as policy and politics, McLean says more and more physicians understand it’s worth the effort. “We can do better, our patients deserve better,” he said. “No system is perfect but we can get a lot closer than we are.”