I’ve spent decades studying US health care. Time to get real: Medicare for All is the only reasonable path to controlling costs and covering everyone.

By Gerald Friedman
USA TODAY, April 8, 2019

There is an instinct among political pundits to confuse caution for practicality — an assumption that those who advocate for incremental change are being reasonable, while those pushing for bold reforms aren’t. This is seen most starkly in the debate around health care reform, despite the fact that the “practical” pushers of limited reform fail to address the real problems in our health care system.

We all recognize that the status quo isn’t working. We spend more per person than any other country on health care, but we aren’t getting any bang for our buck. We have lower life expectancy, higher infant mortality rates and more preventable deaths, and too many personal bankruptcies are due at least in part to medical bills.

Where we disagree is the solution. The favorite new “reasonable” plan is “Medicare for America,” a bill from Reps. Jan Schakowsky and Rosa DeLauro that has won the support of big names like Texas presidential hopeful Beto O’Rourke and the Center for American Progress, the left-of-center think tank where the plan originated as “Medicare Extra for All.” It has been extolled in opinion pieces for some of America’s largest newspapers as a “realistic” plan to fix what’s broken in our health care system.

On the other side, if punditry is to be believed, there are the Medicare for All “hard-liners” who believe in expanding a significantly improved Medicare system to every American, with coverage that includes dental, vision and long-term care. This is portrayed as radical or even unreasonable.

Time to get real. As an economist who has spent decades studying our health care system, I can tell you that Medicare for All advocates are the only ones who are being reasonable, because theirs is the only plan that will control health care costs while finally achieving universal coverage.

Insurance companies are middle men

The problem with incremental plans, whether they are public options, buy-ins to Medicare or Medicaid, or pumping more money into subsidies in the Affordable Care Act’s individual marketplace, is that they preserve the private health insurance system weighing down our health care.

This may be why pundits and centrist politicians view those plans as “reasonable,” but it means that they are leaving the main reason for our system’s dysfunction in place: the multipayer, for-profit financing model.

Commercial insurance companies are nothing more than middle men. They add no value to our system, but they do drive up costs with their bloated claims departments, marketing and advertising budgets and executive salaries. We pay for all of these things before a single dollar is spent on the delivery of care.
They also create extra costs for providers who need large administrative staffs to deal with billing systems, accounting for as much as $100,000 per physician.

Any plans short of Medicare for All leaves these costs in place. In other words, they leave hundreds of billions of dollars a year in savings on the table.

Medicare for All attacks costs

The waste goes beyond administrative savings. While pharmaceutical companies and hospital groups are consolidating and forming regional monopolies, our fragmented, multipayer system leaves no one insurance plan with a large enough share of the market to negotiate effectively. That allows these companies to essentially set their own inflated prices and bilk the public for hundreds of billions of dollars.

Is it any wonder that they oppose Medicare for All?

If we’re talking about which health care reform plans are serious about attacking cost, providing universal coverage and making sure everyone has access to health care, Medicare for All is the only reasonable answer. No other plan does this effectively, which is why I suspect that the Center for American Progress has not come out with spending estimates. Basic economic tenets tell us that their plan will not reduce health care spending as effectively.

Is Medicare for All bold? Absolutely. Is it reasonable? You bet. It is time to accept that Medicare for All is the practical alternative.

Gerald Friedman, a health care and labor economist, is an economics professor at University of Massachusetts Amherst and the director of the Hopbrook Institute. Follow him on Twitter: @gfriedma.

https://www.usatoday.com…

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Comment:

By Don McCanne, M.D.

The incrementalists who advocate for tweaks to the Affordable Care Act, perhaps with the addition of a Medicare-like public option, claim to be taking a reasonable pathway to reform. But is it really reasonable to advocate for a system that wastes tremendous resources while leaving tens of millions without adequate coverage and impaired health outcomes, not to mention financial hardship? Well it is unreasonable to make such a claim when fundamental structural reform of our financing system through single payer Medicare for All would establish an equitable and affordable system that ensures health care for everyone. Claiming that displacing the dysfunctional private insurance system is unreasonable is, well, unreasonable.

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By Emily Gee and Topher Spiro
Center for American Progress, April 8, 2019

Anyone interacting with the U.S. health care system is bound to encounter examples of unnecessary administrative complexity—from filling out duplicative intake forms to transferring medical records between providers to sorting out insurance bills. This administrative complexity, with its associated high costs, is often cited as one reason the United States spends double the amount per capita on health care compared with other high-income countries even though utilization rates are similar.

Components of administrative costs

The main components of administrative costs in the U.S. health care system include BIR costs and hospital or physician practice administration.

To date, few studies have estimated the systemwide cost of health care administration extending beyond BIR activities. In a 2003 article in The New England Journal of Medicine, researchers Steffie Woolhandler, Terry Campbell, and David Himmelstein concluded that overall administrative costs in 1999 amounted to 31 percent of total health care expenditures or $294 billion—roughly $569 billion today when adjusted for medical care inflation. A more recent paper by Woolhandler and Himmelstein, which looked at 2017 spending levels, placed the total cost of administration at $1.1 trillion.

Billing and insurance-related costs

Many studies of administrative costs limit their scope to BIR costs. The BIR component of administration is most relevant to systemwide reforms that seek to reduce the expenses related to claims processing, billing rates, or health insurance. The largest share of BIR costs is attributable to insurance companies’ profits and overhead and to providers where BIR costs include tasks such as record-keeping for claims submission and billing.

Applying the NAM’s (National Academy of Medicine) percentages of BIR costs to recent projections of national health expenditures from the Centers for Medicare and Medicaid Services (CMS), CAP estimates that BIR costs will amount to $496 billion for 2019. According to CAP’s calculations, this includes $158 billion in overhead for private insurance; $56 billion for administration of public insurance programs; and $282 billion for the BIR costs of hospitals, physicians, and other care providers.

Excess administrative costs

Most studies that have attempted to identify excess costs in the American health care system rely on comparisons between the United States and Canada. In their 2010 review of the literature on the difference between the two countries’ health expenditures, economists Alexis Pozen and David M. Cutler… (estimated) per capita administrative excess in the United States, when compared with Canada, translates into a gap of $340 billion (adjusted).

Woolhandler and Himmelstein estimate that the United States currently spends $1.1 trillion on health care administration, and of that amount, $504 billion is excess.

All estimates of administrative costs are inherently sensitive to what portion of health care spending one considers administrative. Such tasks, however, can fall into a gray area between administrative and clinical.

Administrative costs for payers

Within the U.S. system, the share of expenditures that are attributable to administrative costs varies greatly by payer. The BIR costs for traditional Medicare and Medicaid hover around 2 percent to 5 percent, while those for private insurance is about 17 percent. Organisation for Economic Co-operation and Development (OECD) data also show that other nations are able to achieve low levels of administrative costs while maintaining universal coverage across all ages of the population.

International health system data demonstrate that the United States is a clear outlier on administrative spending. Countries with single-payer systems are among those with the lowest administrative costs. OECD data also show that within a country, administrative costs are higher in private insurance than in government-run programs.

Countries that have multipayer systems with stricter rate regulation also achieve much lower administrative costs than the United States. If the United States could reduce administrative costs down to Canadian levels, it would save 68 percent of current administrative expenditures; reducing to German-level administrative costs would save 42 percent of current administrative expenditures. However, to assume that by simply adapting another country’s health care system—whether it is Canada’s single-payer Medicare, Germany’s sickness funds, or Switzerland’s heavily regulated private plans—the United States would automatically achieve the same level of administrative costs may ignore other fundamental differences between countries, including the market power of health care providers, political systems, and attitudes toward health care. Nevertheless, the experience of other multipayer systems such as those in Germany and Switzerland suggests that the United States could substantially reduce both administrative expenditures and overall health care spending by bringing down reimbursement rates and regulating insurance—even while continuing to allow multiple payers and private health care providers.

Administrative costs for health care providers

A study of administrative costs in California found that administrative costs represented about one-quarter of physician revenue and one-fifth of hospital revenue, and BIR costs accounted for roughly half of administrative expenditures for physician and hospital services covered by private insurance. In a separate study, Himmelstein and others reported that one-quarter of U.S. hospital spending went toward administration.

As with BIR costs, provider administrative costs in the United States are higher than those in other comparable countries. Hospital administrative costs in the United States far exceed those of other nations. In their comparison of hospital administrative costs among eight Western nations, Himmelstein and co-authors found that the United States had the highest levels, at 25.3 percent of total hospital expenditures. They conclude that in nations where hospital administrators have minimal responsibilities for procuring financing and where the hospital reimbursement system is least complex, administrative costs can be reduced to 12 percent of expenditures. These findings suggest that reforms that introduce global budgeting or limit the need to bargain with multiple payers could potentially bring down excess hospital administrative costs in the United States.

Lower administrative costs in single-payer and multipayer systems

Although administrative costs contribute to the high expenditures in the United States, they are not the primary reason for the health care spending gap. As economist Uwe Reinhardt and others candidly put it, “It’s the prices, stupid.”

Comparative evidence from U.S. states also suggests that America’s multipayer system explains some, but by no means all, of the discrepancy between the United States and other developed nations. Harvard University researchers Joseph P. Newhouse and Anna Sinaiko observe that “there is considerable variation across the states in spending levels, with the lowest quintile of states spending approximately the same percentage as the higher spending OECD countries other than the U.S. This implies that the [United States’] pluralistic financing system may not be an important cause of the large percentage of GDP that the U.S. devotes to health care.”

Systemwide reforms to lower administrative costs

Health care financing experts believe that changes to how Americans pay for coverage could dramatically reduce administrative costs. Researchers simulating the effects of single-payer programs have assumed that administrative costs would be brought down substantially.

Exactly how such lower costs could be achieved is another question. Reducing BIR costs requires simplifying the billing and payment process, which could be accomplished in a number of ways. Two avenues for reducing administrative costs as well as overall health costs are global budgeting and uniform rate-setting. These two concepts are central to health systems around the world and are also responsible for keeping administrative costs lower, whether a country has a multipayer or single-payer system. Another paperwork-reducing option would be a centralized claims clearinghouse to allow providers to submit all claims to a single entity, as they do in Germany and Japan.

All-payer rates and global budgeting

Setting all-payer reimbursement rates would eliminate the need for providers to negotiate rates with individual private insurers, while also giving policymakers better leverage for controlling overall health care cost growth. In the current U.S. system, providers charge different rates to different payers, and the billing process is complicated and opaque. Setting all-payer rates would simplify billing and improve transparency by establishing a single set of rates for each provider, while also giving regulators a tool to protect consumers from exorbitant rates.

Global budgeting—the practice of paying providers revenue based on their expected costs—also holds promise for both lowering administrative spending and overall costs. As opposed to traditional fee-for-service payments, which reward providers for doing more, global budgeting incentivizes providers to deliver care more efficiently. Global budgeting is a feature of many countries with much lower health care administrative costs, including Scotland, Wales, and Germany. As Woolhandler, Campbell, and Himmelstein point out in their 2003 article, “The existence of global budgets in Canada has eliminated most billing and minimized internal cost accounting, since charges do not need to be attributed to individual patients and insurers.” As Germany shows, both single-payer and multipayer systems can use global budgets.

A system combining all-payer rates and global budgeting is already partially in place in the state of Maryland, where each hospital has a single set of rates it bills to Medicare, Medicaid, commercial insurers, and other payers. Maryland’s system is keeping overall cost growth lower than the national trend. According to RAND analysis of hospital costs, Maryland hospitals have administrative costs that are 9 percent lower than the national average.

In their analysis of three universal health care options for Vermont, including single payer, researchers William C. Hsiao, Steven Kappel, and Jonathan Gruber estimated substantial savings from administrative simplicity from each option. The two single-payer options they examined would result in even greater administrative savings of between 7.3 percent and 7.8 percent, depending on the rate-setting mechanism. The group estimated that a third scenario, which would establish a centralized claims clearinghouse while allowing multiple payers, could generate savings equal to 3.6 percent of total expenditures. This suggests that about half of the total administrative savings from a single-payer system could be obtained within a regulated multipayer system.

Policy proposals directed at administrative costs

While major changes to the U.S. health care system have the greatest potential to bring down costs, more incremental changes could reduce administrative waste. A recent bill proposed by Sens. Bill Cassidy (R-LA) and Tina Smith (D-MN) would direct the HHS secretary to set goals to cut “unnecessary costs and administrative burdens” throughout the health care system by 50 percent over the next 10 years. It would also provide grant money for state-based efforts to bring down administrative costs. Some possible avenues for achieving those kinds of reductions include changes to payment rules, improvements to facilitate electronic record-keeping and information exchange, and simplification of public insurance programs.

In their 2009 article in The New England Journal of Medicine, David Cutler, Elizabeth Wikler, and Peter Basch proposed one such package of reforms. The authors estimated that providers could save $17.9 billion to $23 billion annually with several, more incremental changes to the system, including greater adoption of EHR systems; integrated administrative and clinical systems; national and standardized reporting requirements and credentialing of providers; streamlined enrollment in public insurance programs; and greater automation. In a separate report, the same authors proposed additional reforms that they estimated could reduce excess administrative costs by $40 billion, or 25 percent of total health care expenditures.

In a 2010 study published in Health Affairs, Bonnie B. Blanchfield and other Massachusetts researchers concluded that the administrative burden on physician organizations could be reduced by a “single transparent set of payment rules for a system with multiple payers.” The authors recommended that the United States adopt “a standard set of payment requirements, increased payment-rule transparency, standardized forms, and a standard set of data exchange requirements.” Doing so could save $7 billion in billing costs for physician and other clinical services, according to the authors’ estimates.

Conclusion

Although estimates vary, a large body of evidence shows that the United States is spending about twice as much as needed on the administration of health care. Other nations enjoy world-class health care systems while spending a fraction of what the United States does on governance, billing, and insurance.

A structural overhaul of how health care is financed and priced that includes key features of other countries’ systems—whether one payer or many—would go a long way toward eliminating excess administrative costs. Simplifying the payment system should be an essential part of future health reform and would make the U.S. system work better for taxpayers and patients alike.

Emily Gee is the health economist of Health Policy at the Center for American Progress. Topher Spiro is the vice president for Health Policy and a senior fellow for Economic Policy at the Center.

This publication was made possible in part by a grant from the Peter G. Peterson Foundation.

https://www.americanprogress.org…

15 page PDF:
https://cdn.americanprogress.org…

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Comment:

By Don McCanne, M.D.

The president and CEO of the Center for American Progress (CAP) is Clintonite Neera Tanden. She played a very active role in keeping Bernie Sanders’ single payer Medicare for All out of the Democratic Party platform to help protect her candidate, Hillary Clinton. Although her candidate lost the presidential election, Tanden has continued to oppose the single payer model of reform.

With the growing popularity of the Medicare for All concept, CAP developed the Medicare Extra for All counterproposal – a proposal that would include a Medicare public option. The promotion of this proposal suggested that it would be better than a single payer model because it would preserve the choice of private insurance options, including employer-sponsored plans and private Medicare Advantage (renamed Medicare Choice). They suggested that administrative savings would help fund the program, but they did not present a compelling case for that.

This current report from CAP is important because it does acknowledge the profound administrative waste in our system, citing many of the important studies confirming this (plus some of the lousy ones). They then suggest that we do not have to change to a single government payer to implement the tools that result in the single payer administrative savings, that these savings can be achieved, “whether one payer or many.”

Although most of the report above is composed primarily of excerpts, the section, “Policy proposals directed at administrative costs,” is duplicated in its entirety. They suggest that implementing these policies could save perhaps tens of billions of dollars. Yet earlier in the article they report, “Woolhandler and Himmelstein estimate that the United States currently spends $1.1 trillion on health care administration, and of that amount, $504 billion is excess.” It appears that they have not made the case that it does not make much of a difference by shifting to single payer when administrative savings of a multiplayer system would be in the tens of billions whereas single payer system savings would be in the neighborhood of half a trillion dollars.

Another problem is that they do not explicitly acknowledge the differences between private insurers in other nations and private insurers in the United States. They are very different creatures. In other nations they function more as social insurance models serving the public good. In the United States they are crafted as business models driven by profits (or “margins” in the nonprofits). If we were to have a multipayer system that produced European efficiencies, then we would have to disband current insurers and replace them with European-style insurers. (American insurers walk out of markets for far more trivial reasons.) Obviously it would be far easier and much more efficient to replace them with an improved and expanded version of Medicare.

The media has already been reporting that Americans want to have a choice of private plans, especially employer-sponsored plans, saying that support for single payer Medicare for All declines if individuals are deprived of private options. This CAP report was designed to support that reasoning. Already today, Sarah Kliff (VoxCare) quotes co-author Topher Spiro as saying, “Uniform rate setting is a key feature of a system that would have lower administrative costs. That could be in the context of a single-payer system or a regulated, multi-payer system.”

This report will be used to say that we can leave the private insurers in place. My immediate response is, “Bull!” See if you can come up with a short, emphatic response that addresses the flawed policy instead – a response that would improve our messaging.

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By Joseph Antos and James C. Capretta
The New York Times, April 4, 2019

By backing a flimsy, state-initiated lawsuit to throw out the entirety of the Affordable Care Act, President Trump has made himself and Republican candidates in 2020 vulnerable to attacks that they want to take health insurance away from millions of people.

Yet not all is lost on the issue for Republicans. Many Democrats, by rushing toward a single-payer Medicare for All plan, are being pulled along by ideological yearnings instead of practical realities. Medicare for All would upend all current public and private insurance arrangements, including employer coverage for about 180 million people. Further, even the sponsors admit these plans would require significant middle-class tax increases.

What that means is that the door is open for a responsible Republican plan to improve the nation’s mixed public-private health system. If the party’s leaders were so inclined, they could take advantage of the Democratic overreach by embracing reforms that would build upon what exists and make it work better. Such a conservative reform plan would look something like this:

A Medicaid Compromise

Republicans should embrace a compromise that allows the non-expansion states to expand Medicaid eligibility to 100 percent of the federal poverty line instead of 138 percent as required by the A.C.A. The expansion states could stay at 138 percent if they wanted to. States should also be given more flexibility to run the program with less federal interference in return for accepting limits on overall spending.

Automatic Enrollment

Instead of creating a new insurance program, Congress should make it easier for people to enroll automatically. Eligible individuals could be enrolled in a no-cost plan with the option of paying a premium for more generous coverage.

Equitable Risk-Sharing

Some states have lowered premiums in the individual insurance market by providing reinsurance to insurers or organizing high-risk pools that protect against losses stemming from the very high-expense cases. By lowering the risk of large losses, insurers are able to reduce premiums for all of their customers.

Strengthening Competition and Market Incentives to Control Costs

The most difficult and pressing issue in health care is high and rising costs. Republicans say the answer is stronger market incentives, but they need to back up the rhetoric with concrete reforms. To begin, Congress needs to place an upper limit on the tax break for employer-provided health care to promote more efficient health insurance. The Federal Trade Commission should more aggressively examine business deals that create de facto monopoly providers in local health care markets. Both parties want Medicare to emphasize value instead of volume in the provision of care. To achieve that goal, beneficiaries need clear information on the cost of their care, and they should share in the savings when they choose high-quality, low-cost providers. More broadly, consumers should be able to see the all-in prices they will pay for high-volume procedures. Finally, Republicans should encourage more competition among drug manufacturers and limit abuses that extend monopolistic pricing for years beyond what patent law is supposed to provide.

Republicans keep searching for a politically safe silver bullet that slays Obamacare and yet leaves everyone happy. That plan doesn’t exist.

But voters aren’t looking for a miracle. They would settle for solid progress. It’s time for Republicans to become the party of responsible health care.

Joseph Antos is a scholar in health care and retirement policy at the American Enterprise Institute. James C. Capretta is a resident fellow at the institute.

https://www.nytimes.com…

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Comment, NYT Pick:

By Don McCanne, M.D.

The authors are noted experts in health policy and understand the pros and cons of both market-oriented reform and public financing systems, yet they are driven by their conservative ideology as they dismiss single payer Medicare for All as representing “ideological yearnings.”

The Democrats already made the mistake of yielding to conservative ideology in crafting the Affordable Care Act based on the Heritage model, believing falsely that Republicans would cooperate. Now these authors want to salvage this highly flawed model by merely tweaking it.

Setting ideology aside, the single payer Medicare for All model actually would achieve the goals of true universality, comprehensiveness, accessibility, administrative efficiency, equity, and would use public policies, including tax policies, that would make health care affordable for all of us.

Nobel Laureate Kenneth Arrow showed us that market ideology does not work in health care. Even Nobel Laureate Friedrich A. Hayek, revered by conservatives, in “Road to Serfdom” states, “Nor is there any reason why the state should not help to organize a comprehensive system of social insurance in providing for those common hazards of life against which few can make adequate provision.”

It’s time to throw out stale arguments based on ideology, and enact and implement a program with proven effectiveness – single payer Medicare for All.

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The only big losers are the private insurance companies – and that’s okay with me

By James G. Kahn, M.D., M.P.H.
The Mercury-News, April 2, 2019

How to achieve universal health insurance in California? In our super-progressive, supermajority Democratic state, that’s the health policy question of the day. Not if we should lead the way on universal coverage, but how.

Recently, UC Berkeley economists proposed a solution, dubbed California Dreamin’. Expand current insurance to cover the uninsured, using up to $17 billion in new taxes. That’s a 5 percent bump in health spending. Problem solved, right?

No. While the goal is admirable, the Dreamin’ approach adds a Rube Goldberg appendage to a Rube Goldberg health care financing system. It layers cost and complexity upon cost and complexity. Our insurance system will continue to underperform.

We need to revamp our insurance mess. We can do this with a well-known and proven solution: single-payer.

Also known as improved “Medicare-for-All,” single-payer has these core features: everyone is covered cradle to grave with the same comprehensive benefits package; health care is financed by a single entity; payment is greatly simplified; patients freely choose among doctors; and doctors focus on providing care.

These features aren’t fantasy, they’re standard among wealthy democracies (such as Canada and Australia). They’re captured in the 2017 Healthy California Act, in U.S. Sen. Bernie Sanders’ bill, S1804, and in Rep. Pramila Jayapal’s new HR1384.

Single-payer solves what ails the insurance system in a way that Dreamin’ can only dream about. Here are high points:

Effective insurance: Our current system leaves 5 percent to 10 percent uninsured, and many more underinsured – facing high deductibles, other cost-sharing, and restrictions on covered services. The Dreamin’ approach could fill the uninsured gap but leave millions underinsured, which we know leads to skipped and delayed care.

Some ask, “I like my private insurance. Why give it up?” Just because insurance works well today doesn’t mean it will tomorrow. Most private insurance is employment-based – laid off, lose your insurance. Plus, each year, private insurance deteriorates, with rising cost-sharing and shrinking provider networks. In single-payer, everyone has the same health plan, assuring ongoing shared commitment to quality coverage. Politically, this is critical, as individuals realize the advantage of single-payer over unstable private insurance.

Administrative efficiency: The United States spends 12 percent of health care dollars on excess billing paperwork, from contracting all the way to appealing underpayments. That’s about $1,400 per person per year in administrative bloat, about half at insurers and half via the burden placed on providers. Single-payer captures this 12 percent and puts it into patient care.

Prices: U.S. drugs cost several times more than in Europe. Single-payer would use price negotiations to get a fairer price, with 30 percent savings in drug costs overall.

Affordability: Providing more effective insurance increases costs, by about 10 percent. Reducing administrative waste along with drug prices decreases costs, by about 15 percent. Net costs drop by about 5 percent. Repeating slowly: Net. Costs. 5 percent. Down. Over time, savings grow with global budgets and better data on clinical practices to identify and reduce ineffective practices.

Clinical focus: Freed of distracting reimbursement paperwork, doctors and patients focus on each other! This is what medicine is supposed to be about.

Smart social contract: Perhaps most exciting, single-payer unites us in a just and prudent communitarian undertaking. Single-payer is the poster child for benevolent and smart policy.

It’s benevolent because it truly solves the problems of uninsurance and underinsurance, fulfilling the human right of access to health care. Smart because it saves money – using clever and proven methods to efficiently translate our financial commitments to desired health care. To riff on the venerable advertising slogan: costs less, more filling.

Everyone is in single-payer together – rich and poor alike. This social contract isn’t a good-enough compromise, it’s an improvement for us all. From our fragmented and dysfunctional insurance, step up to universal access to care.

The only big losers are the private insurance companies – yes, they’d really have no role, and that’s okay with me. It’s not un-American; it’s part of the new American dream.

Dr. James G. Kahn is a professor emeritus of Health Policy, Epidemiology and Global Health of UC San Francisco and is past president of Physicians for a National Health Program-California.

https://www.mercurynews.com…

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Comment:

By Don McCanne, M.D.

This article has that special combination of explaining clearly single-payer health policy in terms that the general public can easily understand, written by a noted health policy wonk who knows how to communicate. It should be shared widely so people have a better understanding of the health care system that we could have if we select government stewards who would support this social contract that ensures health care for all of us.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Physicians can have an outsized influence on the debate around Medicare for All versus private insurance.

By Robert B. Doherty
ACP Internist, Washington Perspective, April 2019

When Medicare became law 64 years ago this April, many expected that it soon would be expanded to include all Americans, beyond the elderly initially covered. Much to the disappointment of progressives, more than a half-century later, Medicare remains a program only for persons ages 65 years and older and persons with disabilities.

Robert M. Ball, who worked in the Johnson administration and helped draft the legislation that became Medicare, recalled in a 1995 article in Health Affairs on the 30th anniversary of its enactment that “We all saw insurance for the elderly as a fallback position, which we advocated solely because it seemed to have the best chance politically. Although the public record contains some explicit denials, we expected Medicare to be a first step toward universal national health insurance…”

There is a growing political movement today for enacting a Medicare for All program to replace private insurance, or at least to give everyone the choice of enrolling in a version of Medicare with better benefits and lower out-of-pocket contributions. Most of the current candidates running to be the next Democratic nominee for president have coalesced around one option or the other, betting that this will be a winning issue among its primary and caucus voters. And in the House of Representatives, which is controlled by the Democrats, several bills have been introduced to either require or give people the choice of enrolling in a public program modeled on Medicare.

Yet support for Medicare for All, or Medicare for Anyone Who Wants It, isn’t just limited to the Democratic Party and its base voters. The Kaiser Family Foundation, which has been tracking public opinion on different coverage options for decades, reported in January that “Overall, about six in 10 adults favor a national health plan or Medicare-for-all plan.”

Yet, in pollster parlance, support for Medicare for All is soft, amenable to arguments that might sway opinion against it. “Public support for Medicare-for-all shifts significantly when people hear arguments about potential tax increases or delays in medical tests and treatment,” Kaiser’s pollsters said.

Physicians, because they have unique credibility with the public when it comes to matters affecting health, can have an outsized influence on this debate. Will physicians and their professional associations speak out in favor of allowing or requiring people to enroll in a public program like Medicare? Or oppose it?

The New York Times reported on Feb. 23 that a coalition of industry stakeholders, called the Partnership for America’s Health Care Future, has been formed “to kill ‘Medicare for all,’ an idea that is mocked publicly but is being greeted privately with increasing seriousness. Doctors, hospitals, drug companies and insurers are intent on strangling Medicare for all before it advances from an aspirational slogan to a legislative agenda item.” The American Medical Association is a member of the coalition. The coalition opposes not only a single-payer, Medicare for All system, but according to a statement on the coalition’s website, any public option, saying, “Medicare for All, Medicare buy-in, single-payer or a public option … moves us toward a one-size-fits-all health care system that is wrong for America.”

Robert Pear, the New York Times reporter who wrote the Feb. 23 story, contacted me to get ACP’s perspective, and he accurately included the following in his story based on our conversation: “But the coalition does not speak for all health care providers. The American College of Physicians, the largest medical specialty organization in the country, has supported a Medicare buy-in for people 55 to 64. And ‘during the whole debate over the Affordable Care Act, we supported having a public option in the individual insurance market in every state,’ said Robert B. Doherty, senior vice president of the college, which represents 154,000 doctors who specialize in internal medicine.”

Indeed, at the direction of our Board of Regents, ACP is currently evaluating ways to cover everyone while reducing costs and administrative complexity. We have not concluded what approaches we will call for. Yet it is pretty evident that it would be hard if not impossible to provide all Americans with affordable coverage that is not dependent on place of employment, residence, or health status (universal coverage), without making publicly financed coverage at least available to everyone.

And, while we believe universal coverage is an essential goal, ACP will include in our recommendations ways to ensure that physicians are fairly compensated for their services, billing is made easier and administrative costs reduced, and patients are able to choose their physicians and have access to the care they need. We anticipate that ACP will be ready to release its recommendations before the end of the year.

It’s not necessarily a bad thing for physician membership organizations to have different views on how best to ensure that Americans have access to affordable coverage, since physicians themselves are a diverse lot. Each physician membership society is obligated to advocate based on the policies established by its members. In ACP’s case, our policies have long supported universal coverage, including options for people to enroll in publicly funded coverage; we are committed to building on those policies to issue proposals later this year to achieve truly universal coverage for everyone.

As we do this, we must counter the narrative that “doctors” as a whole oppose making public insurance available to everyone, because they don’t. And, by making our views known, we hope to influence the debate so that the country commits to the next step toward universal national health insurance, as Medicare’s architects intended more than half a century ago.

Robert B. Doherty is ACP’s Senior Vice President for Governmental Affairs and Public Policy.

http://www.acpinternist.org…

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Solution to health plan quandary lies with improved ACA

By Barbara L. McAneny, M.D., President, American Medical Association
AMA, March 20, 2019

Given the high stakes of health reform, the subject will again be a major focus on the campaign trail. Voters will hear multiple similar-sounding proposals, including “Medicare for All,” “Medicare for America” and Medicare buy-ins as a means to achieve coverage for every American.

The AMA strongly believes that all Americans should have access to affordable, quality health insurance coverage. We also believe that the best way to achieve this is to build on the model of private and public coverage already in place, which has successfully increased access to health insurance for millions of Americans previously unable to obtain it.

Disruption aside, the financial burden that would be imposed by a Medicare for All model is unsustainable by any measure. Imagine shifting all current health care spending—by individuals and households, by businesses, and by state and local governments—onto the back of the U.S. Treasury. It has been estimated that Medicare for All would increase federal spending by at least $32 trillion over ten years. How will that be paid for?

https://www.ama-assn.org…

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Comment:

By Don McCanne, M.D.

It is common for the media to cite statements from the American Medical Association to claim that physicians are opposed to Medicare for All. Their current president, Barbara McAneny, states, “a Medicare for All model is unsustainable by any measure.” But only about 17 percent of physicians and medical students are members of the AMA; thus it cannot be said that they are representative of America’s physicians.

Contrast the AMA’s position with the statement by Robert Doherty of the American College of Physicians – the specialty society of America’s internists. ACP has “long supported universal coverage, including options for people to enroll in publicly funded coverage.” ACP is “committed to building on those policies to issue proposals later this year to achieve truly universal coverage for everyone.” It almost appears that ACP is ready to endorse single payer Medicare for All, although they seem to have left the door open for Medicare for America – a model designed to be universal that still leaves the option for private employer-sponsored plans in place, even though that would perpetuate some of the deficiencies of our multi-payer system. But at least the ACP is far more willing to accept the greater efficiencies and equity of public insurance than is the AMA.

Anyone who still contends that physicians are opposed to single payer Medicare for All need only attend a meeting of Physicians for a National Health Program. The passion displayed, including that of the nation’s future physicians, will convince you that the spirit of the Hippocratic ethics of the healing arts is alive and well – it is about placing the patient first, above the interests of the medical-industrial complex. It is the single payer Medicare for All model that comes closest to getting these priorities right. We hope that the ACP will come to the same conclusion, and with the current medical student activity at the AMA, we haven’t given up on them either.

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