"Single Payer", "Medicare for All": Good ideas and about time!

The call for a universal health care system in the US is probably greater than it ever has been. While, of course, the Republicans, whose only firm position is completely kowtowing to billionaires and major corporations, are opposed to it, many Democrats have signed on to the “Improved and Expanded Medicare for All” bill in Congress (120 at last count). Democrats running across the country have been calling for “single payer” as well as “Medicare for All”, from outspoken Democratic socialists like Alexandria Ocasio-Cortez in NY (and of course Bernie Sanders) to moderate Democrats running in states and districts that Trump won. They correctly see this as an issue that cuts across traditional liberal-conservative lines, and even racial lines, and may be their path to victory.

Many Republicans (although not the Republican congressional leadership) are reading the same tea leaves, and are hedging, trying to say that they favor the things that people like about the ACA (most important, the protection against insurers denying coverage for pre-existing conditions). Of course this often requires major dissembling for those who, like our Arizona GOP candidate for Senate Martha McSally, voted to gut the ACA, and even Texas senator Ted Cruz who authored the “Cruz Amendment” that would strip virtually all protections for people under ACA. President Trump, never one for nuance, has no difficulty having it both ways: he calls for the repeal of ACA while insisting that his health care plan will protect people’s ability to have health insurance, pre-existing conditions or not (it won’t).

It is in this context that the recent Sunday NY Times’ Magazine article by Elisabeth Rosenthal and Shefali Luthra, ‘“Don’t get too excited” about Medicare for All’ becomes important. For starters, “Don’t get too excited” is not necessarily the opinion of the authors but a quotation from Rep. Jim Cooper (D-TN). Rep. Cooper was responding to the surprise of one of his Nashville constituents, Dr. Carol Paris, President of the leading physician advocacy group for single payer, Physicians for a National Health Program (PNHP), that he had signed onto the Medicare for All bill. Nonetheless, the article does raise many cautions about the movement to single payer or Medicare for All, mainly about different interpretations of the meanings of this by different advocates, and incomplete and sometimes inaccurate understanding of them by regular people. The most important thing about it, however, is that it had to be written at all because there is such a movement; long-time activists, including PNHP physicians, remember that it was not too long ago that such an idea was poo-pooed, dismissed. Not now.

Clearly, the quantum step forward was the 2016 presidential campaign of Bernie Sanders. The establishment pundits of both parties were shocked at how popular and successful this old Jewish socialist from Vermont (ok, originally Brooklyn) was across the country. He didn’t win the Democratic nomination, true, but he might have won the general election against Trump. Certainly, his straight talk and the fact that he directly addressed the felt needs of regular people was the main reason for his popularity, and people’s fears about their health risks and costs were central to this (see A majority of Americans are worried about health care costs -- and a majority of Congress doesn't care, October 16, 2018). Bernie had advocated for single payer for decades, as had great leaders before him including the late Representative Ron Dellums of California (see Ron Dellums: Loss of a great leader and a job for the rest of us, July 31, 2018), but the visibility of his presidential campaign skyrocketed the visibility of single payer.

Rosenthal and Luthra utilize a good bit of ink describing what single payer is --the government is the only payer for health care, rather than multiple private insurers; Canada is the best example of this, and Britain has a government-owned national health service. They also note that Medicare for All means exactly that, that everyone, not just those over 65 and the blind and disabled, would be in the Medicare program. Of course, since Medicare is a single payer program, it would be single payer. They describe the misconceptions people have (“would I be able to keep my present plan?”), and also talk about other countries, such as France and Germany, that have universal health care without a single payer but with a heavily-regulated marketplace. They observe that partialist solutions do not generate the enthusiasm of single payer, but that the latter would be the hardest and thus (perhaps) most difficult to institute. Among the concerns they note are the displacement of insurance company employees and the decrease in doctors’ income.

But these are the most important points.

1.       Our health care system is not working. Our life expectancy is much lower than other developed countries, about 43^rd, and a recent article in Smithsonian Magazine covers work that projects that it will drop another 21 places by 2040, to 64! Other measures of access to care and quality of care are comparably poor. Yes, there are heroic and wonderful things that medical care can do for people, but if these are not accessible to everyone, and if the cost of them precludes spending on even basic care for everyone, it is not working.
2.   Our health care system is incredibly costly. By far, we spend more, overall, as % of GDP, and per capita, than any country in the world, as illustrated by the graph from the Kaiser Family Foundation. It is more than twice as much as most of the developed countries, all of which have far better health status.
3. Profit is the problem. Specifically, corporate profit made from providing health care services (or, in the case of insurance companies, not providing health care). This is how we manage to do both #1 and #2 – because the functional goal of the US health system is not to increase the population’s health but to make as much money as possible for insurers, hospitals, drug companies, and providers.

These are the core issues that need to be addressed, and what sets the US apart from all other developed countries. Yes, Canada has a single payer system such as we might have with Medicare for All (and they even call it Medicare). Britain has a National Health Service, with most hospital and health care facilities owned by, and some doctors employed by, the government. Britain, however, allows private insurance for those who can afford it, Canada does not. France and Germany and Switzerland have multiple insurers, but they are not unfettered to maximize profit by denying care. In Switzerland, for example, insurers have to be non-profit, have to offer the same benefits, and have to charge the same amount. They compete on quality of service! Can you imagine that here?

So, while Rosenthal and Luthra repeat the idea that single payer, although the most enthusiasm-generating, would involve the biggest change, it is also, in another sense, the least complicated. Trying to get to a system like that that evolved in these other countries over decades will be more complicated to understand and to implement. Many of the suggestions for incrementalism (“Medicare for More”, “public option”) will not solve the problems we have because they do not include everybody, and because they do not eliminate the incentive for making money on the back of denying care that is the core flaw in our current situation.

“Medicare for All” and “single payer” are popular among people because their core meaning is understandable, and they would address the needs that they have.

• ·        Everybody in, nobody out!
• ·        No profiteering!

Simple message. Needed solution.

A majority of Americans are worried about health care costs -- and a majority of Congress doesn't care

People in the US are worried about a lot of things, but apparently the top one is whether, and how, they are going to be able to pay unexpected medical bills. The chart below, based on an August, 2018 survey, is provided by Drew Altman, President of the Kaiser Family Foundation, in the September 24 Axios. Indeed, concern about medically-related costs come in not only as #1, but as #2 (health insurance deductible), #4 (prescription drugs), and #6 (monthly health insurance premium), making up 4 of the top 8 concerns, all of them ahead of “rent or mortgage” (#7) and “food” (#8). All 8 of these concerns are upsetting; it is outrageous that over one-third (37%) of Americans are very or somewhat worried about being able to afford food, or 41% rent or mortgage. But a twice as many people, two-thirds, 67%, are very or somewhat worried about being able to afford unexpected medical bills, and over half (53%) about their health insurance deductibles.

 Of course, those who are worried are not evenly distributed among all Americans. They are not the suburban men who are turning more toward Trump, as they sit on the golf course by their $500,000 homes. They are certainly not the people in power in Washington, whether in the administration like Jared Kushner, who pays no income tax, or his father-in-law, President Trump, who has not released his tax returns, or the senators and even congressmen who make policy, or the members of the Supreme Court.

They certainly do include the poor, including many who are members of minority groups; those who, even in the best of circumstances are barely hanging in there – or often are not. These are the folks for whom paying for housing and food is an all-consuming concern, who do not know where their next meal may be coming from. For them, extraordinary medical bills are not even something that they can spend time worrying about, although they would certainly not be able to afford them.

Those worried, however, also include the large percentage of Americans (see the numbers) who are not poor, but are not all that far from it, people who are not that many paychecks from homelessness (a good measure of real risk). These are people who do not qualify for Medicaid (especially in the states that have not expanded it under the ACA), do not yet qualify for Medicare (and even many of those who do), and who often have health insurance either through their employers or through the ACA marketplaces. The employer health plans, overall, are cutting back on benefits, increasing employee contributions (#6), requiring higher deductibles (#2), and even instituting lifetime caps on benefits as well as excluding many times of illnesses. Fortunately for these people, the ACA has important requirements that help protect them: that people with “pre-existing” conditions be eligible for health insurance (without that, many folks with chronic disease would not be covered), and that there be “community rating”, which means insurance companies can’t charge individuals with particular conditions many times more than they charge others (without which most folks wouldn’t be able to afford the premiums).

It is also true that the current administration and Congress have been trying very hard to limit, when they cannot repeal, these very protections that provide a minimum safety net for most Americans. They are also keeping up a drumbeat about the “cost” of programs such as Medicaid (it’s just poor people, after all, except it is also your elderly parents and grandparents in nursing homes, and this is the bulk of the cost), Medicare (a bit of a “third rail” in politics, but which lots of Republicans keep bringing up as needing to have its benefits cut), and even Social Security, the program that keeps many, many American seniors from being in real poverty even as it continues them in near-poverty. The fear of losing insurance because of having a pre-existing condition is, scarily described by Kurt Eichenwald in a NY Times Op-Ed on October 16, 2018.

The fear of #1, “unexpected medical expenses” is, I assume, primarily about getting sick when you weren’t planning on it. Most folks are not hoping to get sick, but for some the exposure is particularly great because part of the way they handle #6, monthly health insurance premiums, and #2, high deductibles, is not be either uninsured or poorly insured. The latter is particularly common, both in many employer plans and even in ACA individual plans. Indeed, while they call it something different (“free choice” and “granting Americans the freedom to buy health care across state lines”[1]), the administration and Congress are actively encouraging high-deductible, low-coverage policies. This makes premiums seem affordable (or more affordable), but is a disaster when someone gets sick (back to #1).

In addition, limited networks are a quicksand trap for many people, who try to carefully go to doctors and hospitals that are in their networks, only to find themselves faced with huge bills from emergency room physicians, specialists, surgical assistants, and lab and imaging services that are not. This is truly a kind of “gotcha”, a quicksand trap. It is unbelievable; or maybe it is too believable. What may be more unbelievable, to many Americans, is that in most other developed countries health care systems are designed to serve people’s health, not trick and bait-and-switch for the purpose of corporate profit.

Medicare, as currently structured, is not a panacea; 31% of US seniors go without health care because of cost. But it is much better than nothing, and could be really good if it was better funded, and for-profit insurers were not skimming the “cream” (the least sick) into Medicare Advantage plans (which have much higher overhead/administrative costs than traditional Medicare).

Sadly, the issue of whether Americans should have adequate and affordable health care has become highly partisan. This is in some part because at least a portion of the Democratic Party has moved to positions in support of health care as a right, and a universal health insurance system (such as Medicare for all). But it is much more because the Republican Party has moved into complete opposition to any plan to expand health coverage to more Americans (e.g., Medicaid expansion, ACA) and is actively and aggressively moving to cut funding for ACA, for CHIP, for Medicaid, and even for Medicare (“we can’t afford it” is the stated reason, although it really means “we can’t afford it while giving multi-trillion-dollar tax cuts to corporations and the wealthiest”).

Sadder is the fact that many of those most affected, many of those with the greatest worries about health costs, whether unexpected illness, high deductibles, high prescription drug costs, high premiums, are reliable Republican voters. The Associated Press published a piece describing how the Democrats are focusing on health care for the midterm elections, citing the senate race in my state, Arizona. It describes how the Republican candidate, Martha McSally (currently my congressperson) tries to talk with business executives about the tax cuts but is regularly interrupted with questions about health care:

‘They are asking about Democratic ads saying McSally, currently a congresswoman, supported legislation removing the requirement that insurers cover people with pre-existing medical conditions.

"It's a lie," McSally said quickly, accustomed to having to interrupt a discussion of the tax cut to parry attacks on health care. But she had voted for a wide-ranging bill that would have, among other things, undermined protections for people with pre-existing conditions and drastically changed and shrunk Medicaid.’

Actually, then, it is she who is lying. Hopefully she, and other GOP legislators, will pay a price because people vote for those who are actually trying to solve their health care problems, regardless of party. We can hope that more and more Americans will, at least on this important issue, stop voting against their own interests.

I hope.

[1] This is actually the phrase used in the “survey” – completely non-scientific and filled with leading or directive questions – that Trump sends out to his supporters.

Corporate control corrupts medicine and reduces healthcare quality

Medicine and health care is always changing, and the pace of change seems to be accelerating. Some of this change is good for people -- some of the new drugs that come out actually help, either a lot of people, or more commonly a few people. Sometimes new treatments are more effective, less painful, shorter, or less debilitating than older ones. And, sometimes, they are not. One thing we can be sure of, though, when we see a new treatment advertised, whether on TV or in a magazine or on a billboard, is that someone is making a lot of money on it.

There has been a great deal of coverage of two of the most important and egregious industries in which large corporations make lots of money at the expense of our health: pharmaceuticals and insurance. They deserve it, and I have written about them often. But another extremely important area where corporatism and corporate culture has taken hold and is expanding is in the ownership and management of hospitals. The most important thing about this increasing corporatism is that it is about making money (even in “non-profit” hospitals), not primarily about providing the health care that people need; of course, if what you need (or can be persuaded to buy) is profitable for the hospital, they’re all about it. For example, new surgical techniques and imaging, and particularly high-margin, low risk procedures like joint repair and replacement in otherwise relatively young healthy people (let’s go for that high school quarterback or 40-something weekend warrior). Not so much problems that occur in people who have multisystem disease, are old, are high risk, or are poor and uninsured. And some stuff – like psychiatric treatment for the most needy, or trauma care, are big money losers. Hate that if you’re a CEO, although might be good if you are a person who needs it.

This trend has been going on for a long time, particularly in large metropolitan areas, where most big hospitals are, and most of them are now part of hospital systems. Of course, big hospitals were always big, but the overemphasis on making decisions based upon money rather than people’s health has been accelerating. And more recently the process has taken over hospitals in smaller communities, including Critical Access Hospitals in rural areas. The Critical Access designation is meant to reflect the geographic isolation of a community, such that travel to the next-closest hospital creates real health risks for the population, and so even if operating it is inefficient, it receives federal support.

This is discussed in an outstanding editorial by Andrea Wendling in the October 2018 issue of Family Medicine, “Times Are Changing”. Dr. Wendling focuses on two major areas, the reinterpretation of the “value” of physicians and the role of family physicians. Family physicians are the most common specialists in rural areas, in part because they can have such a wide scope of practice. They can care for the medical problems of adults and children, deliver babies, provide care for many musculoskeletal problems, mental health, women’s health care, and provide many procedures. At least as important to patients, they can see them in all the venues where they need to be seen – the office, the hospital, the nursing home, and even the patient’s home. Dr. Wendling notes that this is threatened by the corporate perception of physicians’ value, which is their value to the system, measured financially, rather than their value to the health of the community. Yes, you might find it beneficial to have a doctor who knows you, who has cared for you and your family for years, be able to see you in whatever setting you find yourself in, but the system has decided it is more efficient (read “more profitable”) to have your doctor be only an ambulatory care provider, or only a hospitalist.

It is not only family physicians who are affected, although they predominate in rural areas. While some specialists – those that provide care that is not necessarily the most important, but is the most profitable – have always been more highly paid and more sought after by health systems, even they are seeing decreases in their pay and status. It is hard for the family physician to cry for slight cuts in the income and power of doctors (like orthopedists and radiologists) who are making many times what they do, and in fact it is hard for most Americans to cry for the plight of even the lowest-paid doctors. Perhaps it feels like crying for the white men who bemoan their loss of privileges (real and desired) because women and minorities are finally moving the playing field to being, at least a little, more equal. But the corporate influence is far more malignant.

Family doctors believe that their contribution to people’s health is relatively greater than their income. Doctors believe that, whatever their income, they are working to improve people’s health. CEOs and corporations believe that health is a good thing to try to sell, provided we sell the kind that makes money. They do not put the health of the community first; they put the financial well-being of the corporation first. And, not surprisingly, this affects both poor and rural communities the most, because of the limited access to services they had in the first place; an arrogant and self-serving corporation taking over the only hospital in a community does not bode well for the overall health of the people who live there.

And, adding insult to injury, it is not only the dollar-centered approach that is a problem, it is the egos of the local leaders who, emulating their corporate bosses and our political class, think that they as individuals are important and deserve respect and obeisance. I have a friend who led the physician group at a rural hospital when it was taken over by a larger system, and helped negotiate the criteria for bonuses for the medical staff. Soon after, that physician was fired by the local CEO for “embarrassing them”! The doctor got their job back with the help of lawyers, but imagine the gall of that CEO! If what they were doing was right and good, they had no reason to be embarrassed; if they had reason to be embarrassed because what they were doing was corrupt, self-centered, not good for the physicians or for the community’s health, what they were doing was wrong and should have been exposed. I have no doubt that if the people in that town were asked who they valued more, the physician who had cared for them for years or the new CEO put in by a corporation, which one would get more votes. Maybe the CEO would get that of their spouse.

So we have a health care system that is structured to be corrupt, from the insurance companies, to the drug and device makers, to the big health systems, all geared to profit. We have many physicians, in all specialties from the rich and powerful subspecialists to the family physician, who are trying to figure out how to stay on the “good side” of these corporate systems and of the local martinets. We have physician leaders, in hospitals and medical societies and academic departments who often are looking mostly at themselves and how to show that they as individuals are important (like that rural CEO), maybe believing that what is good for them is somehow good for people. Sadly, this is even true in family medicine, no longer the ‘counterculture’[1] its founders, like Gayle Stephens, wrote about, but now often simply other supplicants for corporate largesse.

All of this is at worst immaterial and at best subsidiary. The criteria for whether a healthcare system or aspects of it are good is whether it improves the health of people and the community. We have a long way to go in our healthcare system. And it’s long since time to get started.

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[1] Stephens GG. Family Medicine as Counterculture. Fam Med 1989; 21(2):103-9.