Universal coverage remains a big deal

Recently JAMA published a special theme issue on critical issues in U.S. health care. Among the contributors was Dr. Ezekiel Emanuel, the oncologist, bioethicist and former White House adviser on health policy.

In his article, “Going to the Moon in Health Care: Medicine’s Big Hairy Audacious Goal (BHAG),” Emanuel argues that contemporary medicine is in need of vision, an overarching, aspirational goal “like going to the moon that can make an organization — or a nation — stretch beyond what it thought was possible to achieve remarkable things.”

He asserts that medicine has no such vision today. In the past, medicine’s BHAG was universal coverage, but now, he suggests, that’s passé.

The goal of universal coverage may have been “transformative for the U.S. polity but not really for the U.S. health system,” he writes. “The Affordable Care Act may result in universal coverage, but that goal no longer has the qualities of a BHAG.”

We strongly disagree. Universal coverage remains a “Big Hairy Ambitious Goal,” especially in view of official estimates that our nation will still have 31 million uninsured people in 2024.

One has to wonder: When Emanuel argues that the goal of universal care “was not transformative for the U.S. health system,” is he speaking of corporate interests, such as the insurance industry? Clearly he does not mean physicians, a majority of whom now support government action to establish national health insurance, which would assure truly universal coverage.

Offering his own candidate for a winning BHAG, Emanuel proposes the financial goal of capping health care cost increases relative to the GDP, or in his words, “By 2020, per capita health care costs will increase no more than gross domestic product (GDP) + 0%.”

Cost control is indeed a worthy and urgent goal, given that economists are unanimous in predicting that health care costs will continue to rise under the Affordable Care Act. But the remedies that Emanuel has traditionally prescribed for this problem fall far short of what is needed.

In point of fact, a single-payer, government-funded system would be the easiest way to control health care costs — and it would also achieve the appropriate BHAG of universal coverage.

A single payer universal insurance system would control costs by:

  • Eliminating the administrative waste and profiteering associated with insurance companies. Far more of the health care dollar would go to health care, not to advertising, administration, or assuring shareholder profits.
  • Allowing the government to negotiate pricing for medications and services to lower costs.
  • Eliminating the need for the poor and uninsured to seek uncompensated health care from ERs.
  • Facilitating a healthier, more productive work force.
  • Employing global budgeting for hospitals, eliminating the incentives driving their role in health care cost escalation.

Emanuel and others have argued that fee-for-service is the driver of excessive health care costs, but there is scant evidence proving this. Other countries provide universal high-quality coverage under a fee-for-service system and are still able to control health care costs.

Obamacare cannot lead to universal coverage. By maintaining the insurance industry’s role as a middleman, it will serve to ensure that health care costs cannot be reined in without draconian restrictions on needed care.

Emanuel rightly suggests that reining in costs will require focusing on outpatient management of patients with chronic conditions. However, the biggest obstacle to this is inadequate access due to uninsurance and underinsurance, not lack of technological tracking of physiologic indicators.

Both access to care and quality improvement would be much easier in a single-payer system.

Emanuel has reframed the crisis in the U.S. health care system as one of cost instead of the approximately 100 million Americans who lack health insurance or have insurance that does not enable appropriate care, leading to many thousands of deaths per year. We suggest that elimination of this travesty is the most important BHAG for physicians and that the solution is a single-payer system.

Philip Verhoef is critical care physician. Stephen Kemble is an internal medicine physician.

Comments are moderated before they are published. Please read the comment policy.

  • Dr. Drake Ramoray

    I have mixed opinions on this article. On one hand you use a survey from pnhp (Physicians for a National Health Program) and I suppose if I took a survey of readers of “Space Daily” I could probably find a majority of people who think there are or were aliens at Area 51.

    That being said I agree that you have pointed out that other single payer systems have a fee for service payment mechanism, and this in and of itself is not the reason for spiralin healthcare costs. You did leave out that physicians under these systems are allowed to collectively bargain, and that the malpractice environment is dramatically different. Other countries don’t use PA’s or NP’s either (ours is never sure how to register for international conferences), but I’m not about to turn this thread into that fight.

    I would also be interested in the authors opinion on the relatively open borders and immigration policy of the United States when considering single payer. I thought of emigrating to Australia or New Zealand at one time (I actually am again) and Australia uses a scoring system that includes age, fluency in English, and a useable skill. They try and keep foreigners out to not be a drag on social services. Switzerland actually requires that I have some existing presence or a current citiZen to vouch me for me prior to approving my immigration.

    Most of the “successful” single payer systems have a small relatively homogeneous population an stringent immigration policies. The US still very much has open immigration policies relative to the rest of the world. How do you square Americas historically laissez faire attitude on immigration in that you come here and make it on your own with the notion of single payer health system?

  • Philip Verhoef

    my estimates for the number of government-insured Americans neglects the fact that there are around 9 million “dual eligibles” covered by both Medicare AND Medicaid… so that would reduce that number slightly (but this would be negated to a certain extent by the ACA).

  • Dr. Drake Ramoray

    I appreciate your reply.

    There are several studies that indicate some movement for single payer, it does largely depend on you ask. I do recall one in a reputable medical journal in 2009 that had it pegged at 42%. As time marches on and gets worse I can see that ( I am more for single payer now than I was in 2009) I for one am more interested in single payer than many of my colleagues. I’d trade it for pay for performance in heart beat but I don’t see that happening in this country. I wouldn’t hang my hat too heavy on Medical students opinion on the subject since they are in the bubble and many have very little real world experience, but you may put stock in that if you like. Linking a poltical advocy group for your studies was my main issue and it still does engender some questioning of your source material, warranted or not especialy from people not familiar with the issue.

    I also don’t dispute your figures with regards to government expenditures as a a part of healthcare spending. I would not include Medicaid as a functioning system given the low reimbursement rates in California and many states, and the poor access in my state despite adequate reimbursement but the hassles to get anything done our prohibitive. Almost none of the podiatrists in my area see Medicaid anymore, lots of fun for me for the diabetics. /s. I have little experience with the VA but the one associated with my medical school was a joke, on the first day I had to find a stretcher and hide it because I was responsible for patient transport, and one of my patient’s called 911 because he was having chest pain and nobody answered his call bell (he ended up in the cath lab.).

    Medicare is currently “functioning” if you don’t dispute that while there has been little statitstical change in the number of physicians accepting Medicare many practices now have waiting lists and such for Medicare. Of the payers I have less issues with Medicare and as I have mentioned I think single payer can work, more than my at least local colleagues. I also agree a single system could have some facets that would be easier (billing is one that obviously comes to mind).

    I am however saying under Medicare physician’s can’t practice as they like (or soon won’t be able to). I don’t want to be involved in a pay for performance scheme. I work in a relatively poor part of the South. I value my independence as a provider and we up to this point have made that work. Pay for performance, EMR, PCMH, all of these things are a large threat to the current way that I practice medicine. Why is my poorly educated low socioeconomoic status patient here going to be compared to an affluent executive in Sam Fransico? I like small towns, I like the South, and I like my independence and the current trajectory of medicine threatens all of that, which I have expressed by my willingness to move elsewhere (even to a single payer.). Yes private insurers are complicit in this change which leads me to my next point.

    The capacity to collectively bargain is crucial to a single payer system, probably why they all have that, and the fact that you don’t see this concerns me. More so than my immigration point (which I will get to in a moment). Medicare this year cut my thyroid biopsy reimbursement by about 40% total (the component cut is 65%). It uses a similar code to simpler procedures that Medicare felt was over valued. There is no negotiation, there is no conract. They up and change it. None of the private insurers can do that as easily. If a private company threatens to do so then I can drop them very easily. You cannot easily get of Medicare and then come back into Medicare. The government has many tools at it’s disposal that private companies do not. Given what we could be doing during the time it takes to do a thyroid biopsy we are doing them at a loss, partly to wait and see if the ruling is changed and partly because it’s better care.

    https://www.aace.com/files/views/012714-mpfs-2014-final-rule-comment.pdf

    As far as immigration goes, please spare me the red herring of if people earn there way here they deserve healthcare. Nobody is disputing that. I’m saying if you continue to allow cheap unskilled labor to flood into this country (see agricultural jobs and the like) with limited English and no marketable skills then they will be net users of government resources. Make the case that employers should pay better wages,and actual citizens should work these jobs and not have millions of illegals rush in so every 30 years we give them amnesty. I support whatever wage is required to have Americans do domestic jobs. This is not a racist statement and it’s a policy that every other country with a single payer system is highly aware of and using.

    I think single payer can work. I don’t think single payer can work in this country given the government, other interests, EMR, and pay for performance statutes that are coming. Single payer does work in many places, I don’t believe that it will work here.

    • Philip Verhoef

      I don’t particularly want to discuss the merits of published
      research… it has its flaws and strengths, but if one wants an evidence-based
      approach to any question, it’s all we’ve got. How we interpret it individually
      is, of course, up to us! For me, there’s no shortage of reasonably good
      evidence suggesting support among MDs for a single payer system, published in a
      variety of peer-reviewed journals which don’t have a single payer agenda per
      se… so individual’s can have opinions and anecdotes, but to anyone who suggests
      that doctors are not in favor, I turn to the evidence to help answer that
      question. You’re right.. I should have linked directly to the Annals article,
      rather than the link on the PNHP page.

      Medicaid, Medicare, and the VA are all functioning in the
      sense that they all enable people to receive health care which they otherwise
      would have to pay for out of pocket, so I have to include them in that
      category. I agree that Medicaid has horrendous reimbursement rates, poor
      access, and we could both point to a variety of studies suggesting that
      Medicaid is flawed. On the other hand,
      as a pediatrician, I know that for many families (especially those whose
      children have complex medical issues) have no other option and Medicaid has
      been absolutely life-saving. I know many
      people with VA horror stories like yours too, although the quality and outcomes
      literature suggests that in spite of that, patients in the VA receive
      excellent, high-level care. As far as Medicare, your experience is similar to
      that of many others (you “have less issues with Medicare”) but I also know that
      there are lots of problems: it’s silly that patients need to purchase Medicare
      supplemental insurance from private companies; coverage of prescription drugs
      is a mess too. And you pointed out other deficiencies, in terms of physicians
      not accepting Medicare, or having waitlists. I think it’s important to
      recognize the flaws (and strengths) in all of these systems and use that to
      inform the ideal system. My personal opinion is that many of these flaws aren’t
      the fault of these being government-run institutions, but rather that private
      enterprise is influencing this process. For instance, there is ample literature
      that both privatized Medicaid plans as well as private for-profit Medicare
      supplemental insurance have higher overhead (read: profits) but provide lower
      quality care than their not-for-profit or public counterparts.

      So, I would take the strengths of these systems (simplified
      billing, monopsony purchase power, larger risk pool, possibility for unified
      EMRs/databases facilitating research, disconnection between insurance coverage
      and specific employers/job status) and create a system which some people call
      “improved and expanded Medicare for All.” That’s what’s in HR 676. There’s no
      reason to accept the patchwork of flawed systems that we currently have, and
      while it’s optimistic, I’m not convinced that physician culture (or American
      culture) would prevent the creation of a more rational, simpler system which
      covers everyone.

      To your concern about not being able to practice as you’d
      like, due to a number of the changes coming down the pike, like pay for
      performance, PCMH, EMR: I think those are reasonable concerns. But like it or
      not, all of those are coming. The insurance industry is certainly complicit in
      the expansion of those goals too, and would love to have reasons NOT to
      reimburse hospitals or physicians. So while CMS (or the ACA) is mandating all
      of this, I’m not sure one can lay the blame solely at the feet of the
      government… especially given the opportunity for undue financial influence by
      pretty much anyone on the direction our government goes. I will say that, for what it’s worth, HR 676
      proposes a government-insurance system, not nationalization of hospitals or
      corporations. In principle, then, you could continue to operate a private
      practice, with a much more simple billing process.

      Your point about collective bargaining is clear, and your
      illustration is effective. I actually don’t know much about physician’s
      capacity to collectively bargain in other countries with single payer systems.
      I will see if my co-author knows anything about this.

      Immigration is a thorny issue. You may support whatever wage
      is required to have Americans do domestic jobs, but there doesn’t seem to be
      much taste for that currently in the government. The point I’m making is 1)
      they’re not straining the system now and 2) I’m not convinced that us changing
      our health care policies will really make them come flooding in to our country
      any more than they already do. Why do you assume that we will have an influx of
      millions of illegals with no marketable skills? That’s not been the case so far
      historically.

      Re: litigation. You say “studies grossly underestimate the
      care provided…” that’s your opinion. I’m just trying to use the published
      literature, because without that, all we have are opinions, and I’m pretty
      hesitant to built national policies based on people’s opinions alone.

      I think single payer can work too, and I really want it to
      in a way that would be acceptable to you. That’s why a dialogue like this is so
      valuable.

      • Dr. Drake Ramoray

        ===================================

        “And you pointed out other deficiencies, in terms of physicians
        not accepting Medicare, or having waitlists. I think it’s important to
        recognize the flaws (and strengths) in all of these systems and use that to
        inform the ideal system. My personal opinion is that many of these flaws aren’t
        the fault of these being government-run institutions, but rather that private
        enterprise is influencing this process.

        ====================================

        Your depth and breadth in the health care policy area dwarfs mine, as it should, and your adherence to scientific methodology is exemplary. I do think that adding things that are difficult to measure (such as effects of immigration policy) don’t intigrate well into your system nor into your way of thinking, and a case could be made that handling immigration is a separate issue.

        That being said you are overthinking the Medicare issue. Doctors have wait lists and restrict access to Medicare when Medicare pays less. It is as simple as making more money from private insurance. Wait lists would disappear if there were more doctors to equal the supply and demand (see the federal government decreasing funding for residency positions despite increased number of medical school graduates), or if Medicare paid equivalent to private insurance.

        Need more residency positions.

        http://thetimes-tribune.com/news/without-more-residency-programs-medical-school-growth-won-t-stave-off-doctor-shortage-1.1506301

        Medicare paying equivalent to private insurance of course opens up the entire can of worms of what doctors should be paid which is linked to the collective bargaining point. Not to belabor the point (I noted your comments on it), but collective bargaining would be a requirement for me to consider single payer.

        It has been a pleasure, and thank you for your time.

  • Bill Viner

    I have to agree with most of what Dr Drake has to say. Probably because we both have worked in the South and in rural settings.

    Did you mention that the survey only had a 51% response rate? So right off the top 1/2 of surveyed docs didn’t care enough about it to respond. So really you have 1/4 of the total docs on board. Even of those only 1/2 were strongly in favour.

    I started private work in ’99 in the Southern US and my income peaked in 2003. Due to increasing business overhead costs and declining Medicare/Medicaid reimbursements, my income dropped yearly thereafter and I had to become a proper businessman and also maximise productivity. After working in 2 separate medical practices over 11 years, where your colleagues would do anything to keep their income stable, I left.

    I’ve been sued 3 times and never deposed. All were dropped, but never leave my record. I think “only 2.5%” of total medical costs due to defensive medicine is greatly underestimated. Besides, 2.5% of a trillion $ is still a lot of money.

    Why should insurers, hospitals, pharma, device companies and attorneys make all the money? We are the ones doing the work and caring for people, but have no decent representation. That is why we need collective bargaining.

    Why should we trust the US govt to implement their version of healthcare? These are the same people that have placed us in Afghanistan and other countries, caused the housing market (and all my investments) to fail, bail out the wealthy on Wall St…

    Simplify the system, unionise doctors, provide universal coverage with a private insurance option, and reform the legal system and then maybe you’ll get some support.

    BTW my current pay is comparable and I have more time with patients, can practise evidence based medicine, and I have a life after work. Private insurance pays rates I haven’t heard of in the US since the 80′s. Life is good again. Come for a visit Dr Drake.

    • Philip Verhoef

      Thanks for your comments.

      Again, I don’t want to debate the merits of published research. You can choose to dismiss the survey, but in fact, that’s pretty close to the response rate for ANY survey (see Cummings et al Feb 2001 in Health Services Research). You’re right that 2.5% of a trillion is a lot of money, and is certainly worthy of reform and attention. But to me, the greater issue is the amount of money spent in the health care industry that doesn’t actually go to providing health care (in the form of the administrative beast that is the private insurance industry) and, more importantly, the fact that the US still has 44 million uninsured.

      And indeed, I agree: all the entities you mentioned SHOULDN’T make all the money. I come at this discussion believing that the provision of health care should not be profit-driven, because I think there’s a conflict of interest. And this argument for collective bargaining is reasonable too… there’s a total vacuum right now in who represents physician’s interests at any level. It’s certainly not the AMA anymore, although my co-author was the president of the Hawaii branch of the AMA (and actually moved that state very close to a single payer system, before the ACA and the Democrats shut that down) so he might argue that one should work within the system to effect change. I’m on the fence myself on that.

      I agree with everything you said too, about simplifying, providing universal coverage, reforming the legal system… I just haven’t seen an example of a private insurance system that works that I could get behind, and I HAVE seen an example of a public one (Medicare) that works well in many areas, and has worked well as a system for providing care in other countries. If there were a private insurance system whose vested interest was NOT in how much care they could deny (since that’s the way to assure profit), or how to keep the chronically ill/complex patient off their roles, perhaps you could change my mind. Other countries do have such systems, but not us. So, we’re left with the government. And I do believe that the government is accountable to us… but we need the will and time to be active enough to hold them accountable.

      • Bill Viner

        The best private insurance system is one that YOU choose to buy and not forced upon you. Sorry I can’t get behind Medicare because all they have done is reduce payments for surgical procedures that take years to master, pay pennies on the dollar for office visits, and deny payments for readmissions. Other than that, I completely agree with you.

  • Dr. Drake Ramoray

    Thank you for your comments. I didn’t know about Japan. That is not a model I would want to see here.

    It has been a pleasure speaking with both of you and I am happy that this has been included in any legislation up for consideration.