President Biden’s quest for a public option [PODCAST]

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“COVID-19 disproportionately impacts those with pre-existing conditions, and our health care system leaves one in five Americans with a pre-existing condition uninsured. Further, with multiple COVID-19 vaccines already in early but slow distribution, attaining universal coverage is critical, particularly in light of uninsurance having an inverse relationship with vaccination rates.

President Biden will need to act with a legislative urgency that matches these times to pass a public option. With two-thirds of the country approving President Biden’s handling of the transition, now is his opportunity. He may just need to take a few pages out of the ‘Johnson treatment’ playbook in crafting the ‘Biden treatment.'”

Jonathan Staloff is a family medicine resident and can be reached on Twitter @jonstaloff.

He shares his story and discusses his KevinMD article, “How President Biden’s quest for a public option mirrors LBJ’s passage of Medicare and Medicaid.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Jonathan Staloff. He’s a family medicine resident, and he wrote the KevinMD article “How President Biden’s quest for a public option mirrors LBJ’s passage of Medicare and Medicaid.” Jonathan, welcome to the show.

Jonathan Staloff: Thanks so much, Kevin. Great to be with you today.

Kevin Pho: We’ll get into your article a little bit, but first off, can you share your story and your journey to where you are today?

Jonathan Staloff: Absolutely. As you had mentioned, I am a family medicine resident. I’m a second-year family medicine resident at the University of Washington in Seattle. This is actually my first time living on the West Coast. I actually grew up in New Jersey and did my undergraduate and medical school training at Brown University in Rhode Island.

What brought me to my interest in health systems is interesting timing, because it coincided with what’s been going on with health care reform in general. I started college in the year 2010, which of course was the year that the ACA was being debated. That year, I took a course called Health Care in the U.S., and that was my first time learning how convoluted and disjointed our health care system was. I was just utterly devastated and utterly fascinated at the same time. And so that year I decided to be a public health major, and I graduated in 2014, which, of course, was the year much of the ACA was being implemented.

So between college and medical school, I decided to take time, and I took a job at a company called Avalere Health, which was a health care policy consulting firm in Washington, D.C. During that time, it reaffirmed my passion for understanding health systems and learning as much as I can about U.S. health care so that we could learn to reform it, and hopefully to be a physician who had that extra layer of expertise in health systems. It also reaffirmed my commitment to primary care as a way to improve population health and build relationships with patients and populations long term. That’s when I went back to medical school and decided to practice family medicine. And here I am at the University of Washington in Seattle, getting my training.

Kevin Pho: Wonderful. And through your journey through medical school and partially through residency, how much public health education did you get?

Jonathan Staloff: So, as you had mentioned, I did a master’s degree in population medicine, which was part of a special program for people who were interested in going into primary care. Certainly in my undergraduate experience, I had a good amount of health systems training because of my studying community health. But I would say, by virtue of just going through medical school, what was taught to med students overall was a basic foundation, but not much more.

Just by virtue of going through medical school and residency, the health systems training that we as the next generation of physicians get is relatively scarce. And I feel like it leaves us as a generation of physicians lacking in an understanding of how our health care system came to be and how it’s letting vast portions of our communities down.

Kevin Pho: And in general, through medical school and the early part of residency, what is the general interest level of your peers when it comes to health policy?

Jonathan Staloff: I’d say it’s pretty high. I think there’s a real hunger for being exposed more to health systems training and an understanding of our U.S. health care system. I think there’s a real commitment to social justice in this generation of physicians. And of course, my experience is my experience and not that of everybody in medicine, but certainly on the path that I’ve led in family medicine, I found that all of my colleagues have a really profound interest in learning how to improve the health care system to inform their own advocacy efforts, and they feel that advocacy on behalf of population health is a part of their Hippocratic Oath and not something separate from it.

Kevin Pho: All right, so let’s transition now into the KevinMD article that you wrote. It’s titled “How President Biden’s quest for a public option mirrors LBJ’s passage of Medicare and Medicaid.” Now, for those who didn’t read the article, can you just walk my audience through it and share the story of why you decided to write it?

Jonathan Staloff: Well, I can’t imagine that there’s anyone out there who hasn’t read the article. But I decided to write the article because after President Biden was elected, I started to realize that there were some real biographical similarities between him and LBJ, or President Johnson. For instance, both of them were vice presidents before they were president. They were each vice presidents to pretty charismatic presidents, in the example of President Biden to President Barack Obama, and in the case of President Johnson to President John F. Kennedy. Each of them had long and storied careers in the United States Senate before they ascended to the presidency. Neither of them had a reputation for being particularly liberal politicians before they ascended to the presidency, but each was taking on historically liberal agendas and progressive agendas once they got to the presidency. Also, each of them took office in the case of national emergencies. President Johnson took office after, of course, the assassination of President Kennedy, and President Biden took office amid a global pandemic that we haven’t seen in 100 years.

What I was really struck by was that each of them was trying to embrace an element of their predecessor’s health care agenda that wasn’t passed. President Kennedy famously, in I believe 1962, tried to pass Medicare, what he considered a health care system for elderly populations. He went on a national campaign, including giving speeches at Madison Square Garden, and was ultimately unsuccessful in passing Medicare. In fact, the AMA launched a campaign against it, calling it socialized medicine, and even had a recording, recorded by a particularly famous actor by the name of Ronald Reagan. And LBJ took up this mantle of wanting to pass what John F. Kennedy could not.

On the flip side, Joe Biden was also trying to pass something that President Obama could not. Of course, President Obama was historically successful in passing the Affordable Care Act. But what President Obama really tried to get into the Affordable Care Act was a public option, and he was famously unsuccessful in getting that included. During the primaries, there was a lot of talk about Medicare for All, and most of the candidates really embraced that progressive mantle. And although President Biden wanted to expand health care coverage, he very specifically did not embrace Medicare for All. He specifically decided instead to try to pursue what President Obama attempted, that being a public option, which is different from Medicare for All because it doesn’t change everybody’s health insurance, but it does create a public health insurance option for people to buy into.

So I saw these real, I would say, beyond-surface-level similarities. And I was wondering if President Biden would be as successful as President Johnson, who famously ushered in the biggest health reform in history, is known as one of the great legislators as president, and ushered in the Great Society, or if he would be unsuccessful by comparison.

Kevin Pho: So, in your opinion, if President Biden’s version of the public option were to pass, how is that going to change our health care system?

Jonathan Staloff: Oh, I think it would make a huge change to our health care system. Well, I guess first I’ll focus on what it wouldn’t change. I think it would not change health care for most Americans. The reason why he embraced a public option is because he doesn’t want there to be much change for people who are satisfied with their health care. People who are getting health care through the existing exchanges can continue with that. People who get health care through Medicaid can continue getting Medicaid, and those with employer-based insurance can continue with that.

But I think our health care system came to be largely by accident and almost as a convoluted puzzle. And I think there’s one big puzzle piece that’s missing, and that’s the millions of people who are uninsured in this country. And I think this would be pretty transformational in having a more inclusive society, and in having a more inclusive way of everybody attaining universal coverage, without everybody having the exact same health insurance product.

Kevin Pho: So I think that, as you know, the opposition to the public option normally is going to come from the private insurance industry, but also the hospital industry as well, because a public option is going to pressure payments both to doctors and hospitals. What was your response to that line of attack from the opposition?

Jonathan Staloff: I think it’s a very reasonable concern. Throughout the health care industry, you’re seeing continued consolidation and acquisitions. Hospitals are merging with hospitals. Hospitals are purchasing physician offices and making integrated health systems. And I think what you’re seeing as a part of that is a real rise in health care prices. There are so many studies about why health care in the U.S. is so expensive, and ultimately most of the studies find that prices are the reason why. And as health systems continue to consolidate, that only increases the negotiating power of these large health systems with health insurers to increase prices.

So while on the one hand, sure, hospitals may see decreased reimbursements from a public payer, on the other side of that, I think that might be a little bit needed, because on the commercial side, you’re seeing so much market consolidation that’s leading to increased prices, leading to, of course, really untenable premiums and health care cost growth. And while Medicare itself is an existing check on hospital prices, a public option would just be an additional check that we need, without, of course, eliminating the market of private health insurers for hospitals to maybe get some of that windfall back.

Kevin Pho: Now, how would you sell that to hospitals, some of which are already struggling, especially in rural areas, and even to physicians who graduated $200,000 to $300,000 in debt? How can you sell a public option to those constituencies when some of them are already financially pressured?

Jonathan Staloff: Great question. I think that the public option would achieve a very specific aim. The specific aim would be to give health insurance coverage to people who do not currently have health insurance coverage. Now, if I were a physician office, or if I were a hospital or otherwise a health system, taking care of populations who don’t currently have health insurance often leads to charity care and uncompensated care. If that population were to be publicly insured, much like with the Medicaid expansion population, then hospitals and health systems, although maybe not getting the same reimbursement as for a commercially covered population, would get coverage and reimbursement for a population that they previously were not.

Also, I would make the public service and public good argument. Health care, in my view, very much is a right and not a privilege. And hospitals and health systems have an obligation to provide health and health care to the people that they serve in the communities that they’re a part of. Most hospitals in this country are technically not-for-profit entities. And I would make the argument that it’s hard for a hospital to really embrace their not-for-profit status if they’re not willing and able to provide equitable care to everyone in the community.

Kevin Pho: There are some who say that with the public option, it’s very difficult to compete with the government, and that a public option is going to grow and grow, and it could be an indirect way to have a backdoor to a Medicare for All system. Do you see that as a plausible scenario?

Jonathan Staloff: I think it’s a possible scenario. I think certainly a lot of people see a public option as a potential bridge to Medicare for All. And I’d also be curious to see what Medicare for All might actually look like, because Medicare for All is often used interchangeably for various ideas. Medicare for All can mean one federally operated program. Medicare for All can also mean Medicare Advantage for All. And Medicare Advantage, for the listeners who might not be familiar, is privately administered Medicare. So it’s essentially public financing, but privately administered.

And Medicare Advantage is becoming increasingly popular, both in the provider community as well as in the patient community. I think the numbers are, and this is a little bit off, roughly one-third of all Medicare beneficiaries have Medicare Advantage, so commercially administered Medicare. And I believe up to half of new Medicare beneficiaries opt for Medicare Advantage.

And so I think people view Medicare for All as an absolute, or a government takeover, or socialized medicine. And certainly there’s a version of Medicare for All that is entirely publicly administered and publicly financed. But Medicare for All and a public option could include a privately administered component, but with government regulations to ensure that everybody has the equitable right to health care.

Kevin Pho: We’re talking to Jonathan Staloff. He is a family medicine resident, and he wrote the KevinMD article “How President Biden’s quest for a public option mirrors LBJ’s passage of Medicare and Medicaid.” Jonathan, you don’t need me to tell you that we live in a very polarized society. Our government’s very polarized, even with Democrats controlling Congress and the presidency. It’s very difficult to get anything done. So if you were to have a crystal ball, what is your opinion in terms of the likelihood of President Biden passing his version of a public option?

Jonathan Staloff: My crystal ball is pretty cloudy. However, I would say that I am hopeful, and there’s a reason why I’m hopeful. In my article, I had mentioned that LBJ said, when he was trying to pass Medicare, that every day that passes, he loses votes, and he needs to pass Medicare as quickly as possible. I, of course, grossly misquoted him just there. But my message is: Time is of the essence.

LBJ very successfully passed Medicare within 7 months of the presidency. More recently, President Obama passed the Affordable Care Act roughly just over one year after coming to the presidency. But before that, he passed the American Recovery and Reinvestment Act.

Pivoting to now, President Biden is mirroring President Obama’s urgency in passing major legislation, and he’s been successful in passing that major legislation. Of course, just this week, he passed and signed the American Rescue Act, which was a massive, massive piece of legislation, and also one that’s pretty big for health care. He made pretty major health care advancements in that bill. What’s important is that he passed that massive $19 billion legislation without a single Republican vote, and he did it with the method of budget reconciliation.

Budget reconciliation is a means of passing legislation with a simple majority. And you have the opportunity to pass a bill with budget reconciliation three times per Congress. And so President Biden has two more opportunities this Congress to pass legislation using budget reconciliation. One might remember that the Affordable Care Act was passed with budget reconciliation.

And so President Biden has this momentum, legislative momentum. He has a sense of urgency around health and health care. He’s indicated in the American Rescue Act that health care is important to him. And he has the same vehicle, budget reconciliation, that President Obama used to pass the Affordable Care Act. And I think that the American Rescue Act is going to build his political capital instead of detract from it. And I think if he acts with a sense of urgency, he might have the capacity to actually pass a public option, understanding that he uses budget reconciliation instead of having to overcome a filibuster.

Kevin Pho: And just to be clear, the public option would qualify for budget reconciliation in the Senate?

Jonathan Staloff: For the most exact answer, you’d have to ask a Senate parliamentarian, but this second-year family medicine resident’s view is that I believe you can. The ACA was passed with budget reconciliation, and I know that two senators have put forward a public option bill with the intention of it being passed with budget reconciliation. So I do believe that’s an option that’s on the table.

Kevin Pho: And taking a step back, for those medical students, residents, and physicians who are more interested in becoming involved in public policy, or even just educating themselves, what are some resources and tools that you recommend?

Jonathan Staloff: That’s a really great question. There are really just so many. For keeping up day to day, I think Health Affairs is a really wonderful publication, as is the new publication JAMA Health Forum, which is really focused on health policy.

For me, I really started to get my interest and background knowledge by reading books related to health policy. And a book that really helped inspire me for this article was a book called “The Heart of Power: Health and Politics in the Oval Office,” which was written by James Morone, who is a political science professor at Brown University, and David Blumenthal, who is the first national coordinator for health information technology.

Basically, that book takes you through every president from FDR through President Obama. It takes you through their personal experiences with health, how that informed their thoughts on health and health care, and then simultaneously takes you through their own efforts while in the Oval Office to try to achieve health reform. And so through this book, you get a sense for how the health care system came to be, as well as, legislatively, what’s needed to pass any kind of health reform. I found it a truly fascinating book, and it’s one of the things that really inspired me to write this article this many years later.

Kevin Pho: And my final question: What’s your take-home message you want to leave with the KevinMD audience?

Jonathan Staloff: I would say health reform is something that comes almost once in a generation. It’s also something that’s possible, and it requires good timing, timing meaning the stars have to align historically, and I think this might be a time where the stars are aligning. I also think that whoever’s in the Oval Office needs to make it their priority to pass health reform. And so if they don’t do so quickly, they likely won’t do it at all.

For a physician, my piece of advice would be, if you have a passion for something that’s not traditionally part of your training, just go for it. Really invest in trying to learn as much as you can, whether that’s health care policy or otherwise. There is no reason why you can’t really invest your time and energy into learning something and making that a part of your life as a decision.

Kevin Pho: Jonathan, thank you so much for sharing your time and insight, and thanks again for being on the show.

Jonathan Staloff: Thanks for having me.

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