Geezer Comments on Single Payer Systems

I’m well into my first year of phased retirement and time moves quickly the older I get, which has made me look at the debate about a single-payer system with increasing interest. There are a couple of options including Sen. Bernie Sander’s Medicare for All Act (S. 1804) and the Physicians for a National Health Program (PHNP) Expanded and Improved Medicare for All Act (H.R. 676), and this link takes you to PNHP web site for a comparison of the two options.

Why is this important? Because I’ll soon have to enroll in Medicare and make decisions about, among other things, how to cover health care costs for me and my wife. Among the choices available to seniors are a couple of ways to to supplement Medicare, since it doesn’t cover everything. These are Medigap supplementary coverage and the Medicare Advantage (or Part C) programs, which combine Part D prescription drug and medical coverage beyond basic Medicare. Some Medicare Advantage programs include eye and dental care coverage; many do not.

Moreover, I’m starting to wonder about Long Term Care coverage. As a Consultation-Liaison (C-L) Psychiatrist in the general hospital, I see patients around my age every day who are not so lucky when it comes to their health. Sometimes it’s kind of a shock to see my age mates looking and behaving 10 years or more older than their chronological ages, often not much different than mine. A few are even younger than I am.

Frequently, I’ll see the U.S. health care system compared to that of Canada’s, which is single-payer funded. I read a recent article about the opinions of a few American physicians of the Canadian system, often praised by Sen. Sanders and PNHP as a model for the U.S. to follow. These doctors have moved from the U.S. to Canada and have formed their view of it based on their experiences in both.

One of them is Dr. Peter Cram, MD, who I vaguely remember working with very briefly years ago; I think we were co-staffing the Medical-Psychiatry Unit. He impressed me as a creative and brilliant clinician and researcher. I was not aware of his move to Canada and his impression of the single-payer system is refreshingly practical and unmarked by the hyperbole I sometimes encounter about it. He’s frank in his opinion about it not necessarily being the perfect model for the U.S. to follow. He says, “If you deny there are trade-offs, I think you’re living in wonderland.” It’s also a two-tiered system, as he points out “…low-income people are likely to wait longer for medical care, which can result in worse health outcomes.”

The video at the PHNP link above is an hour long and very informative. You won’t find a cost analysis of either Sanders’s or the PHNP single payer systems, but you can read Sanders’s white paper for which there is a link. Much of it has been included previously in his speeches to the public and in televised debates. One of the issues with Sanders’s gradual implementation of his single-payer system is that the savings in private insurance administrative costs have to be weighed against the various subsidizing costs ahead of full implementation, which would take 4 years.

The major features of the Sanders bill is outlined in the table at the above link on the PNHP web site. The suggestions for how it could be improved according to PHNP are also listed below the table. One of them is how to assure availability of Long Term Care, one of my concerns as a senior citizen. Another concern is the lack of options for eye and dental coverage that most Medigap and Medicare Advantage policies have. It was hard to miss the the note of suspicion that the narrator of the video (Dr. Adam Gaffney) had about Medicare Advantage programs in general, because they’re run by private insurance carriers, for whom the profitability motive is paramount. They can also drop you without much of a reason, which Medigap carriers cannot do. I was already familiar with this tone of suspicion, which is obvious in the Medicare Advantage in Wisconsin information page. However, they are also frankly intent on educating seniors about the pros and cons of them:

Medicare Advantage plans are annual contracts and are not guaranteed renewable as is required for Medicare supplement policies. Similar to Medicare supplement policies, the premiums you pay for the Medicare Advantage plan may increase. You may also be responsible for paying your doctor and hospital bills if you do not follow the Medicare Advantage plan’s rules.

There was one question about how single payer might affect access to psychiatric care and there was not a clear answer. It turns out you can’t really force doctors and other specialty providers to participate although it’s possible to prevent double billing through both private and single payer systems. Many psychiatric providers are in cash only practices because of issues like lower Medicaid and Medicare reimbursement rates and paperwork and denial hassles from private insurance carriers. One article’s authors’ frankly criticized this practice in light of the shortage of psychiatrists, the subject of a report from the National Council for Behavioral Health:

“The biggest opportunity to expand the workforce is to reduce the portion of psychiatric providers who practice exclusively in cash-only practice,” said the report. “APA and the National Council need to work with their members to implement a wide range of incentives that promote the engagement of psychiatric providers with outpatient and inpatient psychiatric programs that accept commercial, Medicare, and Medicaid coverage that pays for the majority of Americans with psychiatric health care needs.”

The PHNP video speaker suggests that one way to help ensure that psychiatrists and other physicians participate in a single payer system is to subsidize the cost of their training. This would, of course, add to the cost of a single payer system.

This is just a geezer’s perspective on a few aspects of single payer systems for health care funding. There’s a lot to learn and I’m at the kindergarten stage. And, as Dr. Gaffney puts it, “the political window” is widening for the acceptance of single payer as a real choice in health care funding. It’ll have to be wide enough to accommodate a broad variety of needs of many people.

3 thoughts on “Geezer Comments on Single Payer Systems

  1. A couple of opinions in JAMA are pertinent here:

    Fuchs, V. R. (2017). “Is single payer the answer for the us health care system?” JAMA.
    The recent challenges to the Affordable Care Act (ACA), which has increased the number of individuals with health insurance in the United States but has had little effect on cost, has revived the debate about a single-payer health care system.1 Whether a single-payer system is the answer or not depends on what question is being asked and what form single payer will take. Single payer can take many forms, and many questions can be asked. This Viewpoint considers 3 problems of US health care: the uninsured, poor health outcomes (relative to other high-income countries), and high cost. In discussing cost, it will be critical to consider the form that a single-payer health care system might take. Published Online: December 18, 2017. doi:10.1001/jama.2017.18739

    Naylor, C. (2017). “Canada as single-payer exemplar for universal health care in the united states: A borderline option.” JAMA.
    The late great Uwe Reinhardt still called himself a Canadian decades after moving to the United States, but steadfastly rejected the idea that Canada’s health care system was suitable for transplantation to the United States,1 even as he celebrated its comparative strengths and championed its principles of universality, cost containment, and equitable access to care.2 Reinhardt instead recommended European models and highly regulated multipayer arrangements as an alternative means to those worthy ends.1 Published Online: December 18, 2017. doi:10.1001/jama.2017.19668

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  2. “The PHNP video speaker suggests that one way to help ensure that psychiatrists and other physicians participate in a single payer system is to subsidize the cost of their training.”

    What about:

    1. Actually paying them – “behavioral health” reimbursement is the worst for psychiatry relative to any other specialty.

    2. Eliminating onerous utilization review and PBM reviews. You want to talk to me about authorizing a generic drug or an inpatient stay that is capped at the DRG payment? Really?

    3. Providing quality services – not the inpatient units where the only way in is if you are “dangerous” or the 1970s based outpatient “med checks” every 15 minutes.

    Those are just a few of the reasons psychiatrists are in private practice. More than a little ironic that a managed care front organization wants to force them to work for managed care companies considering most of them don’t accept insurance. Their services are not costing MCOs cash – just the embarrassment that psychiatrists don’t want to be affiliated with them.

    George

    George Dawson, MD, DFAPA

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