September 17, 2021
Dear Interested Readers,
Why Is Universal Healthcare Coverage Such an Elusive Goal?
This week’s New England Journal of Medicine has two thought-provoking articles in its “Perspectives” section. The first article is “State Public Option Plans — Too Modest to Improve Affordability?” The authors are Erin C. Fuse Brown, M.P.H., J.D., Katherine L. Gudiksen, Ph.D., and Jaime S. King, J.D., Ph.D. Their article explores what has been learned as Washington State, Nevada, and Colorado have attempted to introduce a “public option.” If you remember that “Romneycare” in 2006 presaged the ACA in 2010, you can appreciate that the states can be learning labs for ideas that can occasionally become the law of the land.
The second article of note is “Medicare for More — Why We Still Need a Public Option and How to Get There.” It was written by Jacob S. Hacker, Ph.D. Dr. Hacker is the Stanley B. Resor Professor of Political Science at Yale and he is an expert on the politics of U.S. health and social policy. His article outlines what is wrong with Medicare as it is currently experienced and how in time improving Medicare could be a big step toward universal coverage. Both articles raise the same question for me. Why is it that the richest nation on earth, and the source of so many breakthroughs in the science and technology of practice, unable to make its expertise and services available to every American?
Most of us first heard of “a public option” during the run-up to the ACA. It was a good idea that did not make the final cut because it was the victim of special interest politics. The public option was rejected as a key part of the ACA back in 2010 because Senator Joe Lieberman of Connecticut, the home of powerful commercial health insurers, said that he would withdraw his support for the ACA if it contained a public option. Without Lieberman’s vote, the ACA would not have passed because there would have not been the sixty votes necessary to override the certain filibuster of Republicans.
The likelihood of getting a public option into law is not improved now. It is interesting to realize that even though an “enhanced” public option was a prominent campaign proposal of President Biden it has little chance of becoming a reality, even if it was part of a bill that could be passed by the “budget reconciliation” process that avoids the hurdle of the filibuster. In 2010 the obstruction for creative social legislation was Joe Liberman of Connecticut. In 2021, the obstructionist may be Joe Manchin of West Virginia and Krysten Sinema of Arizona.
Short of equity and racial harmony, there has probably been nothing that has been more elusive in American history than universal access to equitable healthcare. Many of us take the history of the struggle for this dream back to Franklin Roosevelt and the debates and tradeoff’s around the passage of Social Security. I would not object if you wanted to begin the history with Harry Truman at the end of World War II. Great Britain was able to introduce its National Health Service as it recovered from World War II in the late forties. We missed the innovation bus and went with employer-provided health insurance. It is depressing to realize that the concept of universal coverage got its start in Europe in the 1880s and finally got attention in America back in 1906 during Teddy Roosevelt’s time as president as part of the “progressive era.” The movement gained some strength until the AMA and organized labor opposed it about the time of World War I.
Labor preferred to use healthcare as a bargaining chip. The AMA has a long history of opposing most suggestions that might increase access to care and disrupt the status quo no matter how many suffer from their attention to their own agenda. It is a strange reality when we think about why people say they become healthcare professionals. Go figure. It is true that I have never heard an individual doctor say that their motivation for a medical career was to get rich, but the sum total of our collective actions through the AMA seems to suggest that the economics of practice have always been a barrier to care for many Americans whether it was 1917 or 2021.
While we all know that the USA stands alone as the only prosperous economy without universal healthcare most of us do not know just how universal access to care happened in other countries. The concept of universal access could hardly be considered an impossible dream if every country in our financial bracket and many that our former president has disdained as “sh– hole countries” have found a way to do it. In December 2020 the Commonwealth Fund put out a 200 plus page PDF that tells the story of how it was done country by country and gives us a review of many of the reasons why America has not been successful. The Commonwealth Fund also published a summary document that you may want to look at for an overview. In June 2020 the Commonwealth Fund focused its effort on America and published “International Health Systems Profile–United States.” The authors describe our system of care as if they were describing it to someone from another planet. I guess that is a good way to start if you are trying to explain why something that should exist doesn’t. They begin:
The United States does not have universal health insurance coverage. Nearly 92 percent of the population was estimated to have coverage in 2018, leaving 27.5 million people, or 8.5 percent of the population, uninsured. Movement toward securing the right to health care has been incremental.
There is even some deception in that statement since we know that although only 8.5% do not have coverage, the number is much higher in some states and in minority populations. What the description omits entirely is that 43% of “insured” Americans are inadequately insured and are likely to have uncovered costs that they can not pay. That fact comes from another Commonwealth Fund paper from August 2020 entitled “U.S. Health Insurance Coverage in 2020: A Looming Crisis in Affordability.” I bolded the last sentence of the quote because it is my key concern.
I am sure that you think that you understand the complexities of our healthcare system, but I would also bet that there are components of it that you do not fully understand. I would recommend that you peruse the article that describes our system of care and the second article that focuses on the continuing expenses that occur for those who would like to think that they are “covered.” Compared to many other countries many of us who think we are “covered” are in for a big surprise when we need efficient, cost-controlled access to services.
Incremental progress as a description of our story of the pursuit of universal coverage is a deceptive description. Glaciers move faster than our progress. I have some specific concerns and biases about our system. The list is too long to name all of my concerns here, but the collective weight of our system’s defects has been to make our system of care fragmented beyond what incremental improvements could ever rectify.
Many of my concerns may be labeled as “deceptive myths.” The first myth is that we have the best care in the world. We don’t. Many Americans would be healthier if they lived in Portugal, Cuba, or Costa Rica. My second big objection is the variable experience of care and access to care by location. If you live in any European country you can expect very similar care no matter where you live in your homeland. Because so much of our care is financed with a combination of state and federal resources with the states setting the criteria for coverage, the experience of care and access to care varies hugely from state to state. At the level of care, we are not “one nation, inadvisable…”
We like to blame victims. “Individual responsibility” is a laudable attribute, but in this country it has been used as a reason for not providing care for many of our poor. How individually responsible can a person be who loses their job and their access to care when they develop a debilitating disease? The ACA was a big step toward providing more consistency in minimal coverage and removed much of the disadvantage of “preexisting” problems, but it did not remove the differences in access and quality by location or income.
Over the decades we have depended on employer-based insurance for the coverage of more than half of the population, but healthcare is an expense that employers have consistently tried to minimize. There was a time when many employers used generous policies to attract talent. It is increasingly true now that with each passing year employers are transferring more and more of the cost of care to employees. We all want to applaud progress, even incremental progress, but “incremental progress” should be considered the next thing to failure when you realize that as a concept it ignores the pain, suffering, unnecessary deaths, and financially destructive expenses that are the plight of the uninsured and the underinsured. “Incremental” brings us back to the two articles in this week’s NEJM.
By definition and design “public option” programs are at best “incremental” steps toward universal coverage. As a part of the ACA, they would have perhaps reduced the number of uninsured by several million more. They may have lowered the cost of care had commercial insurance been forced to compete against the federal government as a payer. We will never know more than that the idea frightened enough people that Joe Liberman’s chain was pulled, and he put an end to the idea for at least a decade. The authors of the first paper about the state trials of a public option give us the obvious answer to why the public option was opposed in 2010 and is still close to impossible in 2021 when there is great reason to believe that it would help millions if it was passed. I’ve bolded key points in what they write:
The effectiveness of a public option at both reducing premiums and controlling overall health care costs hinges on lawmakers’ ability to significantly curb provider payment rates. Designed to place competitive pricing pressure on private insurance plans, public option plans can offer lower premiums than private plans by setting or negotiating lower provider payment rates than those paid by private plans and often benchmarking them to Medicare rates. The cost savings can expand if private plans then reduce their provider rates to compete with the public option; in that sense, the creation of a public option applies a soft cap to the provider rates in the private insurance market. Though a public option may not be the only or best policy tool for reducing systemwide costs, it is a significant policy development warranting assessment of its potential as a health care reform model.
I have sat on several healthcare boards, and I have heard very few serious discussions about how a practice, a hospital, or a system plans to do its part to lower the cost of care. The conversations that I hear at board meetings are almost always about how we can get paid more, about how we are not paid enough, or about how another system is getting a better deal and is paid more by Blue Cross or even Medicare. Indeed, the current NEJM article about the state plans of Washington, Nevada, and Colorado boils down to, as it should, a discussion about how to pay less.
I have encountered substantial resistance whenever I have pointed out that the major challenge facing American healthcare is how to reduce the cost of care. It has seemed absurd to me that the public, and the public and private payers have been unable to demand that healthcare control its obscene cost structure that is primarily driven by bad practice that overtreats and mistreats some while failing to treat others until successful treatment is impossible no matter how much money is spent.
I have always believed that through innovation and the deployment of continuous improvement processes we could have improvements in all of the domains of quality while preserving the financial health of institutions and offering fair compensation to all healthcare professionals. Time has shown that it is easier said than done when the political system is controlled by the self-interest of those who benefit from the status quo. Attitudes have not changed much since 1917, 1935, 1945, 1965, 1978, 1993, or 2010. If you can’t attach meaning to those years I would be happy to send you a syllabus.
The authors of the first article supply some depth and color to my commentary. Again I am the one doing the bolding.
The biggest challenge that state public option plans face is limiting provider rates — the key to affordability. All three bills started out with strong rate controls, but these withered in the face of hospital opposition. Washington State ultimately set its cap at a generous 160% of Medicare rates, and as a result, public option premiums have not been cheaper than those of private plans. Even with such modest rate regulation, many areas in Washington lacked a public option plan because hospitals refused to participate. The state therefore amended the law in 2021 to require hospital participation…
Though states face more fiscal and legal constraints than the federal government, all must contend with the biggest challenge: political opposition from the health care industry to any threat to its revenues.
I have come to believe that we are destined to have our cost and coverage problems get worse before they get better. The pandemic has distorted healthcare finance even as it has uncovered so many of our healthcare inequities and the inadequacy of our ability to work in concert to combat a challenge to the health of the public. I do believe that in time, how much time I have no idea, we will realize that our lack of adequate coverage (As above, many who think they have access to care don’t have access to the care they need and can afford.) is a national disgrace and a potential liability for every American. At that time a better public option may be able to overcome our disabling myths and become the next incremental step that will create a cleaner and more efficient eventual move to the equivalent of “Medicare for all.”
In the second article, Dr. Hacker calls the public option described by President Biden as “Public Option 2.0” He contends that it could in time, not now but later, lead to universal coverage through an improved Medicare that would be available for all. The first step in his long and incremental process is to improve Medicare which is really a very poor product compared to what government-sponsored healthcare provides in other countries.
Here is a condensation of his argument:
…Public Option 2.0 proposals are much more robust than their predecessors. And though Medicare for All would indeed cover everyone and restrain costs,.. it faces much fiercer opposition from powerful stakeholders than a public option does. The public option would certainly require new financing, displace some private coverage, and provoke substantial opposition. But because it would build on the ACA and employment-based coverage, these effects would be more limited.
As a result, the public option is also less likely to provoke voter fear…Indeed, the largest plurality of voters think it should be a stepping stone to universal Medicare. The public option thus offers the prospect of continued progress toward universal public insurance with less intense backlash than would be likely with Medicare for All.
…Public Option 2.0 is not currently in the cards. Still, its proponents should not fold their hand. They should use the cards they have to strengthen their position for the next round, focusing on three strategic imperatives.
First, Medicare has to be improved for older Americans and those with disabilities if it is to be expanded to everyone else…Fortunately, good politics is also good policy. For all its virtues, Medicare has substantial gaps — most notably, no cap on out-of-pocket costs and no drug benefit integrated into the traditional public program. Expanding Medicare benefits will help beneficiaries now, and it will help the cause of expanding Medicare later…
Second, reformers will have to provide tangible benefits for Americans now covered by private insurance. Any proposal that envisions a sizable proportion of Americans in ACA plans and workplace coverage has to make these offerings work better for the tens of millions of people who remain vulnerable to high medical bills and unexpected insurance gaps…
Finally, reformers should resist interim steps that would erode the foundations for the public option. Among the riskier ideas are accepting the notion that the public option could be a private plan regulated by the government and redefining the public option as something more like Medicaid, varying from state to state and delinked from Medicare…
Indeed, even when particular upgrades prove impossible, fighting the good fight for these highly popular initiatives will most likely redound to reformers’ favor, helping to create more reliable allies and larger pro-reform margins in the future. Until that future arrives, advocates of the Public Option 2.0 …can build power to finally make Medicare an option for all Americans who need it.
Dr. Hackler’s suggestions make sense, but something tells me that there may be moss on my tombstone before a greatly improved Medicare, a public option, or universal access through an improved Medicare for all is ever possible. It is sad to say, but it seems that any possibility for true success will require that things first must get much worse. When we contemplate our inability to do anything about global warming even as our cities are flooded and our forests burn with increasing frequency and intensity it makes me a little nervous to contemplate what we will have to experience before we can put together the congressional supermajority necessary to do the right thing for the health of the nation. I hope that I am wrong. Perhaps, the best path to success might be to strategize about how to reduce the time between our incremental improvements. It is now eleven years since the last incremental improvement.
This Time Of Year
In September we begin getting ready for winter. Fall is a glorious season, but it is fickle, or if you prefer, it is an inconsistent season. Fall often begins with heavy weather that is the tail-end of storms that began in the over-heated waters of the Atlantic or the Caribbean and then after pummeling Florida or Louisiana have wandered north to trouble us.
In these parts, people still remember the hurricane that bypassed Florida and Louisiana and directly hit New England on September 21, 1938, as the storm of the century. My lake is divided into an east side and west side by a slender peninsula named Colby Point that is over a quarter of a mile long and not much more than a hundred yards wide. There is a private beach, but there are no homes on Colby Point. Before the storm hit on September 21, 1938, Colby Point was thickly covered with magnificent white pines that were probably more than two hundred years old and two hundred feet high.
I learned about the impact of the Hurricane of ‘38 a couple of years ago when I joined a nature walk on Colby Point with a forester from the University of New Hampshire. He showed us aerial pictures of the peninsula after the storm had passed. The big white pines were flattened. They looked like a game of “Pick Up Sticks” for giants. Eventually, all the wood was salvaged and most of it ended up being made into crates for munitions during World War II. An environmental error was made when the forest was replanted. The forest service chose to replant the peninsula with faster-growing “red pines” from Michigan. Those trees have not done well in our environment and many now are diseased.
So far this year we have only gotten heavy rainfall from the “tail-end” of weakened storms coming up from the gulf although to listen to the local weather people on TV each storm is treated like it will be another Hurricane of ‘38 or a repeat of Hurricane Sandy. This year we have been drenched by the remnants of Henri and other storms that I can’t name. It’s been a wet summer. The big question is whether this is just a routine example of “normal cause variation” or is it the “new normal” of global warming?
While waiting for the next hurricane, September can be beautiful. The evenings are cool and it’s rare for the daytime temp to exceed 75 degrees. The water temperature in the lake is falling so it’s time to get out my wet suit.
One task every September is to get my cars inspected. My wife takes care of her car, but I have three cars. One is a gently used Acura sedan that is reliable transportation. The other two cars are antiques. One is a 1968 Mustang convertible that I bought in 1989 to replace a 1966 Oldsmobile 88 convertible that died of rust, and the other is a red 1973 TR6 that was acquired in the mid-90s in memory of another TR6 I had loved that died in the early 80s. I have had many adventures in these old cars. I think of the mechanic that inspects them every September like he is their PCP. Since I “found” him about ten years ago and transferred my cars to his “practice,” they have enjoyed good health.
My routine is to make three sequential appointments for my cars. The master mechanic’s “office/garage” is about three miles from my house if you take a shortcut on an unpaved back road that runs through a huge lumber operation. In past posts, I have pictured some of the huge white pine logs that are lying around in enormous piles at the operation waiting to be cut into lumber.
I discovered the “shortcut” through the lumber operation to my garage on an exploratory walk several years ago. The scene took my breath away the first time I saw it. It was strangely like looking into the Grand Canyon for the first time or suddenly have Yosemite Valley come into view for the first time from “Inspiration Point.” The only thing that has been more dramatic was when one of the warehouses full of drying lumber lit up the sky when it burned one night a few years ago.
Today’s header reveals a huge pile of white pine logs that represents probably less than five percent of the logs that are waiting to be cut into lumber. Almost as impressive as the logs are the acres of lumber in neat stacks that are surely over thirty feet high that overflow from the numerous warehouses that line the road I walk.
After I drop off the first car, I usually walk the three miles home through the lumber yard. When the first car is inspected and any necessary work is done, I drive the second car over. When it’s done I drive the third car over. When the third car is ready I must walk to pick it up because I have no more cars to be inspected. I was lucky that when the last car was ready to be retrieved the weather was picture-perfect glorious. Lucky me; all three cars were done between two days with downpours! With the cars inspected, I am free to enjoy the rest of September and most of October until it is time to pull out the boats and put away the lawn furniture as the final preparation for winter.
I am hoping for many glorious September and October days. Who knows, with the new normal we may have summer between hurricanes through November. If it’s too late to prevent global warming, let’s learn to enjoy it.
Be well,
Gene
