A 'Grand Bargain' in health reform that we should support

The smart path to single-payer: Combine universal access to health care with an overhaul of punishing bureaucratic rules

By Dr. Matthew Hahn
New York Daily News, October 19, 2017

Sen. Bernie Sanders' "Medicare for All" bill — onto which just about every Democrat aspiring for the 2020 presidential nomination has signed on — is a serious attempt to fix the American health care system.

That is not to say that the proposal, in its present form, warrants our support. In fact, I will tell you exactly why it should not be supported without significant changes. But Berniecare goes vastly farther than either Obamacare or recent Republican health care plans, and therefore, ought to be considered the real starting point of an in-depth conversation about how we can finally fix American health care.

I'm a family doctor, and from my vantage point, the American health care system is defined by four main problems. First and foremost, too many people lack access to care. Second, health care costs too much - both for individuals, and for the nation as a whole. Third, American health care is low-quality care. And fourth, American health care is a bureaucratic and administrative nightmare for both patients and providers alike. Any serious proposal must address all of these issues.

Obamacare increased access to care for some, but it did not seriously address cost issues. Republican reform proposals may cut costs, but they do so at the expense of access to care for millions of Americans. Therefore, neither is the solution we need.

Berniecare, on the other hand, provides access to all. And for patients, the cost issue is solved. One fee, an income tax, pays for everything. So the two biggest issues in American health care are ostensibly fixed. That should be enough to get everyone to give this proposal serious consideration.

But criticisms of single payer are relevant, and must be taken seriously. In fact, how these issues are addressed makes or breaks the plan.

Many question whether our government, which has a hard time managing complex problems, is capable of properly administering such a system. This is a legitimate issue. Any practicing physician or nurse will tell you that excessive and unnecessary government bureaucracy has contributed as much as any other single factor to the destruction of American health care.

Billing for Medicare patients in the current system may actually be more complicated than providing their medical care.

An average appointment for a Medicare patient that I see pays about $75, but the amount of effort it takes my small office to collect that amount is incredible. At one point a few years ago, all of our Medicare payments were stopped for months because Medicare officials could not decide which credentialing form we needed to fill out, the 855I or the 855R.

We were not paid a penny the entire time. We were forced to draw from our line of credit to pay our staff.

This barely begins to scratch the surface of the administrative overkill that plagues health care professionals every day. The government's mandatory Meaningful Use program doomed a generation of modern physicians to purchase expensive and essentially unusable electronic health record programs. Compliance with such programs is so complicated that I now spend as much time today trying to figure that out as I do reading medical journals.

The worst may be yet to come. The government's complicated new "value-based payment" program (best-known by its abbreviation, MACRA) uses clinical, computer use, and cost data to determine physicians' Medicare pay rates. It increases physicians' administrative burdens substantially, and will actually penalize doctors who see the oldest, sickest, and poorest patients, who tend to generate the worst data.

Even more frustrating is the fact that the American health care system holds back genuine value at almost every step. The other day, one Medicare patient, who happens to have diabetes, had prescriptions for insulin and glucose testing supplies rejected four times because we could not successfully figure out all of the coding and authorization requirements. Misguided programs like MACRA will encourage physicians to stop taking care of the most difficult patients.

What this means is that it is not unrealistic to fear that out-of-control government bureaucracy could ruin a single-payer health care system. In fact, recent history, as evidenced by these examples, argues that without significant reform it would do just that.

Does this mean that we should reject "Medicare for All"? I don't think so. But we need to give a good deal of thought to developing more efficient, less invasive ways to regulate health care.

In fact, let's consider striking a grand bargain: Guarantee health insurance for all, in exchange for a major deregulation of the day-to-day decisions of most doctors.

Matthew Hahn, M.D., is author of "Distracted: How Regulations Are Destroying the Practice of Medicine, and Preventing True Health-Care Reform."


Earlier this week a proposed "Grand Bargain" by Georgetown Professors Gregg Bloche and David Hyman published in Health Affairs was discussed in a Quote of the Day. Excerpts from my comment: "This is a call for more of the same. Numerous studies have shown that this is the most expensive model of health care reform and that it falls far short on reform goals of universality, comprehensiveness, access, equity, efficiency, quality, and affordability. A well designed single payer model would achieve those goals." "We can get the policy right, but we need to change the politics."

Gregg Bloche responded to my comments with the following: "We didn't set out to propose an ideal system. We're proposing a way forward that takes account of stakeholder power and ideological divides, preserves access to care for millions of Americans, and addresses the long-term challenge of rising costs. Yes, politics stands in the way. But we think our way forward is politically more plausible than the maximalist positions many Democrats and Republicans have staked out."



By Don McCanne, M.D.

There is general agreement that, in spite of a few beneficial policies contained in the Affordable Care Act, serious problems remain in our health care system and especially in its method of financing. A few days ago a "Grand Bargain" in health reform was discussed in a Quote of the Day. As with many other similar proposed compromises, it was presented by its authors, Gregg Bloche and David Hyman, as a politically plausible solution. Bloche says that they "didn't set out to propose an ideal system," and that is the problem. Most of these compromise proposals insist on sacrificing an ideal system by perpetuating highly flawed policy for the sake of political feasibility. As we have said many times, it is the policy that we need to get right, while it is the politics that we need to change.

That brings us to the "Grand Bargain" proposed by Matthew Hahn, a family physician practicing in Hancock, Maryland. His approach to a grand bargain is quite different from compromise proposals. He has written a book,"Distracted: How Regulations Are Destroying the Practice of Medicine and Preventing True Health-Care Reform" (I have ordered the book but have not read it yet, only the reviews).

Matt Hahn, Russ Mokhiber and I had long conversation two days ago about his thoughts on reform. He does generally support the single payer model of comprehensive reform, but he is understandably very concerned about the response of several other physicians who have expressed disdain towards Medicare, blaming much of the dysfunction in health care on government bureaucracy. That has made it difficult to convince them that a government administered single payer system - an improved Medicare for all - is the solution.

The problems Hahn addresses in his book are familiar to everyone in health care, especially since they have contributed significantly to the burnout being experienced by about half of all physicians. At PNHP we have repeatedly expressed concern about many of these issues - MACRA with MIPS and APMs, and the intrusive EMRs being prime examples. So in his article, Hahn proposes a "Grand Bargain" of combining the single payer model with a massive overhaul of regulations to tame the "out-of-control government bureaucracy."

Well, he is right that the government has gotten carried away with regulatory measures such as those that would "replace volume with value." The experimental models are now being implemented throughout the nation even though they have already failed to deliver on significant cost containment, and the impact of the quality measures have been negligible, but they are driving physicians crazy.

Token acknowledgement of some of these issues has been given by the current administration, especially by CMS administrator Seema Verma. Unfortunately she is recommending the wrong path toward deregulation. She is pushing patients into the private sector while relaxing essential government oversight of the insurers. They are proposing reductions of federal contributions to health care - a move that will only compound the problem of a lack of affordability of insurance and health care.

It is important to understand that the primary defect is not government regulation alone but rather the highly dysfunctional health care financing system. Most of the administrative excesses come from the private insurance industry and the administrative burden that these private insurers are placing on physicians, hospitals and other health care institutions. It is the private insurers, including private Medicare Advantage plans and private Medicaid managed care organizations that are limiting patients to networks of providers. It is the private plans that are erecting excessive financial barriers to care through very high deductibles and other cost sharing. It is the private insurers who insist on intrusive prior authorization requirements, and it is private pharmacy benefit managers who create access barriers to much needed medications. It is the avoidance of adverse risk selection by the private insurers that help to keep tens of millions of Americans on the rolls of the uninsured.

Without government regulation the insurers exclude patients with greater health care needs from their risk pools, thus we need guaranteed issue. Community rating is required to ensure that selected groups will not be gouged by the insurers. Market competition is not enough to prevent insurers from pulling out of less profitable regions. But keep in mind that these important government regulations of the private insurance industry would not be necessary with a universal public single payer system. A public program does not need special regulations to prevent the government insurer from gouging patients - public service is a given.

Hahn has expressed some concern that the current single payer bills HR 676 and S 1804 do not explicitly correct many of the public (and private!) bureaucratic abuses. As to just how explicit the bills should be can be debated, but it is imperative that we get the word out that Hahn's grand bargain - a combination of a well designed single payer model with attention to regulatory, bureaucratic abuses - is the model supported by PNHP, even if we haven't always been explicit in addressing the concerns of Dr. Hahn and his colleagues. We need to direct more attention to this topic in our efforts to educate our colleagues and the public at large.

It is not government bureaucrats alone that we have to fear. It is the highly dysfunctional, fragmented, private and public financing system that is the problem. The private sector will not fix it with their business model. They have had over half of a century to prove that they are incapable. We will need to rely in the future on our own public service model - single payer - but we will have to select public stewards who understand that it is all about the patient. Create a system that takes good care of patients, and the health care professionals will do just fine.

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