• Eight Questions for 2018: Yes, Single Payer Is One of Them

    "It's the most wonderful time of the year.
    With the kids jingle belling,
    And everyone telling you be of good cheer."
    – Andy Williams

    The holiday season is upon us. I know most of you are preparing to take some time away from work to spend with family and friends. This is a time of year when we celebrate the successes of our lives, mourn the loss of loved ones no longer with us, and prepare for our lives heading into the new year. I wish you happy holidays and a healthy and prosperous new year. I hope 2018 brings you and your families health and success in all aspects of your lives.

    26457167 - health insurance word cloud

    Since many people use the transition from one year to the next as a time to reflect on major issues impacting their lives and establish goals and resolutions for the new year, I thought I would do some reflecting myself.

    This has been, by any measure, quite a year. The year in health policy and politics has been defined largely by a single issue -- namely, efforts to repeal and replace the Patient Protection and Affordable Care Act. Congress devoted a substantial portion of the legislative calendar to this issue with multiple votes on various proposals aimed at achieving the single objective of repealing all or major portions of the ACA. As you know, those efforts failed. It appears, sadly, that the issue will return in 2018.

    In the era of "fake news" and "alternative facts," I would like to provide you an overview of U.S. health care coverage. If nothing else, this information will allow you to dominate the health care reform conversations at your holiday parties.

    As I have noted several times in this blog, our country has a tortured history when it comes to health care reform. Despite our struggles, we continue to have a thirst for success, which propels us forward with new ideas and new attempts to achieve the ever-elusive and uniquely American solution for health care reform. Our efforts have not gone unrewarded. In fact, we have achieved significant successes.

    We made and have honored a promise to provide our soldiers with health care for life in recognition of their sacrifices for our country. In the 1960s, we established programs aimed at providing health care coverage for the "aged and infirmed" with the enactment of Medicare and Medicaid. In the 1990s, we established the Children's Health Insurance Program (CHIP) and, as a result, more than 95 percent of children have health care coverage today.

    Here are some interesting statistics, gleaned from a recent Census Bureau report, regarding health care coverage in the United States in 2016:

    • 91.2 percent (292 million) of the nation's 320 million people had health care coverage -- a 3.6 percent increase since 2013;
    • 8.8 percent (28 million) were uninsured at some point during the year;
    • 98.8 percent of individuals older than 65 or younger than 19 were insured;
    • 41 percent of individuals younger than 19 had coverage via CHIP;
    • 87.9 percent of individuals between 19 and 64 were insured;
    • 216 million people had coverage through a private provider;
    • 178 million people had employer-sponsored insurance;
    • 51 million had private, non-group health insurance;
    • 12 million had insurance through the Health Insurance Marketplaces (ObamaCare);
    • 119 million people had health coverage through a government-sponsored insurance program;
    • 53 million people had coverage through Medicare;
    • 62 million people had coverage through Medicaid; and
    • 14 million people have coverage through the U.S. military.

    For the past two decades, I have been involved in numerous debates and legislative activities that have sought to reform the health care system. Each of these debates has been different, but they have been similar in many ways. In my experiences, every health care reform debate comes down to two driving questions:

    • Does the proposed reform lower cost for individuals and purchasers of health care coverage?
    • What is the role of government?

    The country has failed to address the cost issue in a meaningful way to date. Clearly, there is a need to have an honest debate about the escalating costs of health care services, but the concept of "rate-setting" is so politically charged that we are likely a few years from such a debate.

    The role of government, on the other hand, we talk about quite frequently. I suggest that we all should be able to admit that the stalking horse of "socialized medicine" has been an outsized figure in our health care debates for decades. Our resistance to the never-present threat of "socialized, single-payer health care" has driven the health policy debate dating back to the early 1900s. This has always amused me slightly since thought-leaders in both political parties have historically pointed towards a "uniquely American solution" to reform of our health care system. Despite our national opposition to socialized, single-payer health care, there has been an expansion in government health care programs, and, as noted by the statistics above, nearly 120 million people have health care coverage through a government-supported program today, with that number expected to continue to grow during the next decade. (Medicare alone will increase by about 20 million.)

    Based on the trends in health care coverage and cost, we will be on the front edge of some difficult policy conversations heading into the 2020 presidential election. So, for the purposes of healthy holiday dinner and cocktail party debates, here are eight questions for 2018 that you can contemplate with your eggnog:

    • Is it time to view government health care programs differently?
    • Should we explore policy options that allow individuals to buy into Medicare or Medicaid?
    • Should there be a so-called "public option" that competes with private health insurance plans?
    • Should primary care be guaranteed as a core benefit by all providers of health care coverage?
    • Is it time to explore a single-sourced health care financing system?
    • Should the purchase of health insurance be compulsory as outlined in the ACA's individual and employer mandates?
    • Should there be more robust rate-setting mechanisms in our health care system?
    • Should we return to a more consumer-directed (cash on the barrel) health care system?

    Have fun with these questions, and I look forward to your thoughts and comments. Oh, and remember, email and eggnog usually don't mix well!

    Scheduling Note

    Due to the holidays, the next posting of In the Trenches will be Jan. 9.

    Wonk Hard

    There has been a consistent mantra in the comments section of this blog and other AAFP communication outlets in recent weeks that some of you feel that the AAFP "isn't listening" or "doesn't care about me." As an individual who spends each day trying to improve your practice environment, payment, and professional satisfaction, I promise the entire AAFP team is listening, and we care a great deal. We review the comments you submit closely and constantly strive to identify ways we can improve your practice environment. I admit that I am slightly sensitive to concerns some of you have raised that we at the AAFP -- specifically your humble blogger -- are out of touch with what is commonly described as "rank-and-file" AAFP members.

    I do not believe this is the case, but I hear your concerns and I am prepared to do something about it. In the first quarter of 2018 I am going to spend a day with a solo family physician or small group practice somewhere in America. I want to witness your day and see firsthand the challenges you encounter and outline in your comments. If you are interested in hosting me at your practice, please email my colleague Bethany Burk. I ask only three things. First, that you own your practice. Second, that you have an EHR. Third, that you participate in the Medicare program. I look forward to hearing from you, and learning from you, in 2018.


    Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.  Read author bio »


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