Is access to basic health care services a right or a privilege that is available only to those who can afford to pay? Most nations—ours included—embrace the notion that access to some level of care is consistent with humane values. But what level of care? And how should it be provided?
A tribal conflict over the fate of President Barack Obama’s Affordable Care Act has rekindled support for universal access and the single-payer model. At the national level, Sen. Bernie Sanders’ Medicare for All Act has its supporters. In our state, the New York Health Act of Assemblyman Richard Gottfried is under active consideration.
The Rochester Beacon asked the St. Joseph Neighborhood Center’s Sr. Christine Wagner and former Excellus CEO David Klein to address this important topic.
Sr. Christine Wagner is the former executive director of St. Joseph’s Neighborhood Center, which has provided comprehensive health care, counseling, adult education and social work to individuals and families since its establishment in 1993.
For many years I have worked at the St. Joseph’s Neighborhood Center, a health care facility that provides care for those who do not have access to health insurance or have inadequate coverage under the insurance policy they do have. The staff of 20 and 300 volunteers are dedicated to the delivery of health care no matter someone’s ability to pay. The services they provide are unmatched in quality and outcomes. We have been called “the safety net for the safety net” in our community.
The people and families we serve travel a long road through the many hazards and pitfalls of our broken health care system before they find us. Usually they have had to navigate this fragmented and confusing system despite illness, language challenges, literacy, financial and countless other barriers to enrollment and delivery of care.
We hear about the barriers to care that insured and uninsured people face on a daily basis:
“I make too much money to enroll in Medicaid, but private insurance is too expensive.”
“I tried to enroll through the NYS website, but it was too confusing, and I gave up.”
“I signed up for insurance but after I pay my premiums and deductible, I can’t afford the co-pays to see the doctor.”
“I am covered by my employer but the family plan was too expensive, so my wife is uninsured and is very sick. We can’t afford the cost of the doctor visits and medicine.”
“There is no coverage for dental and I have a terrible toothache.”
“I need glasses for work, but I can’t afford them. Insurance doesn’t cover eyecare.”
“I am afraid that the protection for pre-existing conditions is going away. I have cancer. What will I do?”
These questions and uncertainties don’t only plague poor people or the unemployed. Who among us comfortably navigates our own health care coverage? Who can understand the coverage limits, the premiums, the co-pays, the need for pre-authorization, Medicare Parts A, B, C, D and annual recertification? Who understands three-tier drug schedules and what is covered? I heard an insurance company executive, in charge of premium rates and their calculations, call it a “house of cards.”
These barriers would not exist under the single-payer health care system legislation currently under consideration in New York State. When a social system is broken there are effects that ripple out from the individual to their families and then to the community as a whole. Every day we see the negative effects of a broken and fragmented health care access and delivery system:
- Loss of work due to illness results in the loss of a job; loss of income can lead to eviction and an increase in the city’s homeless rate.
- An unaffordable, thus unfilled prescription results in high blood pressure or uncontrolled diabetes, often leading to avoidable emergency room visits. Hospital costs go up, the community pays the price.
- Co-pays for necessary mental health therapy are unaffordable at $50 per visit. Anger fuels domestic violence, sometimes death, arrest, disrupted families and traumatized children. The community pays for the resulting court and jail costs, educational disruption, truancy and care for the traumatized children, health care costs from injury, and evictions. The ripple effect from domestic violence is devastating.
- Missing front teeth prevents someone from getting a job because of their physical appearance. The unemployment rate is affected by a problem that could be prevented.
Over the last 25 years I have seen people die because they do not have health insurance. There have been no mitigating factors in these deaths. There was direct and indisputable causation between their lack of health insurance and their death. These deaths are tragic in the face of a fixable problem. These costly and tragic ripple effects would not exist or at least be mitigated under the single-payer health care system legislation currently under consideration in New York State.
The health care system in the United States is inextricably linked to the health insurance and pharmaceutical industries and the system of state and federal policies that regulate them. I have been to many meetings over the years about health care where the word “patient” is never used.
At our center we have been piloting for many years a different model of health care access and delivery that puts the patient squarely in the middle of the health care equation. Imagine a model of health care that is comprehensive in scope and integrated in action. Imagine a model of care that sees the patient as a whole person, including their physical health, mental health, and social health.
Imagine a health care model that knows that where you live affects your physical and mental health; that your race, gender, family situation, family history, financial status affects your health; that if you can’t see or hear well or if you are feeling depressed and anxious you can’t be your best self. Imagine a health care provider who is interested in whether you have access to and can afford good food or can exercise safely in your neighborhood. This is the model of care delivery that is practiced at St. Joseph’s Neighborhood Center.
Every provider can spend as much time with a patient as needed. All providers, across care disciplines, talk to each other about the patients they share and develop care plans together with the patient. Affordable medications are prescribed and provided if the patient cannot pay for them. Lab work is done at a fraction of the cost usually charged. Complementary therapies of chiropractic, massage, physical therapy and acupuncture are offered on site. Sub-specialists come to the Center to see patients, rather than the patients having to travel.
The potential for this kind of health care would exist under the single-payer health care system legislation currently under consideration in New York State. Working at St. Joseph’s Neighborhood Center has allowed me to see that this model of health care results in much better outcomes for patients and their families and has given me a grounded perspective on the notions of health, health care and health insurance – three very different things.
- Attaining and maintaining the very best level of health is something we want for ourselves, our families, indeed our community. When we are functioning at and feeling our very best, no matter our ability or situation, the community benefits. The spectrum of health includes our physical well-being, our mental health, and our social and spiritual wellness. I believe that we want to live in a community where each member can reach their health potential.
- Health care is the process of intervention that allows us to reach our health potential. The practice of medicine and the healing arts have been evolving for centuries. Doesn’t it feel intuitively right to you that every person should benefit, without limit or discrimination, from the vast medical knowledge that has been attained? Is it not to our benefit to consider health care a human right, along with all the other things we need to survive and thrive as a species such as food, housing, education, and meaningful work?
- Health insurance makes access to health care conditional on one’s financial means. Health insurance providers have inserted themselves into the process of the delivery of health care. They have, over time and with the support of government, built up a system of limits, laws, regulations, pricing schedules, affiliations with health care systems, pharmaceutical companies, providers of durable goods, and others involved with the delivery of health care. The profit-based insurance system dictates who gets health care and at what level depending on ability to pay. This, in turn, compromises the ability of many to reach their health potential and in the end affects the health of our human community. Even those of us fortunate enough to have health insurance live with the uncertainty that our policy will not fully protect us, a procedure or medicine might be denied, or only partially covered, or the fine print limitations will lead to devastating personal financial implications.
Our peers among the nations of the world have healthier citizens and better health outcomes because they facilitate the delivery of health care to all people without discrimination – no financial tests, no pre-existing condition limitations, no anxiety of choosing between health care, food and housing. Health outcomes for all citizens in these countries are far better than the health outcomes for the citizens of the United States despite the vast amount of resources we spend each year.
The nation already successfully administers Medicaid and Medicare. The ability to successfully administer a single-payer system already exists. The numbers have been run, the savings have been calculated, the potential improvement of the health of American citizens is real.
On June 14, 2018 the New York State Assembly passed the New York Health Act (A4738) which calls for a single-payer system in the state. Under the bill, every New York resident would be eligible to enroll, regardless of age, income, wealth or employment. There would be no network restrictions, deductibles or co-pays. Benefits would include comprehensive outpatient and inpatient medical care, primary and preventative care, prescription drugs, laboratory tests, rehabilitative, dental, vision, hearing and all benefits required by current state insurance law, by publicly funded medical programs or provided by the state public employee package.
A single-payer system will save lives and will help us achieve the health potential that will build a stronger community.
Here are David Klein’s views on the topic. Klein is the retired CEO of Excellus BlueCross BlueShield. He serves as a special adviser to the CEO of the University of Rochester Medical Center. His opinion does not represent Excellus or the URMC.
There is huge dissatisfaction in this country about health care. Recent Kaiser Family Foundation polling found 25 percent of the population says health care is their No.1 concern, edging out the economy and jobs. Seventy-nine percent say health care is their most important or a very important issue.
This is despite the fact that the Affordable Care Act or Obamacare significantly reduced the uninsured rate from 16 percent in 2010 to 9 percent in 2017. Americans express frustration with cost, access and quality. They have decreasing amounts of coverage with 43 percent of Americans now having high-deductible health plans. They don’t understand why the U.S. spends 50 percent more than most other western countries but achieves, for most, lesser outcomes.
To deal with the angst towards health care, support is growing for adoption of a single-payer approach. The words “single payer” words mean different things to different people. Differences in favorability emerge as the description changes. “Medicare for All” polls more favorably at 62 percent than “socialized medicine” at 44 percent, according to a 2017 Kaiser Family Foundation Health Tracking Poll. A public option program which has private health insurance competing with Medicare is liked by 75 percent of the population, according to a 2018 Kaiser Health Tracking Poll.
Given this absence of understanding, if not consensus, tinkering with the status quo should be done very carefully. Despite best intentions, change could lead to even more dissatisfaction with the health care system.
Health care was a major theme of many of the mid-term campaigns. The most visible federal proposal is Sen. Bernie Sanders’ Medicare for All Act (S.1804). There are seven other similar proposals with variations in what services are covered, how the program is funded and whether the government-run program is exclusive or competes with private insurance.
The Sanders plan would cover everyone without co-payments or premiums (other than up to $200 a year on prescription drugs). Payment rates would be set by the federal government. Coverage would be comprehensive. The program aims to be budget neutral through administrative simplification and the set-fee schedule. Additional funding would come from increasing the income tax on the top 5 percent of earners, a progressive excise tax on payroll and self-employment income, and a new tax on stock and bond transactions.
Despite the rampant dissatisfaction and extensive debate, there is little chance federal action to address these issues will occur in the near term. There is just simply too much polarization in Washington.
New York is getting close to taking action. The legislation receiving the most attention is the New York Health Act (A.04738A/S.4840) sponsored by Assemblyman Richard Gottfried and Sen. Gustavo Rivera. It has passed the Assembly five times, including the previous four years, but failed in the State Senate by one vote. With control of the State Senate flipping to the Democrats, the chance of the bill making it to Gov. Andrew Cuomo’s desk is materially increasing.
Cuomo has previously indicated support for both federal and state single-payer legislation. He has also been a corporate centrist. As business doesn’t support the proposal it is unclear whether he would sign or veto the bill.
Key features of the New York Health Act:
- All residents of New York State would be covered, including undocumented immigrants and seniors over the age of 65 (if federal waivers are approved).
- Scope of coverage would be equivalent to that provided under Medicare, Medicaid, Child Health Plus and the Affordable Care Act; long-term care may be added later.
- Patients would have no deductibles, co-pays or other out of pocket costs
- Financing would come through a federal government block grant (provided through a waiver), current state health care funding, a payroll tax funded 80 percent by employers and 20 percent by employees and a progressive tax on non-payroll income.
- Provider rates would be set by the state. Rate changes are assumed to be equal to the trend in Medicare and Medicaid increases.
- Administrative costs would be limited to 6 percent of spending.
- The program designers assert that the program will cost the same as current spending, assuming there are administrative efficiencies and slower provider payment growth
The New York Health Act is intended to achieve the goal of universal coverage with no patient cost sharing and improved access to care. These are good and worthy outcomes. Worrisome questions are:
- Would the program be truly budget neutral?
- Can needed federal Medicare and Medicaid waivers be secured?
- Might the action to prohibit sale of private health insurance be construed as an illegal seizure of assets?
- Can NYS compel firms to pay premiums to the plan without violating ERISA provisions that pre-empt state law?
- Would adding a new payroll tax to New York’s already deemed unfriendly business environment cause a loss of jobs?
- Would the tax increases on New York’s wealthy spur a further exodus of high-income taxpayers?
These are all very legitimate concerns. There are four additional areas that haven’t received much attention: underfunding, implementation, innovation and choice.
Possible underfunding: With a single source of funding, if rates are set too low there may be insufficient staffing, facilities and other resources to provide high quality, accessible services. Today’s pluralistic approach to funding creates a safety net of sorts, with some payers providing higher reimbursements than others, enabling cross-subsidization and provision of sufficient resources.
Patients that have multiple illnesses, are poorer and less literate generally cost more to treat. Academic centers, because of their training and research costs, are more expensive to operate. Rural and inner city sites are usually, on a per-capita basis, more resource intensive. Places that deal with culturally diverse patient populations are appropriately more costly. How will these differences be accommodated in the rate setting?
How should anticipated population growth or shrinkage be handled in rate setting? How will the cost of new technology like precision medicine, robotics and telemedicine be accommodated? Will centers of excellence be supported and if so, how will they be chosen? Will hospitals with older buildings be treated differently than those with new facilities? Should access to capital be a consideration (whether through charity or investment)? Today, these are largely market decisions.
Government rate setting will strongly influence capacity, thus the ability of New York’s health care system to address needs. This will place new burdens on the state’s health care planners. How long should one wait in an emergency department? For a diagnostic mammogram? For a joint replacement?
If underfunded and capacity constrained, what will be the impact of the competitive positioning of medical centers that draw their patients not just from New York State but nationally if not beyond? Is this a jobs issue? Will we be inadvertently sending patients to other states? This potential for underfunding exists whether the single-payer model is developed on a state or national platform. The safety net provided through pluralistic funding erodes with both single payer and public option as the government rates will effectively become ceiling payments. How will all of these factors be addressed? How will the evolving political situation affect the solutions?
Implementation: While New York State has relevant experience with Medicaid and the New York State Health Insurance Program, scaling to the size and complexity required to serve 20 million New Yorkers involves material risk. It is more than just a modest incremental change. Even if contractors (that is, existing health insurance companies and third-party administrators) are used for the work, it will still be challenging and some functions (like rate setting) would likely be retained by the state. A bureaucracy will need to be created to select and to manage the contractors. How long will it take to set up the bureaucracy? What happens to providers and patients if it doesn’t work as planned?
Innovation: With a single-payer system, market-initiated innovation may be inhibited. What accommodations should be made to ensure that creativity is encouraged and rewarded? If New York’s health care environment becomes bureaucratized, will the best and brightest go to other states where entrepreneurship is valued to a greater degree?
Choice: Finally, some believe that choice engages and empowers consumers. How would consumers react if there is were only one grocery store, bank or airline? Would they be complaining about service and quality due to the absence of competition? What should we learn from the success of Medicare Advantage plans which now cover about a third of all seniors? Did the post office get better when Federal Express began to disenfranchise their delivery monopoly? Choice may cost more due to added administration but does the public understand that a pure single-payer model eliminates choice?
Given this list of worries, isn’t the state or nation better served by pursuing incremental change? This could include:
- Regulating the scope and level of benefits to ensure adequacy and coverage of pre-existing conditions.
- Selectively applying price controls, perhaps initially for prescription drugs and out-of-network services. The remainder of the western world uses price controls extensively; price differences explain most of the variation in health care costs across countries.
- Providing more information to consumers about provider performance, including cost and quality of care.
- Providing subsidies, perhaps through the tax system, for those unable to afford premiums.
The state or nation could see how these changes work before doing something more massive, costly and perhaps irreversible.
Rochester has much to lose
Rochester’s health care system is remarkable. The angst over health care rampant elsewhere is less intense here. That is not to say there aren’t opportunities for improvement or that there aren’t fellow Rochesterians who are having trouble accessing care or paying their bills. These problems need to be addressed.
But Rochester also has a world class academic medical center, nationally top-ranked health plans, among the country’s lowest uninsured rate, and just about the lowest prices paid anywhere for health insurance and medical care. The quality of care Rochester enjoys isn’t found in other comparably-sized communities! Rochester is very fortunate.
This did not happen by accident. This high value care is a legacy George Eastman and other sage community leaders bequeathed to Rochester. It began with the University of Rochester and Eastman’s belief that, for his company to be successful, quality of life in Rochester had to be good.
The first priority in ensuring health care quality was the need to train and to retain best-in-class physicians. This led to UR being one of the best medical schools anywhere and Strong Memorial being among the country’s best hospitals. Further, this excellence found its way to the other Rochester hospitals (Rochester Regional and its predecessors) with physicians trained at the University of Rochester.
Others, like Marion Folsom of Kodak and Joe Wilson of Xerox, followed Eastman’s lead with their support for health planning and policies that preserve Rochester’s special status. Today, iconic individual leadership has been replaced with professionally-driven collaborative efforts. Noteworthy is the work of these Rochester-centric organizations:
- Common Ground (formerly, the Finger Lakes Health Systems Agency) with its excellent contributions in health planning, primary care practice management and reducing disparities in care delivery;
- Community Technology Assessment Advisory Board (CTAAB) through its advisory role providing recommendations to health plans regarding need for additional capacity and whether new devices, procedures and pharmaceuticals should be covered;
- Greater Rochester Health Information Organization (GRHIO) which has created infrastructure enabling the exchange between providers of electronic medical records (rarely found in other communities); and
- Excellus BlueCross BlueShield, the health plan market leader, which rewards providers for better quality and lower cost through their value-based payment Alternative Cost and Quality Agreements (ACQA).
It is hard to imagine important community assets like these coming into existence with a single-payer system.
The two big health systems, University of Rochester Medical Center and the Rochester Regional Health, also deserve much credit as they evolved from single hospitals to multi-hospital, regional operations. These initiatives not only added to their scale but ensured continued local access throughout the region to medical services, without which the future economic vitality of these rural communities would be jeopardized. With a single-payer system, would they be as interested in expanding their footprints and protecting ex-urban areas?
There is something in the Rochester DNA that keeps the Eastman’s spirit alive.
This list of worries is material. Given the strength of Rochester’s health care system, we have much to lose if the replacement for the status quo isn’t a real improvement.
In an ideal world, whether at the state or federal level, there would be extensive education and debate to develop a broadly supported consensus about actions needed to ameliorate the angst about current health care financing and delivery. The failure to apply that type of process robbed the Affordable Care Act of broad-based support. No major social change program has succeeded without bipartisan support.
Health care is too important to not get it right. There are some avenues of change that could make it worse.