Are doctors finally realizing the market won’t cure our health care system?

Last week the American College of Physicians, the largest medical specialty organization and the second largest physicians group in the U.S., broke ranks with its medical brethren who have staunchly opposed any serious health reform for decades by calling for either a single-payer system or a government-run public option. This is huge! The physician group’s announcement could be a game-changer if other similar organizations come to the same realization that bold steps are needed to fix the American system and add their voices to meaningful change.

In a lengthy interview, Dr. Robert McLean, the president of the American College,  told me, “We said as an organization enough is enough and asked ourselves how can we drive the conversation to a better place?” McLean said the group decided to follow the same rule we have been trying to teach newbie health journos: Follow the evidence and report what works and what doesn’t.

McLean said his group looked around the world at what other countries were doing to produce better care and outcomes. “Our goal is to take down preconceptions and look at the evidence,” he said. “We know the Western wealthy countries deliver better quality care at lower costs and that they have better primary care.” In an editorial accompanying a series of papers explaining the need for health reform and the reasons why the status quo is not acceptable, the physicians group acknowledged some will “admonish the organization not to be political. Yet, to enact policy through the legislative and regulatory arms of government, one cannot avoid politics. Policy and politics are intertwined.” It sure sounds like the doctors’ group will be heavily involved in advancing major changes for what it calls a “gravely ill” health system.

After studying other countries’ health systems, the American College made twin recommendations to improve the current U.S. arrangements and supported them with a series of documents that should be essential reading for any reporter covering the topic.

In one of the accompanying articles published in the Annals of Internal Medicine, Drs. Steffie Woolhandler and David Himmelstein strongly argue for a Canadian-like single-payer system. In crafting their argument, they carefully dissect what has happened with two types of public choice models in the U.S. — the co-ops set up under the Affordable Care Act to compete with traditional insurance sellers (which have largely disappeared because the funding wasn’t available to compensate for the high-risk patients who signed up) and Medicare Advantage plans. In the case of Medicare Advantage plans, insurers are engaging in practices that push out unhealthy and unprofitable seniors, sending them back to traditional Medicare. In both cases, the problem of adverse selection, an insurance term that means sicker individuals will gravitate to a plan or a company, can cause premiums to rise astronomically and affect an insurer’s profitability and threaten its survival.

Their review of these programs suggests that a public option presents significant challenges, among them unstable risk pools. McLean also acknowledges “for the public option to work there would have to be significant regulation of private insurers.”

In either case, McLean said, “We need to get to a place where our society does not look at health care as a commodity. Simple market-driven approaches do not work.” That conclusion, reached by a medical group that represents 159,000 doctors, is also huge.

Recall that over the past couple of decades the conventional wisdom has dictated that medical care is a commodity that should be bought and sold, much like canned peaches or computers. I and others have long argued that health care can’t function like a commodity, a position now taken by the American College.

If the doctors’ group can debunk that notion and switch the public discourse from calling health care a market good into a social good worthy of public financing, that would be a major contribution on the way to constructing a healthier system.

McLean also told me the American College wants to remove other “misleading” labels like “socialized medicine,” which has been used for decades as a rallying cry against the prospect of universal health insurance system. “It’s just plain not accurate,” he said. Socialized medicine traditionally means that the government owns and operates the health care facilities, employs the health care professionals, and pays for the services. Many countries with universal systems do not have socialized medicine. In Canada, for instance, doctors own their own practices but federal and provincial governments pay for the services.

McLean and I talked about the buzzy term “Medicare for All,” which his group wants to ditch. “We did not use the term ‘Medicare for All’ because it means so many different things to different people,” he said. 

My interview with McLean came just as I was beginning to write about how the health care debate is getting bogged down in confusion, despite a ton of public interest in the issue. It has been a topic at nearly all of the Democratic primary debates and the media has shown a keen interest in reporting on it. Meanwhile, the long-term future of the Affordable Care Act is very much in doubt given the possibility of another adverse ruling from a Texas district court that doesn’t much care for the law.

The debate we’ve had so far, though, has served to confuse the electorate more than illuminate what’s at stake. Polls show many Americans may support Medicare for All, but I’d wager most wouldn’t be able to explain exactly what that is.

What exactly are “Medicare for All,” “Medicare for Some,” and “Expanded Medicare”? Would Medicare for All guarantee lifetime health care for every citizen the way Medicare guarantees those 65 and older health coverage until death? Or does it mean something else? What is Expanded Medicare? Is it an option to allow those between age 55 and 65 to buy into the program? Would it give this age group the same benefits older beneficiaries now get? And where does the public option fit in? Does that mean anyone who doesn’t have or want employer-provided coverage can choose the government option? Or is it intended as a high-risk pool for sick people who have nowhere else to turn, as Woolhandler and Himmelstein suggest might happen?

“We need to get to a place where our society does not look at health care as a commodity. Simple market-driven approaches do not work.” — Dr. Robert McLean, president of the American College of Physicians

The media coverage has been vague, with stories laced with terms that offer little illumination of their meaning. What we have had are stories that say we can’t afford a comprehensive program — too many trillions of dollars in taxes and onerous tax burdens for the middle class — without noting that Americans would not pay premiums, deductibles and co-insurance, which collectively amount to thousands and thousands of dollars for families each year. Instead of labels, a discussion of tradeoffs would better serve the public, as would a more thorough discussion of the exorbitant prices Americans pay for medical services and drugs.

“The reform language is dominated by the anti-reform people,” says Yale professor emeritus Theodore Marmor. McLean warns of that too. “The more positive the name of the organization the more skeptical people should be about what’s going on behind the scenes,” he said. The Partnership for America’s Health Care Future comes to mind. It was formed in 2018 by the Federation of American Hospitals, a trade group for the for-profit facilities, pharmaceutical companies, and America’s Health Insurance Plans, the lobbying organization for health insurers.

The American College has a tall task ahead, but a really important one. Its advocacy for what have historically been unpopular positions in the medical profession may force clarity in the public discussion, which up to now has been sorely lacking. The College is also challenging the media for more reportorial precision. Labels that are plainly inaccurate or highlight scary but inaccurate scenarios just don’t cut it when it comes to policy issues as monumental as changing how Americans will get and pay for their health care.

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care column.