Blogged Arteries

No one likes to be told what to do. 

We physicians, especially, are tired of government agencies and insurance companies and hospital administrators telling us how to take care of our patients. So I won’t be surprised if physicians around the state are feeling a little angst and anger over the coming March 1 requirement for physicians to check the Texas prescription monitoring program (PMP) before writing prescriptions for opioids, benzodiazepines, barbiturates, and carisoprodol. 

I don’t fault them one bit. This is just one more administrative burden placed on physicians. But I want all of you to understand just how much worse it would have been without the intervention of the Texas Medical Association. 

TMA began our work to simplify physicians’ administrative burden when prescribing opioids and other controlled substances early in the last decade. We claimed two important successes during the 2015 session of the Texas Legislature. Until that point, Texas doctors needed both a state controlled substances registration (CSR) permit and a federal Drug Enforcement Administration permit to write prescriptions for any controlled substance. Also, until that point, the state PMP was a law enforcement tool housed in the Texas Department of Public Safety. And, physicians who wanted to check a patient’s controlled substance history had to perform that task personally. 

Thanks to TMA's advocacy during the 2015 session, the CSR permit was eliminated, the PMP was moved to a new online system created by the Texas State Board of Pharmacy, and physicians were authorized to delegate checking the PMP to members of their staff. (That's a valuable time saver for our doctors that I encourage you to use.)

As the opioid abuse epidemic raged across the country, elected officials clamored for a crackdown on prescribing practices. In 2010, Colorado, Delaware, Louisiana, Nevada, and Oklahoma were the first states to require prescribers to search patients' drug histories before prescribing. By January 2017, when the Texas Legislature was ready to convene, 26 more states had imposed that mandate. (Currently, that number is up to 43 states.) 

Political pressure to do something was growing here in Texas. State lawmakers already had filed some extremely onerous pieces of legislation. It was obvious that Texas was about to join the list. It became TMA’s job to buy time for you and make sure the state was pushing a useful clinical tool for physicians, not another useless administrative burden. 

As we do so often, TMA and organized medicine went to work educating senators and representatives about the real-world impact of the bills they had filed. We pushed back hard against a proposed sweeping mandate for physicians to check the PMP before issuing prescriptions for any controlled substance. We persuaded lawmakers to limit the requirement to the four drug classes I mentioned above. And we won a two-year delay in the mandate so physicians, the Pharmacy Board, and other key players could prepare for this massive change. 

Finally, during the 2019 legislative session, we obtained two more big improvements for physicians. While at that point, most of the major electronic health record (EHR) vendors were working to integrate the PMP into their systems, they were not likely to be done with their work before the Sept. 1, 2019, deadline. We persuaded lawmakers to delay the mandate until March 1, 2020, to give physicians and EHR vendors time to properly integrate their systems with the PMP. Plus, the legislature appropriated an additional $5 million for the Pharmacy Board to upgrade the PMP to make it easier to integrate, as well as to cover the integration licensing fees for all state prescribers and pharmacists. 

To use a bad pun, this mandate is still a pain, but it hurts far less than it could have because TMA has been there for you. We also have a new PMP Resource Center on the TMA website that includes all the background on the mandate and a way to check if your EHR is connected to the PMP. We put together a webinar with 1.25 hours of CME (free to TMA members) to make using the PMP easier for you and the staff you delegate the task of checking the database, and more beneficial for you and your patients. We also are working on a public campaign to make sure your patients know the PMP mandate is coming and what it may mean the next time they visit their doctors. 

My hope is that because of all the work we’ve done, the PMP will actually be a valuable tool to help physicians prevent drug abuse, drug diversion, and doctor shopping, and that it will not delay, thwart, and complicate care for our patients.

This is an excerpt of a post originally published on Sarah Fontenot’s website. The opinions expressed are Ms. Fontenot’s. Texas Medicine Today is sharing them to further the conversation on the future of health care reform.

Support for Medicare for All has swept the nation – or at least Democratic primary voters.

In a September Kaiser poll of likely Democratic voters, 40% said they were in favor of replacing the Affordable Care Act (ACA) with Medicare for All. Of that segment 14% said they would only support a candidate who would bring Medicare for All to America (as opposed to other solutions, such as the Public Option).

With two of the current top Democratic candidates – Sens. Bernie Sanders (I-Vermont) and Elizabeth Warren (D-Massachusetts) – espousing Medicare for All, supporters and detractors alike are asking more in-depth questions about the proposal, particularly how much it will cost.

What do Senators Sanders and Warren mean by “Medicare for All”?

Medicare for All is a concept that has been around since the early 1900s, was an unrealized component of President Franklin Roosevelt’s New Deal, and was in the background of the Medicare law President Lyndon Johnson signed in 1965.

Senator Sanders picked up the banner in 1987 and has run on it ever since – most memorably in the 2016 presidential election.

In April, Senator Sanders updated his Medicare For All plan (the fifth time he has done so) in Senate Bill 1129. Among his 14 co-signers were four senators who were running for president at the time: Elizabeth Warren, Cory Booker, Kamala Harris, and Kirsten Gillibrand.

SB 1129 would create a single-payer health system in America, eradicating private health insurance and current government health care programs over four years.

The insurance described in the Sanders plan would be more comprehensive than any policy currently available on the market, more generous than Medicare as we know it now, and more generous than any government program in the world (including Canada, the United Kingdom, and Norway).

Almost every resident of the United States would be entitled to comprehensive health care through a new government program modeled on Medicare (not included: veterans, who would continue to receive health care through the U.S. Veterans Administration; and Native Americans, who would be served through Indian Health Service).

Under Senator Sanders’ plan, Medicare for All would include:

• Care in any hospital;
• Care outside of a hospital (free-standing facilities, labs, etc.);
• All preventative health care and chronic disease management;
• Comprehensive reproductive, maternity, and newborn care, including abortion;
• Emergency health care services and treatments;
• Primary and specialty health care;
• Palliative and long-term care (including home-health);
• Care for vision, hearing, and oral health problems;
• Mental health and addiction services;
• Prescription medication (the first $200 a year out of the patient’s pocket);
• Medical equipment and supplies;
• Diagnostic tests; and
• Other services (this list is not all-inclusive) 

All this care would be available at no out-of-pocket cost to the patient, and there no longer would be insurance premiums, copays, or deductibles in America.

It is understandable why the concept of Medicare for All has proven so attractive to many Americans.

It is also apparent why the cost of the plan has remained one of the most consistent arguments against it. What level of investment by the federal government will be necessary to make Medicare for All possible?

What does Senator Sanders say about the cost of his plan?

He has historically been vague about the cost of Medicare for All. The last time he ran for president, the “false charms” of his plan were widely criticized (and that was before he added long-term care to the 2019 version of his proposal). 

Variables make projections of the cost of Medicare for All difficult: How many new patients will enter the system? How many health care services will be requested when insurance companies no longer act as gatekeepers? How low can payments to hospitals and physicians go before the health care community closes and creates access issues for patients? What will it cost to build an administrative agency large enough to manage the health care of the entire country? 

Even so, many economists have attached a specific price to Medicare for All. Senator Warren released her price tag recently. Senator Sanders remains more opaque, and inconsistent. 

For example, in an interview in July with the Washington Post, Senator Sanders quoted the price to the government at $30 trillion to $40 trillion over 10 years. 

However, during the September debate in Houston, Senator Sanders did not refute former Vice President Joe Biden’s assertion that Medicare for All would cost over $30 trillion. Instead he added, "Status quo, over 10 years, will be $50 trillion." 

In another interview in October, it appeared Senator Sanders was frustrated by the cost question: “We’re trying to pay for the damn thing” [through, in part, taxes on the top 1% in income in the country]. He later added, “You’re asking me to come up with an exact detailed plan of how every American – how much you’re going to pay more in taxes, how much I’m going to pay. I don’t think I have to do that right now.”

What does Senator Warren say Medicare for All will cost?

Senator Warren does not have a separate plan for Medicare for All, saying instead, "I'm with Bernie on Medicare for All," as she said in the Democratic candidate debate in June. But the two candidates differ on how to pay for the plan, and how much it will cost.

Senator Warren released her plan for funding Medicare for All in November. Her lack of an explanation on how she could deliver it without a tax increase on the middle class, as has been her promise, was a prominent moment in the last Democratic debate.

And here is her number: $26.6 trillion. (I know the headlines said “$20.5 trillion, but that was ignoring the $6.1 trillion she expects the states to chip in to support the program.)

As reported by the New York Times:

Ms. Warren would pay for the new federal spending, $20.5 trillion over 10 years, through a mix of sources, including:

• Requiring employers to pay the government a similar amount to what they are currently spending on their employees’ health care, totaling $8.8 trillion over a decade.
• Changing how investment gains are taxed for the top 1% of households, raising $2 trillion, and ramping up her signature wealth tax proposal to be steeper on billionaires, raising another $1 trillion.
• Creating a tax on financial transactions like stock trades, bringing in $800 billion.
• Beyond the $20.5 trillion total, she is also counting on states and local governments to contribute an additional $6.1 trillion to help pay for the system. 

Senator Warren explained more details on her plan in November, but for our purposes, here is the crucial line: “We don’t need to raise taxes on the middle class by one penny to finance Medicare for All.”

Senator Warren’s announcement immediately prompted criticism from Republicans as well as fellow Democrats. Saturday Night Live parodied her talking about her plan on the Cold Open the following night.

In the meantime, Senator Sanders retorted that his plan is “far more progressive” than Senator Warren’s. Recognizing his proposal includes raising taxes on the middle class, Senator Sanders predicts those taxes would balance with lower health care costs, while Senator Warren’s plan “might have a ‘very negative impact’ on job creation because of funds it could take from employers.”

(Vox.com has more details on the differences between the Sanders and Warren plans.)

What do economists say?

The Congressional Budget Office (CBO) provides Congress with financial estimates on proposed legislation, including Senator Sanders’ SB 1129. In May, the office released a detailed report on the primary features of establishing Medicare for All in America, explaining that the magnitude “is difficult to predict because the existing evidence is based on previous changes that were much smaller in scale.”

The CBO refrained from providing a specific, detailed cost estimate (as it would usually do), noting “that such a system would be so different from the country’s current situation that any hard estimates would be difficult, even with all the specifics laid out.”

However, economists outside of the government have been willing to derive specific numbers for the cost of Senator Sanders’ plan.

For my money (pun intended), the best guide to the Medicare for All cost estimates from economists (as opposed to politicians) is an interactive article in the New York Times.

I like this resource because it has dynamic, interactive visuals for each estimate, and compares figures from very conservative sources (such as the Mercatus Center) to very liberal ones (such as the Urban Institute).

I encourage you to access the resource yourself, but here are the bottom-line projections for the total costs of Medicare for All from that publication:

• Gerald Friedman, a professor of economics at the University of Massachusetts, Amherst, whose estimates were frequently cited by the Sanders campaign in 2016: $2.76 trillion
• Charles Blahous, a senior research strategist at the Mercatus Center at George Mason University, and a former trustee of Medicare and Social Security: $3.46 trillion
• Analysts at the RAND Corporation, a global policy research group that has estimated the effects of several single-payer health care proposals: $3.24 trillion (plus $506 billion*)
• Kenneth E. Thorpe, the chairman of the health policy department at Emory University, who helped Vermont estimate the costs of a single-payer proposal there in 2006: $3.20 trillion (plus $706 billion*)
• Analysts at the Urban Institute, a Washington policy research group that frequently estimates the effects of health policy changes. $3.87 trillion (plus $514 billion*)

(*Some estimates of the Medicare for All price tag are not inclusive of all health care costs.)

What will voters say?

This is, of course, the most important question of all.

We will get the voters’ answer in November.

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers.

 This is an excerpt of a post originally published on Sarah Fontenot’s website. The opinions expressed are Ms. Fontenot’s. Texas Medicine Today is sharing them to further the conversation on the future of health care reform.

Medicare For All has become a rallying cry for many (if not most) Democrats, but it was independent Sen. Bernie Sanders of Vermont who started the movement in the 2016 presidential election.

Senator Sanders introduced his Medicare for All Bill in September 2017 with 13 Senate co-sponsors, including five who have announced their candidacy for president in 2020.

The public is embracing the concept as well. Polling is mixed, but as high as 70 percent of Americans now support Medicare for All, including 85 percent of Democrats and 52 percent of Republicans, according to a recent Reuters survey.

However, as popular as the concept is, the details are lost in the simple slogan of “Medicare for All.”

To further confuse the issue, the specifics of any Medicare for All plan may differ between advocates, with “Single-Payer,” “Public Option,” and “Universal Health Care” all added into the mix to further confuse what any politician or pundit believes.

“Voters have become casualties as candidates toss around these catchphrases – sometimes vaguely and inaccurately,” Kaiser Health News wrote in November.

Health care was the top issue in the midterm elections, and is expected to be a dominant issue in 2020 as well. The potential of an overhaul of our health care delivery system is far too complicated (and weighty) to capture in a jingle.

I will take four options all affiliated with Medicare for All and provide a bit of detail on each.

Option No. 1: Senator Sanders’ plan

The most common interpretation of Medicare for All is the option espoused by Senator Sanders. Although he did not invent the idea of a single-payer health care system, he made the concept a trend.*

Senator Sanders’ plan dispenses with private insurance and creates a government-run health coverage plan (like Medicare) for everyone. There would be no copays or deductibles, and everyone would have access to inpatient and outpatient care for needs as diverse as substance-abuse treatment and long-term care. Prescription drugs, diagnostic tests, and vision care will be obtainable to all.

Unlike a socialist health care system (for example the United Kingdom), in this plan doctors, hospitals and other health care providers will remain independent – the government will pay for care but not provide it.

Paying for this version of Medicare For All is controversial and has incited debate. It will at least be paid for partially by multiple new taxes in the bill, such as a tax on households earning more than $28,800 (escalating for those with annual earnings over $250,000), as well as taxes on capital gains and dividends, and a new “Responsible Estate Tax” on Americans inheriting more than $3.5 million. The tax on employers under Senator Sanders’ bill is 6.2 percent of their employees’ incomes.

As helpful as those revenues may be, the biggest argument against Senator Sanders’ plan is the predicted cost. Senator Sanders estimates a $1.38 trillion per year expenditure; other calculations range from $2.4 trillion to $2.8 trillion – and a report last July by the Mercatus Center at George Mason University placed the cost at a staggering $3.26 trillion annually.

Cost is a significant barrier, but there are other reasons not everyone is endorsing Senator Sanders’ plan. A federal government takeover of health care raises questions about federalism, and there are a lot of people that like the insurance they currently have – such as people with generous employment benefits. The eradication of the health insurance industry would hit small-town insurance brokers on “Main Street, Everywhere” and devastate insurance centers like Hartford, Conn. Finally, this plan would destroy much of the structure created by the Affordable Care Act (ACA), when support for the law is at an all-time high.

*Although I am focusing on the Bernie Sanders’ Bill, in March an even more ambitious plan for Medicare For All – HR 676 – was introduced by 124 progressive Democratic representatives in the House. The bill makes health insurance illegal as well as any for-profit health institution.

Option No. 2: The Public Option

Other lawmakers who endorse Medicare for All want the return of the Public Option. (Some of these people are arguing for both plans simultaneously.)

I wrote about the Public Option in detail in Fontenotes No. 25. This version of “Medicare for All” would not extend government-backed health care coverage to everyone but would make a Medicare-like product available for purchase on the ACA (also called “Exchanges”). Presumably, this would help to control costs within the pool of available policies and could help bring insurance costs down across the industry.

This idea – individuals choosing to buy in to Medicare – was born (and died) in California in 2001. Presidential candidate John Edwards revived the idea in 2008; candidates Barack Obama and Hilary Clinton adopted similar proposals in their campaigns that year.

As President Obama and Congress moved forward writing the ACA, the Public Option remained part of the design, but increasingly it became controversial as private insurance companies argued they could not compete in the market with a government-backed alternative. Democrats ultimately killed the public option, with Sen. Joe Lieberman (D-Conn.) delivering the final blow. (Why? Hint: Where is the Insurance Capital of America?).

Hillary Clinton raised the public option from the ashes as part of her 2016 Presidential Platform.

Now, as we face the presidential election cycle of 2020 the public option has resurfaced again, but under the rubric Medicare for All.

The persistence of this idea was predicted in 2010; that tenacity may point to its value.

The Public Option does not require destroying the private insurance industry, people can keep the insurance they like, and the structure of our providers (profit and not-for-profit) remain the same – there is no immediate government takeover of health care.

The only downfall may be the threat the Public Option poses to the private insurance industry, but that would seem to prove the point. Could the Public Option ultimately lead to a single-payer government-run health care system? Yes, but over time and only if the insurance industry fails to adapt.

Option No. 3: Expanding Medicare eligibility

There are some in Washington with a much smaller expansion of Medicare in mind – simply lowering the age of eligibility to 50 (or 55). Private insurance companies charge more to cover those who fall in the 50 to 64 age range (known as the “age tax”).

Arguments for allowing people as young as 50 into Medicare include the prevention of health conditions that could cost the government more in the long run if untreated until 65, and the business opportunity for private insurance companies offering Medicare Advantage plans to this segment of the population.

The reason to not expand Medicare is, of course, the cost to American taxpayers.

Option No. 4: Leave it to the states

And as another wrinkle, some Democrats want Medicare for All to be a choice each state makes – state-run single-payer plans.

How do any of these options compare with what voters envision?

It is possible that none of the options I described match the expectation of Americans marching under the Medicare for All banner.

Based on promises from politicians, talking heads, and 30-second sound-bites, the vision of many Americans appears to be a health care system even more glorious than any under consideration in Washington. The prospect of obtaining all the care they need, from any provider, without permission from an insurance company, and at no cost is a clarion call for voters.

Democratic politicians, particularly those with their eyes on the presidency, continue to stoke those dreams without addressing the realities: the costs, payoffs, and pitfalls of their plans. One progressive leader described the “pleasant ambiguity” of Medicare for All, which creates “a broad umbrella where any candidate can embrace some version of it.”

American voters deserve better. We need to demand facts, numbers, and clarity as we head into this heated political season. The first question we should ask is “What do you mean by Medicare for All?”