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Editorials: Point and Counterpoint |

POINT: Should Pulmonary/ICU Physicians Support Single-payer Health-care Reform? Yes FREE TO VIEW

Adam W. Gaffney, MD; Philip A. Verhoef, MD, PhD; Jesse B. Hall, MD, FCCP
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: A.G. has received a National Institutes of Health grant [T32 HL116275]. None declared: (P. A. V., J. B. H.).

aDivision of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA

bSection of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL

CORRESPONDENCE TO: Philip A. Verhoef, MD, PhD, Department of Medicine, Section of Pulmonary and Critical Care, 5841 S Maryland Ave, MC 6076, University of Chicago, Chicago, IL 60637


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(1):9-11. doi:10.1016/j.chest.2016.02.660
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Published online

Has the Patient Protection and Affordable Care Act (ACA) finally ensured the longstanding goal of universal health care? Although the ACA helps many people, in several crucial respects it falls well short of a universal system. Rather than comprehensively cover all individuals in a single public program (eg, Medicare for those aged > 65 years), the ACA broadens coverage through a patchwork of provisions predicated on a continued major role for the private health insurance industry. Together, the provisions of the ACA significantly expand insurance coverage. However, even with the law fully implemented, the most serious shortcomings of our health-care system persist. Here we outline why the ACA falls short (with a focus on issues pertinent to pulmonary and critical care medicine) and propose an alternative, truly universal approach to health care in the United States.

Despite the expansion in access under the ACA, ∼27 million individuals are projected to remain uninsured under the law. Uninsurance has grave implications for patients with lung disease and critical illness. For patients with cystic fibrosis, uninsurance has been associated with increased mortality. Similarly, a retrospective evaluation of critically injured pediatric trauma patients revealed that those without insurance were 4.6 times more likely to die compared with the privately insured.

In addition to the problem of uninsurance, disparities among patients with different types of insurance will persist. Much of the expansion of insurance under the ACA is through Medicaid. However, Medicaid—compared with Medicare or private insurance—has been associated with inferior processes of care and outcomes for patients with lung cancer. Nonelderly adults both without insurance or with only Medicaid coverage are also more likely to die during a hospitalization for sepsis. Although these types of studies can be susceptible to residual confounding, Medicaid participants clearly face disparities in access to care, thereby limiting the capacity of the ACA to eliminate insurance-related inequalities. For example, children covered by Medicaid are more likely to be denied appointments to see pediatric specialists.

To summarize, both uninsurance and insurance-related disparities in care will persist under the ACA.

Equally problematic, however, is the problem of increased cost-shifting to patients. High out-of-pocket expenses or exposure in the form of copayments, deductibles, or coinsurance has left an increasing number of Americans (almost one-quarter of insured, nonelderly adults) “underinsured” in 2014. These individuals, although insured, still struggle with medical bills and avoid needed care. Underinsurance, unfortunately, is “built into” the ACA. Plans purchased on the ACA exchanges, for instance, leave families responsible for as much as $13,200 a year in out-of-pocket payments after premiums are paid (depending on income).

Such cost sharing can be particularly burdensome for patients with pulmonary issues. High cost-sharing plans for inhaled medications used by patients with COPD or asthma have been associated with a 41% increase in emergency hospitalizations as well as reduced medication adherence., Similarly, high-deductible health plans deter those of low socioeconomic status from seeking emergency care even for “high-severity” conditions such as acute asthma.

Overall, the ACA perpetuates the misguided notion that more “skin in the game” (or in our case, “lung in the game”) is a wise or just means to control health-care usage and costs.

The economic burden of lung disease in the United States is high. By one estimate, $67.7 billion was spent in direct costs for asthma, COPD, and pneumonia in 2008. The ACA, however, lacks potent cost-control mechanisms.

In recent years, prices for many medications have soared. However, Medicare is still prohibited under the ACA from using its purchasing power to negotiate with pharmaceutical companies for lower prices, and drugs are generally priced at what the “market will bear.” This approach can result in extraordinarily high drug prices in the United States, such as the $373,000 reported annual price of ivacaftor (for cystic fibrosis). Unfortunately, this problem is not limited to new or innovative medications: rising prices for newly patented albuterol inhalers have contributed to spiraling medication costs for patients and an increase of $1.2 billion annually in health-care expenditures in the United States by one estimate.

In contrast with direct negotiation over drug prices, many of the ACA’s cost-saving initiatives have little basis in evidence. For example, under the ACA, Medicare will penalize hospitals that have excessive readmissions for certain conditions, including COPD. However, there is no clear evidence that any specific currently available interventions prevent COPD readmissions. Moreover, penalizing resource-poor safety-net hospitals that care for low socioeconomic status patients may potentially worsen COPD health disparities.

Our current system has also done poorly with respect to the control, planning, and regionalization of ICU infrastructure. Despite decreasing numbers of total hospital beds, the number of ICU beds continues to rise. Because ICU bed supply likely drives ICU bed use, excesses in ICU infrastructure may be driving increased costs without clear benefits, underscoring the importance of a more rational system of ICU capital planning.

Finally, the ACA does not address what may be the most wasteful aspect of the US health-care system: the massive administrative costs that are unavoidable in a fragmented multipayer system. Compared with Canada, the United States spends much more on health-care administration and has a much greater percentage of the health-care workforce engaged in administrative work. This large and unnecessary burden of excessive health-care administration—in the private insurance industry, the hospital billing office, or the outpatient practice—is by no means diminished, and indeed may grow, under the ACA.

A single-payer national health program (NHP) system would address the numerous problems that we have outlined thus far. A proposal for such a program has been published previously and is briefly summarized here as follows.

Unlike the ACA, the NHP would provide coverage for the entire US population, replacing existing public and private insurance plans. Benefits would be comprehensive and would include medical care, dental care, prescription drugs, long-term care, and mental health care. Such a system would eliminate disparities on the basis of insurance status and eliminate financial barriers to care in the form of cost sharing.

This expansion of care would be funded in a cost-neutral manner through powerful cost-control mechanisms. First, as discussed earlier, a single-payer reform would dramatically lower spending on health-care administration, in part through the “global budgeting” of hospitals. Second, a NHP would directly negotiate with pharmaceutical companies over drug prices. Third, operating expenses would be separated from capital expenditures, facilitating the rational, planned expansion of health-care infrastructure such as ICUs.

There could be additional benefits from such a comprehensive reform. Physicians, for instance, although still paid through various currently existing modes of payment, could expect dramatic reductions in the clerical work required of billing. For investigators, a centralized single-payer system might facilitate population-level research, which is currently impeded by the current, multipayer environment. A single-payer system would also allow health-care administrators to focus on optimizing system performance, shifting the emphasis away from business activities such as advertising and acquisitions.

Most importantly, for patients and their families, an NHP would mean that sickness and health would be entirely divorced from financial concerns. Our health-care system would again be centered on the mission of health.

As pulmonary and critical care physicians, we aim to utilize the highest quality evidence, in conjunction with our understanding of the pathophysiologic and social determinants of health, to provide the best care for patients. By taking such an evidence-based approach to the realm of policy, we conclude that only a single-payer system can address the problem of rising health-care costs, while simultaneously ending the grave inequalities that continue to plague our critically ill health-care system.

Congressional Budget Office. Insurance coverage provisions of the Affordable Care Act-CBO’s March 2015 Baseline.https://www.cbo.gov/sites/default/files/51298-2015-03-ACA.pdf. Accessed May 6, 2015.
 
Curtis J.R. .Burke W. .Kassner A.W. .Aitken M.L. . Absence of health insurance is associated with decreased life expectancy in patients with cystic fibrosis. Am J Respir Crit Care Med. 1997;155:1921-1924 [PubMed]journal. [CrossRef] [PubMed]
 
Cassidy L.D. .Lambropoulos D. .Enters J. .Gourlay D. .Farahzad M. .Lal D.R. . Health disparities analysis of critically ill pediatric trauma patients in Milwaukee, Wisconsin. J Am Coll Surg. 2013;217:233-239 [PubMed]journal. [CrossRef] [PubMed]
 
Slatore C.G. .Au D.H. .Gould M.K. . An official American Thoracic Society systematic review: insurance status and disparities in lung cancer practices and outcomes. Am J Respir Crit Care Med. 2010;182:1195-1205 [PubMed]journal. [CrossRef] [PubMed]
 
O'Brien J.M. Jr..Lu B. .Ali N.A. .Levine D.A. .Aberegg S.K. .Lemeshow S. . Insurance type and sepsis-associated hospitalizations and sepsis-associated mortality among US adults: a retrospective cohort study. Crit Care. 2011;15:R130- [PubMed]journal. [CrossRef] [PubMed]
 
Lyon S.M. .Douglas I.S. .Cooke C.R. . Medicaid Expansion under the Affordable Care Act. Implications for insurance-related disparities in pulmonary, critical care, and sleep. Ann Am Thorac Soc. 2014;11:661-667 [PubMed]journal. [CrossRef] [PubMed]
 
Bisgaier J. .Rhodes K.V. . Auditing access to specialty care for children with public insurance. N Engl J Med. 2011;364:2324-2333 [PubMed]journal. [CrossRef] [PubMed]
 
Collins S.R. .Rasmussen P.W. .Beutel S. .Doty M.M. . The Problem of Underinsurance and How Rising Deductibles Will Make It Worse—Findings from the Commonwealth Fund Biennial Health Insurance Survey. The Commonwealth Fund. 2015;:- [PubMed]journal
 
Dormuth C.R. .Maclure M. .Glynn R.J. .Neumann P. .Brookhart A.M. .Schneeweiss S. . Emergency hospital admissions after income-based deductibles and prescription copayments in older users of inhaled medications. Clin Ther. 2008;30:1038-1050 [PubMed]journal. [CrossRef] [PubMed]
 
Dormuth C.R. .Glynn R.J. .Neumann P. .Maclure M. .Brookhart A.M. .Schneeweiss S. . Impact of two sequential drug cost-sharing policies on the use of inhaled medications in older patients with chronic obstructive pulmonary disease or asthma. Clin Ther. 2006;28:964-978 [PubMed]journal. [CrossRef] [PubMed]
 
Wharam J.F. .Zhang F. .Landon B.E. .Soumerai S.B. .Ross-Degnan D. . Low-socioeconomic-status enrollees in high-deductible plans reduced high-severity emergency care. Health Aff (Millwood). 2013;32:1398-1406 [PubMed]journal. [CrossRef] [PubMed]
 
National Heart, Lung and Blood Institute. Morbidity and mortality: 2012 chart book on cardiovascular, lung, and blood diseases. National Institutes of Health website.http://www.nhlbi.nih.gov/files/docs/research/2012_ChartBook.pdf. Accessed March 3, 2015.
 
O’Sullivan B.P. .Orenstein D.M. .Milla C.E. . Pricing for orphan drugs: will the market bear what society cannot? JAMA. 2013;310:1343-1344 [PubMed]journal. [CrossRef] [PubMed]
 
Hendeles L. .Colice G.L. .Meyer R.J. . Withdrawal of albuterol inhalers containing chlorofluorocarbon propellants. N Engl J Med. 2007;356:1344-1351 [PubMed]journal. [CrossRef] [PubMed]
 
Prieto-Centurion V. .Markos M.A. .Ramey N.I. .et al Interventions to reduce rehospitalizations after chronic obstructive pulmonary disease exacerbations. A systematic review. Ann Am Thorac Soc. 2014;11:417-424 [PubMed]journal. [CrossRef] [PubMed]
 
Sjoding M.W. .Cooke C.R. . Readmission penalties for chronic obstructive pulmonary disease will further stress hospitals caring for vulnerable patient populations. Am J Respir Crit Car Med. 2014;190:1072-1074 [PubMed]journal. [CrossRef]
 
Halpern N.A. .Pastores S.M. . Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med. 2010;38:65-71 [PubMed]journal. [CrossRef] [PubMed]
 
Gooch R.A. .Kahn J.M. . ICU bed supply, utilization, and health care spending: an example of demand elasticity. JAMA. 2014;311:567-568 [PubMed]journal. [CrossRef] [PubMed]
 
Woolhandler S. .Campbell T. .Himmelstein D.U. . Costs of health care administration in the United States and Canada. N Engl J Med. 2003;349:768-775 [PubMed]journal. [CrossRef] [PubMed]
 
Woolhandler S. .Himmelstein D.U. .Angell M. .Young Q.D. . Physicians' Working Group for Single-Payer National Health Insurance. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA. 2003;290:798-805 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Congressional Budget Office. Insurance coverage provisions of the Affordable Care Act-CBO’s March 2015 Baseline.https://www.cbo.gov/sites/default/files/51298-2015-03-ACA.pdf. Accessed May 6, 2015.
 
Curtis J.R. .Burke W. .Kassner A.W. .Aitken M.L. . Absence of health insurance is associated with decreased life expectancy in patients with cystic fibrosis. Am J Respir Crit Care Med. 1997;155:1921-1924 [PubMed]journal. [CrossRef] [PubMed]
 
Cassidy L.D. .Lambropoulos D. .Enters J. .Gourlay D. .Farahzad M. .Lal D.R. . Health disparities analysis of critically ill pediatric trauma patients in Milwaukee, Wisconsin. J Am Coll Surg. 2013;217:233-239 [PubMed]journal. [CrossRef] [PubMed]
 
Slatore C.G. .Au D.H. .Gould M.K. . An official American Thoracic Society systematic review: insurance status and disparities in lung cancer practices and outcomes. Am J Respir Crit Care Med. 2010;182:1195-1205 [PubMed]journal. [CrossRef] [PubMed]
 
O'Brien J.M. Jr..Lu B. .Ali N.A. .Levine D.A. .Aberegg S.K. .Lemeshow S. . Insurance type and sepsis-associated hospitalizations and sepsis-associated mortality among US adults: a retrospective cohort study. Crit Care. 2011;15:R130- [PubMed]journal. [CrossRef] [PubMed]
 
Lyon S.M. .Douglas I.S. .Cooke C.R. . Medicaid Expansion under the Affordable Care Act. Implications for insurance-related disparities in pulmonary, critical care, and sleep. Ann Am Thorac Soc. 2014;11:661-667 [PubMed]journal. [CrossRef] [PubMed]
 
Bisgaier J. .Rhodes K.V. . Auditing access to specialty care for children with public insurance. N Engl J Med. 2011;364:2324-2333 [PubMed]journal. [CrossRef] [PubMed]
 
Collins S.R. .Rasmussen P.W. .Beutel S. .Doty M.M. . The Problem of Underinsurance and How Rising Deductibles Will Make It Worse—Findings from the Commonwealth Fund Biennial Health Insurance Survey. The Commonwealth Fund. 2015;:- [PubMed]journal
 
Dormuth C.R. .Maclure M. .Glynn R.J. .Neumann P. .Brookhart A.M. .Schneeweiss S. . Emergency hospital admissions after income-based deductibles and prescription copayments in older users of inhaled medications. Clin Ther. 2008;30:1038-1050 [PubMed]journal. [CrossRef] [PubMed]
 
Dormuth C.R. .Glynn R.J. .Neumann P. .Maclure M. .Brookhart A.M. .Schneeweiss S. . Impact of two sequential drug cost-sharing policies on the use of inhaled medications in older patients with chronic obstructive pulmonary disease or asthma. Clin Ther. 2006;28:964-978 [PubMed]journal. [CrossRef] [PubMed]
 
Wharam J.F. .Zhang F. .Landon B.E. .Soumerai S.B. .Ross-Degnan D. . Low-socioeconomic-status enrollees in high-deductible plans reduced high-severity emergency care. Health Aff (Millwood). 2013;32:1398-1406 [PubMed]journal. [CrossRef] [PubMed]
 
National Heart, Lung and Blood Institute. Morbidity and mortality: 2012 chart book on cardiovascular, lung, and blood diseases. National Institutes of Health website.http://www.nhlbi.nih.gov/files/docs/research/2012_ChartBook.pdf. Accessed March 3, 2015.
 
O’Sullivan B.P. .Orenstein D.M. .Milla C.E. . Pricing for orphan drugs: will the market bear what society cannot? JAMA. 2013;310:1343-1344 [PubMed]journal. [CrossRef] [PubMed]
 
Hendeles L. .Colice G.L. .Meyer R.J. . Withdrawal of albuterol inhalers containing chlorofluorocarbon propellants. N Engl J Med. 2007;356:1344-1351 [PubMed]journal. [CrossRef] [PubMed]
 
Prieto-Centurion V. .Markos M.A. .Ramey N.I. .et al Interventions to reduce rehospitalizations after chronic obstructive pulmonary disease exacerbations. A systematic review. Ann Am Thorac Soc. 2014;11:417-424 [PubMed]journal. [CrossRef] [PubMed]
 
Sjoding M.W. .Cooke C.R. . Readmission penalties for chronic obstructive pulmonary disease will further stress hospitals caring for vulnerable patient populations. Am J Respir Crit Car Med. 2014;190:1072-1074 [PubMed]journal. [CrossRef]
 
Halpern N.A. .Pastores S.M. . Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med. 2010;38:65-71 [PubMed]journal. [CrossRef] [PubMed]
 
Gooch R.A. .Kahn J.M. . ICU bed supply, utilization, and health care spending: an example of demand elasticity. JAMA. 2014;311:567-568 [PubMed]journal. [CrossRef] [PubMed]
 
Woolhandler S. .Campbell T. .Himmelstein D.U. . Costs of health care administration in the United States and Canada. N Engl J Med. 2003;349:768-775 [PubMed]journal. [CrossRef] [PubMed]
 
Woolhandler S. .Himmelstein D.U. .Angell M. .Young Q.D. . Physicians' Working Group for Single-Payer National Health Insurance. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA. 2003;290:798-805 [PubMed]journal. [CrossRef] [PubMed]
 
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