Healthcare has emerged as one of the flash points in the Democratic presidential race.
Vermont Sen. Bernie Sanders has been a longtime supporter of a concept he calls “Medicare for All,” a health system that falls under the heading of “single-payer.”
Sanders released more details about his proposal shortly before the Democratic debate in South Carolina Sunday night. “What a Medicare-for-All program does is finally provide in this country health care for every man, woman and child as a right,” he said in Charleston.
Sanders’s main rival for the nomination, former Secretary of State Hillary Clinton, has criticized the plan for raising taxes on the middle class and said it is politically unattainable. “I don’t want to see us start over again with a contentious debate” about health care, she said Sunday night.
Some of the details of Sanders’s plan are still to be released. But his proposal has renewed questions about what a single-payer health care system is and how it works. Here are some quick answers.
What Is Single-Payer?
Single-payer refers to a system in which one entity (usually the government) pays all the medical bills for a specific population. And usually (though again, not always) that entity sets the prices for medical procedures.
Single-payer is not the same thing as socialized medicine. In a truly socialized medicine system, the government not only pays the bills but owns the health care facilities and employs the professionals who work there.
The Veterans Health Administration (VA) is an example of a socialized health system run by the government. It owns the hospitals and clinics and pays the doctors, nurses and other health providers.
Medicare, on the other hand, is a single-payer system in which the federal government pays the bills for those who qualify, but hospitals and other providers remain private.
Which Countries Have Single-Payer Health Systems?
Fewer than many people think. Most European countries either never had or no longer have single-payer systems. “Most are basically what we call social-insurance systems,” said Gerard Anderson, a professor at Johns Hopkins Bloomberg School of Public Health, who has studied international health systems. Social insurance programs ensure that almost everyone is covered. They are taxpayer-funded but are not necessarily run by the government.
Germany, for example, has 135 “sickness funds,” which are essentially private, nonprofit insurance plans that negotiate prices with healthcare providers. “So you have 135 funds to choose from,” Anderson said.
Nearby, Switzerland and the Netherlands require their residents to have private insurance (just like the Affordable Care Act does), with subsidies to help those who cannot otherwise afford coverage.
And while conservatives in the United States often use Britain’s National Health Service as the poster child for a socialized system, there are many private insurance options available to residents there, too.
Among the countries that have true single-payer systems, Anderson lists only two — Canada and Taiwan.
Are Single-Payer Plans Less Expensive Than Other Health Coverage Systems?
Not necessarily. True, eliminating the profits and duplicative administrative costs associated with hundreds of different private insurance plans would reduce spending, perhaps as much as 10 percent of the nation’s $3 trillion annual health care bill, Anderson said. But, he noted, once that savings is achieved, there won’t be further reductions in following years.
More important, as many analysts have noted, is how much health services cost and how those prices are determined. In most other developed countries, even those with private insurance, writes Princeton Health Economist Uwe Reinhardt, prices “either are set by government or negotiated between associations of insurers and providers of care on a regional, state or national basis.” By contrast, in the U.S., “the payment side of the health care market in the private sector is fragmented, weakening the bargaining power of individual insurers.”
Would Medicare For All Be Just Like The Existing Medicare Program?
No, at least not as Sanders envisions it. Medicare is not nearly as generous as many people think. Between premiums (for doctor and drug coverage), cost-sharing (deductibles and coinsurance) and items Medicare does not cover at all (most dental, hearing and eye care), the average Medicare beneficiary still devotes an estimated 14 percent of all household spending to health care.
Sanders’s plan would be far more generous, including dental, vision, hearing, mental health and long-term care, all without copays or deductibles (which has given rise to a lively debate about how to pay for it and whether middle-class families will save money or pay more).
WouldPrivate Insurance Companies Really Disappear Under Sanders’s Plan?
Probably not. Private insurers are fully integrated into Medicare, handling most of the claims processing and providing supplemental coverage through “Medigap” plans. In addition, nearly a third of Medicare beneficiaries are enrolled in private managed care plans as part of the Medicare Advantage program.
Creating an entirely new federal claims processing structure would in all likelihood be more expensive than continuing to contract with private insurance companies. However, Sanders makes it clear that insurers in the future would no longer be the risk-bearing entities they are today, but more like regulated utilities.
Physicians’ practices are increasingly trying to reach their patients online. But don’t expect your doctor to “friend” you on Facebook – at least, not just yet.
Physicians generally draw a line: Public professional pages – focused on medicine, similar to those other businesses offer – are catching on. Some might email with patients. But doctors aren’t ready to share vacation photos and other more intimate details with patients, or even to advise them on medication or treatment options via private chats. They’re hesitant to blur the lines between personal lives and professional work and nervous about the privacy issues that could arise in discussing specific medical concerns on most Internet platforms.
Some of that may eventually change. One group, the American College of Obstetricians and Gynecologists, broke new ground this year in its latest social-media guidelines. It declined to advise members against becoming Facebook friends, instead leaving it to physicians to decide.
“If the physician or health care provider trusts the relationships enough … we didn’t feel like it was appropriate to really try to outlaw that,” said Nathaniel DeNicola, M.D., an ob-gyn and clinical associate at the University of Pennsylvania, who helped write the ACOG guidelines.
But even the use of these professional pages raises questions: How secure are these forums for talking about often sensitive health information? When does using one complicate the doctor-patient relationship? Where should boundaries be drawn?
For patients, connecting with a physician’s office or group practice on Facebook can be a simple way to keep up with basic health news. It’s not unlike following a favorite sports team, your child’s middle school or the local grocery store.
One Texas-based obstetrics and gynecology practice, for instance, uses a public Facebook page to share tips about pregnancy and childcare, with posts ranging from suggestions on how to stay cool in the summer to new research on effective exercise for post-birth weight gain. Practices have also been known to share healthy recipes, medical research news, and scheduling details for the flu shot season..
“I have people come up to me and say, ‘I follow you on Facebook — thank you for posting this particular article. It helped me and my husband and my family,’” said Lisa Shaver, M.D., a primary-care physician based in Portland, Ore.
But unless they’re already friends, she won’t add patients to her personal account — where, she said, she posts less health information and more cat videos.
Historically, professional groups including the American College of Physicians and American Academy of Family Physicians have advised against communicating through personal Facebook pages. The American Medical Association notes that social media can be a valuable way to spread health information, but urged doctors in its 2010 guidelines to separate their personal and professional online identities to “maintain professional boundaries.”
Finding ways to use Facebook and other forms of social media to connect with patients — even if it may just be through professional pages — fits a trend in which patients seek more equal footing with their doctors, said Zack Berger, M.D., an assistant professor of medicine at the Johns Hopkins School of Medicine who studies patient-doctor relationships and social media. It also follows what James Colbert, M.D., a hospitalist at Massachusetts-based Newton Wellesley (Mass.) Hospital, described as the growing consumer approach to medicine — including the notion that patients should be able to reach their physicians at all hours. Colbert is also an instructor at Harvard Medical School who researches how patients want to fit social technology into their health care.
Email can be particularly convenient method, though it isn’t without concerns. Eva Schweber, 44, emails her doctor from a personal account and sends messages through an online portal — a more digitally secure system that is being adopted by a growing number of practices. The portal, she said, is for discussing complex, specific information. She’ll email her doctor from her personal email for less private concerns: scheduling, filling prescriptions and asking if certain symptoms might warrant a check-up.
“The unsecure email is easier, in that I can do it from my phone, my tablet, whatever,” said Schweber, of Portland, Ore.
In a recent study published in the Journal of General Internal Medicine, almost 20 percent of patient respondents reported trying to contact doctors through Facebook, and almost 40 percent through email. “Patients want to communicate with doctors [in whatever way] is convenient,” said Joy Lee, a postdoctoral research fellow at the Johns Hopkins Bloomberg School of Public Health, and the study’s lead author.
Doctors don’t yet seem to share that enthusiasm, Colbert said.
Meanwhile, security questions persist.
Social-networking platforms aren’t usually digitally encrypted, increasing the odds they could get hacked or shared with third parties. The same worries hold true for other, casual forms of online communication such as email and text-messaging.
That means doctors who discuss specific health concerns with patients through those could break the Health Insurance Portability and Accountability Act, the patient privacy law.
“Those concerns are always going to be there,” said David Fleming, past president of the American College of Physicians. “How private is it when we share, when we talk to people? … Once I’ve written it or once I’ve emailed it, it’s gone, and I have no control.”
But because HIPAA was written before email and social media’s ascent, it may not address patient preferences or behavior, Colbert said. With more patients becoming comfortable using personal accounts for health needs, he said, the law perhaps deserves another look.
“Should we allow patients to be able to share or send messages without going through these privacy safeguards if they’re willing to do so? Or do we say that that’s not safe and even if patients don’t care about privacy we need to protect them,” he said. “That’s an open question.”
That public nature is a real worry for such patients as Katie Cardenas, 45, who lives in Garner, N.C. She doesn’t think that Facebook is secure enough for personal medical details. For sensitive information, she’ll usually send messages through a patient portal, the more secure website her doctor’s practice has set up.
Doctors could address that, several said, by using social media in other ways. These include maintaining active Twitter presences and professional Facebook pages for less-tailored health tips. That way, patients can get useful information and a sense of their doctors as people, but privacy stays intact and physicians maintain distance.
At the Minnesota-based St. Cloud Medical Group, patients can follow a public page. Doctors who are part of the practice post updates with safety tips and seasonal health reminders, or use the page to coordinate and publicize small projects, such as a week-long initiative geared to reducing children’s screen time.
Julie Anderson, a family physician who is also part of the practice, sees the value in this option, but doesn’t personally befriend patients on Facebook. Beyond patient privacy, she said, she fears blurring her personal and professional lives, or patients using that access to seek extra care when she’s off the clock.
“I’ve known colleagues that have friended somebody and have had inappropriate questions asked online, in terms of kind of abusing service,” she said. “Or abusing that … Facebook friendship, where they’re asking medical advice and you’re not even their physician.”
When Michael Kamins opened the letter from his insurer, he was enraged.
His 20-year-old son recently had been hospitalized twice with bipolar disorder and rescued from the brink of suicide, he said. Now, the insurer said he had improved and it was no longer medically necessary for the young man to see his psychiatrist two times a week. The company would pay for two visits per month.
“There was steam coming out of my ears,” Kamins recalled, his face reddening at the memory of that day in June 2012. “This is my kid’s life!“
His son again became suicidal and violent, causing him to be rehospitalized eight months later, said Kamins, a marketing professor at the State University of New York at Stony Brook. Kamins is suing the insurer, OptumHealth Behavioral Solutions, which disputes his version of events and denies that it left the young man without sufficient care.
Seven years after Congress passed a landmark law banning discrimination in the treatment of mentally ill people, many families and their advocates complain it stubbornly persists, largely because insurers are subverting the law in subtle ways and the government is not aggressively enforcing it.
The so-called parity law, which was intended to equalize coverage of mental and other medical conditions, has gone a long way toward eliminating obvious discrepancies in insurance coverage. Research shows, for instance, that most insurers have dropped annual limits on the therapy visits that they will cover. Higher co-payments and separate mental health deductibles have become less of a problem.
But many insurers have continued to limit treatment through other strategies that are harder to track, according to researchers, attorneys and other critics. Among the more murky areas is “medical necessity” review – in which insurers decide whether a patient requires a certain treatment and at what frequency.
Kamins is among a small group of people around the country to file lawsuits alleging federal or state parity laws were violated when patients with mental illness were held to a stricter “medical necessity” standard than those with other medical conditions.
“’Medical necessity’ is the insurers’ last hurrah,” said Meiram Bendat, Kamins’s lawyer, who filed the lawsuit in New York State court.
Bendat, who is seeking class-action status in the Kamins case and has filed other parity suits in New York, Illinois and California, said attorneys are acting because the government won’t.
Enforcement of parity laws is lax, he said, and companies are getting away with skirting their requirements.
In fact, only a handful of states have dug into whether insurers are complying with parity laws. And in the seven years since the federal law was passed, the U.S. government has not taken a single public enforcement action against an insurer or employer for violating the law.
Clare Krusing, a spokesperson for America’s Health Insurance Plans, the industry’s main trade/lobbying group, said it is “a misperception” that enforcement has been weak. Insurers are working closely with federal and state governments, she said, and “have taken tremendous steps to implement these changes and requirements in a way that is affordable to patients.”
Ensuring that mental health and other medical treatments are exactly on par is challenging, she said.
“A treatment plan for diabetes or a chronic heart disease is very different from a treatment plan for a patient that’s seeking care for depression or another mental illness,” she said. “It’s not a math formula.”
But Henry Harbin, former CEO of Magellan Health, a managed behavioral- healthcare company, said insurers are taking advantage of minimal oversight.
“They can micromanage care down to almost nothing,” said Harbin, who also served as Maryland’s mental-health director before becoming a consultant. “The enforcement in this area is a joke.”
Great Expectations
When it passed in 2008, the federal mental health parity law was seen as a major achievement for Americans with mental illnesses.
Though some states already had their own parity laws on the books, there were serious gaps in the protections they offered. This law was to force insurers across the country to provide the same access to treatment as they do for cancer, diabetes and other conditions.
At the time, then-Sen. Edward Kennedy called the law “historic,” and praised his colleagues for finally ending “the senseless discrimination in health-insurance coverage that plagues persons living with mental illness.”
But enforcement was not assigned to any one agency. Instead, it fell to the departments of Labor, Health and Human Services and Treasury, as well as state insurance commissioners.
The Department of Labor, which is responsible for monitoring health insurance offered by large employers, set up a complaint line for consumers. Still, advocates say, most consumers don’t know they have new rights, and those that do often don’t know where to turn.
“It gets very complicated for the average person,” said Carol McDaid, who runs the Parity Implementation Coalition, an advocacy group created to make sure parity laws were properly enforced.
“They’re already in a [mental health] crisis, looking for help, and they don’t know if they should write and complain to their state insurance commissioner, the Department of Labor, the health department. It gets very difficult.”
Since 2010, just 867 of the 1.5 million total health insurance inquiries made to the Department of Labor had to do with the parity law, most of which were not complaints, a spokesman for the department said in May. A total of 140 cases of alleged parity law violations were found, and they were resolved through “voluntary compliance,” in which the employer agreed to pay for the patient’s services, the spokesman said. He said that the investigators also requested that the insurers change their broader policies, when appropriate.
Separately, HHS found 196 possible violations of parity law by insurers from September 2013 through September 2014, a spokeswoman said. In each case, she said, plans voluntarily made changes or told the agency they believed that their plan was in compliance with the law.
No action by a federal agency, however, resulted in a lawsuit, fine or public announcement.
“Our problem is that these investigations are all kept secret,” McDaid said. That means the decisions have no effect on what other employers or insurers do, and consumers don’t learn what to look out for, she said.
Former Congressman Patrick Kennedy, one of the authors of the parity law and who has suffered from bi-polar disorder, said timing was partly to blame for the administration’s sparse enforcement record.
“Parity got kicked down the track until the Obama administration could get the Affordable Care Act on track,” he said. It took five years for the government to issue final rules explaining exactly what insurers had to do to comply.
Enforcing laws against insurance companies, he added, was also a delicate undertaking.
“Insurance companies were part of the coalition that helped bring the ACA to life, and the administration feels an enormous debt of gratitude,” he said. “It’s a challenge politically to then step on the toes of those that brought them to the dance.”
Meanwhile, research points to some continuing inequities in coverage.
Data compiled on health plans in 2010, the first year of the national parity law’s implementation, disclosed that insurers frequently reviewed mental health treatment more strictly than other care. For instance, they more often required “preauthorization” for doctor visits or made patients “fail first” at one level of care before getting approval for another.
A study this year from the Johns Hopkins Bloomberg School of Public Health found that a quarter of the plans sold on two state Obamacare exchanges appeared to violate the federal parity law in various ways, including requiring higher cost-sharing for mental health. The states, one large and one small, were not named.
In a 2015 survey by the National Alliance on Mental Illness, an advocacy group for mentally ill people and their families, patients said they were denied payment because treatment was deemed “not medically necessary” twice as often for mental health as for other medical conditions.
Without strong government enforcement, patients and families say they are left to their own devices.
But demonstrating that an insurer has violated parity rules requires a detailed analysis of a plan’s mental health and medical benefits. And though the law requires that insurers disclose those documents, critics say they often are not complying.
The Parity Implementation Coalition in Washington, D.C., has received hundreds of consumer complaints to its helpline, but McDaid said virtually none of the health plans have been willing to release the necessary documents to demonstrate that there has been a parity violation, she said.
Krusing, of the insurers’ association, insisted that documents are being made available to patients and providers. “Plans are committed to being transparent about their coverage decisions,” she said. Decisions to deny treatment, she said, are based on ensuring that patients receive care based on the best medical evidence.
“We are still at a point in the health system where patients face wide variation in the type of care they’re receiving,” she said. “Oftentimes we see tests and procedures done that are costly and unnecessary for the type of care that they’re seeking or even help or benefit their condition.”
The federal government is considering whether to tighten disclosure rules for insurers. In the meantime, some consumers, including the Kamins family, are turning to the courts.
Debating What’s ‘Medically Necessary’
Kamins’s son had always been a star, according to his father, who holds his power of attorney and asked that the young man’s first name be withheld for privacy reasons.
As a boy, he was a quiet but quick-witted jokester, who graduated fifth in his high school class in 2010, Kamins said.
A few months after heading to an Ivy League college, however, he was overcome by depression, his father said. His grades slipped. He began experimenting with drugs. Then, in the spring of 2011, he tried to kill himself, according to Kamins and the lawsuit.
His parents brought him home to Los Angeles, where the family lives while Kamins commutes back and forth to New York. The family has insurance through Kamins’s job.
But Kamins said OptumHealth Behavioral Solutions would not cover inpatient care before his son had tried an outpatient program that focused on drug addiction.
That marked the first of several violations of parity law, according to Kamins’ lawsuit, which seeks a change in Optum’s policy and reimbursement for benefits denied, plus attorneys’ fees. By requiring the young man to “fail first” at a lower level of care before paying for more expensive residential treatment, Optum, a subsidiary of UnitedHealth Group, had created an illegal obstacle to mental health treatment, the lawsuit alleges.
“Imagine someone going to a hospital and being told you can’t get open-heart surgery in the midst of a heart attack because you haven’t tried aspirin or nitroglycerin first. That’s the absurdity of it,” said Bendat, Kamins’ lawyer. “It’s just a way to discourage higher levels of care that we would never tolerate in the non-psychiatric context.”
After the addiction program, Optum paid for the young man to see a psychiatrist a few times a week. His father said he began showing signs of improvement and seemed on track to return to school back East.
But in June 2012 — four months after the young man was hospitalized during a manic episode — the insurer’s letter arrived saying it was no longer “medically necessary” for him to see his psychiatrist so frequently.
That fall, the suit alleges, Kamins’ son tried to return to his Ivy League school. He found a psychiatrist and began going twice a month as he had been authorized to do in the letter, Bendat said. Kamins said he tapped into his retirement fund to pay for extra visits, but his son spiraled downward.
In court documents, Optum alleges that Kamins’ sson actually was entitled to more frequent visits with a new mental-health provider, suggesting that the limitation on visits applied only to the psychiatrist he had been seeing in California. The insurer argues that his subsequent hospitalization in February had nothing to do with limitations put on visits in California.
In a written statement, Optum officials said they “take the mental health needs of each of our members very seriously, and we are committed to helping them get care that has shown to be most effective in helping people overcome and live better with mental and emotional challenges.”
Kamins said that was not his experience.
“The irony in all this is that Optum fights tooth and nail to dole out care for my son. But had they allowed him upfront to get the care he needed, he might not have ended up back in the hospital, which they had to pay for,” he said.
As for Kamins’ sson, he returned to college in the fall of 2013. The next year, his father’s employer contracted with a new insurer, which Kamins said gave the young man greater access to care and helped him stabilize.
