If you ask a pharmacist or student pharmacist what motivated them to follow their career path, a common answer will likely include the desire to improve people’s lives through quality pharmaceutical care. If you ask a practicing pharmacist what most frustrates them about their pharmacy career, you are likely to hear a litany of complaints about insurance companies (e.g., prior authorizations, pharmacy benefit managers [PBMs], clawbacks, closed networks, direct and indirect remuneration [DIR] fees, etc). These are “features” of the byzantine United States (US) healthcare system, which is centered on private insurers and where an estimated 34.2% of health care dollars are spent on administrative costs versus 17.0% in Canada. Pharmacists and other health professionals spend an inordinate amount of time navigating these “features” instead of focusing on patient care. Fortunately, there is a solution: a single-payer healthcare system (e.g., Medicare for All).
What is a single-payer healthcare system?
When defining “single-payer healthcare system” in the context of recent Medicare for All (M4A) proposals, it may be helpful to emphasize what it is not. First and foremost, despite the scare tactics of M4A opponents, single-payer M4A is NOT government-run healthcare. Rather, as Physicians for a National Health Plan specifies, single-payer is financed through a single, typically public entity, while private entities (e.g., physicians, pharmacists, hospitals, pharmacies, etc) continue to deliver health care to the public. Current single-payer proposals would provide US residents with universal healthcare coverage. Cost savings would primarily come from substantially lower administrative costs as a result of having one payer rather than more than 900. With a single-payer, networks would be eliminated thus providing people with the ultimate freedom of health care choice.
Healthcare should not be a politicized issue
Some folks may balk at moving towards a single-payer system. They may ask: ‘Don’t we have the most advanced health care in the world?’ or ‘We are the richest country in the world, isn’t our healthcare system the best?’ While the US may have the most advanced health care available, access to that health care is not universal, which contributes to rampant health disparities. Our healthcare system is certainly the best at spending. We have the highest per capita healthcare spending as a function of gross domestic product (gross domestic product (GDP). Despite that spending, as Galvani et al point out, the US “ranks below 30 countries for many public health indicators, including preventable deaths, infant survival, maternal mortality, and overall life expectancy.” While many factors contribute to poor health outcomes in the US, the lack of adequate healthcare access (including those with insurance) is a major contributor. Even though the Affordable Care Act has enabled many people to obtain coverage through Medicare and Medicaid, the National Health Interview Survey estimated the number of uninsured to be about 30 million in the first half of 2020. As the pandemic and the recession continues, extended employee-sponsored coverages and furlough protections are expiring; the number is only expected to be higher. According to the latest estimate by the Economic Policy Institute, 12 million Americans have lost their health coverage.
The support for the single-payer system stems from Medicare and Medicaid which are equally popular public health programs in the United States. The Kaiser Family Foundation reports 77 percent of the public perceive Medicare as an important program. 63 percent of the respondents say medicaid is very important. Support for public programs are similar among party lines (85 percent of Republicans, 89 percent of independents, and 92 percent of Democrats favor Medicare). As M4A is becoming a staple conversation in our healthcare, the attitudes towards the implementation of a single-payer system remain divided. Eight out of ten democrats favor M4A while three-fourth Republicans oppose its implementation. Differences of public opinions are more evident around terminologies that politicians use in their arguments (e.g. universal health coverage, national health plan, socialized medicine etc.). This means political affiliation is swaying more divisive public opinions even though the evidence might be leaning in favor of a universal national program aka a single-payer system. A recent survey representing the experiences of more than 61 million US adults showed that respondents with public health insurance (Medicare, Medicaid, and veterans Health Administration) were more likely to have a personal physician and less likely to report instability in insurance coverage, difficulty seeing a patient or taking medications because of costs, and having medical debt compared with employer-sponsored coverage (79% had employer-sponsored coverage). Individuals with employer-sponsored insurance also reported less satisfaction with their care compared to those covered by Medicare. These findings favor the implementation of a single-payer system that can potentially deliver more cost-effective care than private options.
The data is clear on affordability and access
Affordability has been overwhelmingly cited as the primary reason Americans opt out of healthcare. According to a 2019 survey published by the Center for Disease Control and Prevention, the inability to pay premiums was the most common reason for being uninsured among uninsured adults aged 18-64. Adults in fair or poor health were more likely to be underinsured due to affordability than those in excellent, very good, or good health. A recent survey by AccessOne showed 66% of Americans were concerned about being able to afford health care in 2021. Loss of health insurance can impact certain populations more than others. About 33% of Gen Z and 29% of millennials had their health insurance affected by the pandemic versus 12% of baby boomers.
The national average for a premium benchmark marketplace plan in 2021 is $452 per month which increased from $273 in 2014 (66% increase). Most plans also carry high deductibles and/or co-pays on top of in/out-of-network complexities. A recent 2020 survey showed 47% participants chose their healthcare based on costs. This means people are forgoing necessary interventions/procedures because of cost. Private insurance companies are also notorious for maximizing profit by minimizing short-term costs. Since insurance companies do not have lifespan commitments to their patients (compared to a single-payer system), short sighted cost cutting techniques are implemented at the expense of the patient’s long-term health. Canada (single-payer health system) spends more per capita on prevention as a share of total national health expenditure than the US (6.2% versus 2.8%). As a result, when both countries are compared in terms of chronic diseases, US men have a 28% higher mortality rate from cardiovascular diseases when compared with Canadian men.
What does a true single-payer system bring to the table? Apart from the savings in administrative and billing (roughly $219 billion), clinical and hospital fees ($100 billion), and unified billing system ($284 billion), a single-payer system removes unpaid medical bills for hospitals ($35 billion), eliminates avoidable emergency room visits and hospitalizations through improved access to primary care ($100 billion), and reduces pharmaceutical prices through pharmaceutical price negotiation strategies implemented by the US Department Veterans Affairs ($188 billion). A single-payer system will expand people’s access to healthcare and most importantly save lives. Substantial disparities based on race/ethnicity (American Indians are 2.9 times, Hispanics 2.5 times and Blacks 1.5 times likely to be uninsured compared to whites) and income (individuals are 4 times likely to be uninsured if they earn below the poverty line) will cease to exist. Some estimates show universal coverage can save 68,531 lives (predominantly younger lives) in the US and save 1.73 million life-years annually (adjusting for age distribution based on preventable premature deaths).
How would a single-payer system affect pharmacists?
Well, the specifics will depend on the details of the system. A unified billing system will spare the countless hours pharmacy professionals spend on processing prescriptions and/or services. That means more time and resources can be dedicated to provide patient-centered care. The increased demand for providers secondary to unrestricted access to care may ultimately lead to expanded scope of practice for pharmacists. A number of states have passed bills expanding pharmacist scope of practice, which could lead to provider status. During the 2021 legislative season, legislators proposed over 200 pharmacist provider-status bills in 43 states of which 32 bills in 18 states were signed into law. If a single-payer system is implemented on a fee-for-service principle, pharmacists will qualify for reimbursements for clinical services provided. Furthermore, there would be no networks in a single-payer system thus truly giving patients freedom in choosing their pharmacy.
Creating a single-payer healthcare system in the US will not guarantee improvements in health outcomes nor in eliminating health disparities. The implementation of such a system via the laws, regulations, and policies will determine how well such a system accomplishes these goals. As Ramachandran et al, recently highlighted, pharmacists must be active participants in shaping healthcare legislation including those surrounding the single-payer healthcare system. Towards that end, Pharmacists for Single-Payer (PSP) is a grassroots organization with the mission of promoting the role of pharmacy professionals in delivering evidence-based, patient-centered care within a universal healthcare system. At PSP, we are working to bring the voice of pharmacy to the single-payer healthcare system discussion. Now is the time for that pharmacy voice to be heard.
Guest Writers Profiles
Thomas J. Cook, PhD, RPh (one of the co-founders of Pharmacists for Single Payer) is a freelance medical/scientific writer, consultant, and medical cannabis pharmacist. After completing his Bachelor of Science in pharmacy at Northeastern University, Dr. Cook pursued his graduate studies in pharmaceutics at the University of Michigan.
The bulk of Dr. Cook’s career has been in academia where he served as a researcher, faculty member, and administrator. Dr. Cook’s current work focuses on continuing education for the medical professions; consulting for specialty pharmacy accreditation and pharmacy research projects; and providing pharmacist services at a medical cannabis dispensary.
Tashrique Rahman, PharmD, MBA, is a current Post Graduate year-1 pharmacy resident at Hillcrest Medical Center in Tulsa, Oklahoma. He completed his Doctorate of Pharmacy at Southwestern Oklahoma State University College of Pharmacy and his Master in Business Administration from The Everett Dobson School of Business and Technology at Southwestern Oklahoma State University in 2020.
Dr. Rahman is passionate about single-payer advocacy. He is one of the co-founders of Pharmacists for Single Payer, a board member, and the research coordinator. He lives in Tulsa with his partner, a veterinarian, and their six animals (3 dogs and 3 cats). Dr. Rahman describes the household as a “petting zoo” that he is never going to financially recover from. In his free time, he enjoys riding bikes, kayaking, running, playing his guitar, trying new restaurants, and spending time with family and friends.