What is single-payer?

Single-payer national health insurance describes a system in which one public agency is responsible for health care coverage, but the delivery of health care services continue to be provided by mostly private businesses.¹ This means all payments health care services would come from one agency, but physicians’ offices, hospitals, and pharmacies would continue to be owned and operated by organizations or individuals, as they are in the current system. The two proposed bills for single-payer in the United States are commonly known as Medicare for All. While there are differences between the House bill² and the Senate bill³, both endeavor to provide robust health care coverage – medical, pharmacy, dental, vision, etc. – for everyone living in the US and to eliminate the private insurance industry’s role in covering health care services included in this legislation. Projected costs vary between analyses⁴, but most show the overall cost of health care services remaining about the same or decreasing, due to minor increases in utilization as more uninsured or underinsured people can afford to seek the care they need, coupled with major decreases in overhead – Medicare spends about 2% on administrative costs compared to private insurers spending up to 18%⁵ – and decreased cost of health care services, including drug pricing.

How would it impact pharmacy?

Perhaps the most obvious change that would impact pharmacy is in drug pricing. Brand name drug prices have increased dramatically in the last decade.⁶ Based on data from Australia and New Zealand, some experts estimate the cost of brand name drugs would drop as much as 50%. While the generic market is less likely to see dramatic price changes, there is greater opportunity for rapid intervention and improved access during drug shortages and for negotiation on prices with both brand and generic manufacturers of “me too” drugs if there is one national formulary.⁷ This is a role some argue pharmacy benefit managers (PBMs) can play, but again, drug prices continue to climb. In scenarios where savings are achieved by a PBM this is often to the benefit of their shareholders or partnering businesses, rather than to taxpayers or patients.⁸ By consolidating negotiating power with a single-payer, there would be greater leverage over drug companies’ asking prices.

Additionally, with a single-payer and the eradication of the PBM model, the idea of “preferred pharmacies” would no longer exist. Patients would be free to fill their prescriptions at the pharmacy that best meets their needs, at no cost. This would mean simplified billing and predictable reimbursement. What would you do with the time you previously spent on the phone trying to understand why an override wasn’t working, or trying to help a patient or physician determine the covered “preferred formulary alternative” when you get a rejection? What if you could spend more time focusing on ensuring therapy is safe and effective, instead of on whether or not your patient could afford it? Would you expand clinical pharmacy services? Would you open your own independent pharmacy, perhaps in an underserved rural area, or in the pharmacy deserts on the south or west sides of Chicago?

We have plenty of evidence from other countries to suggest how patients would respond to a single-payer system. The United States currently has the highest rates of cost-related medication non-adherence (CRMN).⁹ In places where patients don’t need to worry about copays and deductibles, the overall rate of cost-related medication non-adherence is < 3%. Even in Canada, which does not fully cover prescriptions with their single-payer system, rates of CRMN are about half of what they are in the United States. This example highlights the importance of thoughtful inclusion of pharmacy benefits in a single-payer health care coverage plan.

Why do pharmacists need to be involved?

Currently proposed Medicare for All bills in the House and Senate differ in their plans for prescription coverage. The House bill calls for no deductibles and no copays at any point. The Senate bill would allow for up to $200 per year in out-of-pocket prescription costs. This may sound like a small distinction, but has the potential to disproportionately impact low income patients.¹⁰ Pharmacists who have worked with patients with high-deductible prescription plans will immediately recognize this issue. Physicians may not, but they are the primary health care professionals advocating for Medicare for All.¹¹ Most physicians have a limited understanding of the intricacies of pharmacy billing and reimbursement.¹² We don’t know if single-payer will move forward in the next few years, or if it will take several decades, but we do know pharmacists will need to have a seat at the table when the time comes to ensure the changes made are appropriate and sustainable. The best way to guarantee that seat at the table is to get involved in the conversations happening around single-payer now.

To our knowledge, there are less than a dozen pharmacists actively involved in the single-payer movement right now, as compared to the over 23,000 physicians and 1,200 medical students who are members of Physicians for a National Health Plan (PNHP). We know pharmacists are extraordinarily effective advocates when we work for change to improve the lives of our patients and to advance our profession.¹³ We continue to rank among the top professions year after year for honesty and ethical standards.¹⁴ We are trusted experts, and we have the authority to speak on issues facing our broken health care system, particularly when it comes to medications. It’s time to put our expertise to use in advocating for structural change, and to make sure the plans behind it support our patients and align with our goals as a profession.

For those looking to get involved, two Illinois based organizations that focus on this issue are IL Single Payer Coalition (http://ilsinglepayer.org) and PNHP Illinois (https://pnhp.org/chapter/illinois). Other ways to take action include contacting your state and federal legislators to ask them to support single payer legislation, writing op-eds or letters to the editor in local newspapers, public speaking, lobbying, and organizing.

References

1. Physicians for a National Health Program. About Single Payer. https://pnhp.org/what-is-single-payer (accessed 2019 Nov 22).

2. Medicare for All Act of 2019, H.R.1384, 116th Cong. (2019). https://www.congress.gov… (accessed 2019 Nov 22).

3. Medicare for All Act of 2019, D.1129, 116th Cong. (2019). https://www.congress.gov… (accessed 2019 Nov 22).

4. The New York Times. Would ‘Medicare for All’ Save Billions or Cost Billions? https://www.nytimes.com… (accessed 2019 Nov 22).

5. Center for Economic and Policy Research. Overhead Costs for Private Health Insurance Keep Rising, Even as Costs Fall for Other Types of Insurance. http://cepr.net… (accessed 2019 Nov 22).

6. Wineinger NE, Zhang Y, Topol EJ. Trends in Prices of Popular Brand-Name Prescription Drugs in the United States. JAMA Netw Open. 2019 May 3;2(5):e194791.

7. Gaffney A, Lexchin J; US; Canadian Pharmaceutical Policy Reform Working Group. Healing an ailing pharmaceutical system: prescription for reform for United States and Canada. BMJ. 2018 May 17;361:k1039.

8. The Commonwealth Fund. Pharmacy Benefit Managers and Their Role in Drug Spending. https://www.commonwealthfund.org… (accessed 2019 Nov 22).

9. Heidari P, Cross W, Weller C, Nazarinia M, Crawford K. Medication adherence and cost-related medication non-adherence in patients with rheumatoid arthritis: A cross-sectional study. Int J Rheum Dis. 2019 Apr;22(4):555-566.

10. Kaiser Family Fund. Medicaid. The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings. https://www.kff.org… (accessed 2019 Nov 22).

11. TIME. A New Generation of Activist Doctors Is Fighting for Medicare for All. https://time.com… (accessed 2019 Nov 22).

12. Tseng, C., Lin, G.A., Davis, J. et al. Giving formulary and drug cost information to providers and impact on medication cost and use: a longitudinal non-randomized study. BMC Health Serv Res. 2016 Sep 21;16(1):499.

13. Little J, Ortega M, Powell M, Hamm M. ASHP Statement on Advocacy as a Professional Obligation. Am J Health Syst Pharm. 2019 Feb 1;76(4):251-253.

14. Forbes. America’s Most & Least Trusted Professions. https://www.forbes.com… (accessed 2019 Nov 22).

In 2017, a study found that more than 15% of people living in the United States went without a needed medication because of its cost. This is significantly higher than the nonadherence in a majority of European countries. While there are multiple bills at the state and federal level aimed at reducing drug prices for single classes of drugs, such as insulin, or targeting high-cost drugs as a category, none of these bills has the potential to make the same impact as a switch to a single-payer system, commonly known as “Medicare for All.”

Creation of a single-payer system has the ability to drive down drug prices by consolidating negotiating power. This is something we’ve been told pharmacy benefit managers (PBMs), middlemen in our current system, could achieve. But despite their presence, drug costs have continued to skyrocket. A single-payer system, on the other hand, is projected to reduce brand name drug prices by about 50%. These changes in average wholesale price (AWP) or any other price measures used by the industry or in retail pharmacies aren’t necessarily tied to the copay you see at the pharmacy counter, though. Medicare for All would address that piece as well, with no copays or deductibles in one proposed version, and a maximum of $200 per year on prescriptions in the other.

Another unique advantage of Medicare for All is that it would restore patient choice in pharmacy. Private insurance and PBMs ensure greater profits for themselves by restricting choice, driving prescriptions to the chains they own. When they do permit patients to use alternative pharmacies, the reimbursement to those small businesses can be so low that prescriptions are often filled at a loss. The end result is the pharmacy deserts we see on the South and West sides of Chicago, and closing of independent pharmacies in the Chicago area in general.

Medication only helps if you can take it, and you can only take it if you can afford it. Everyone deserves to get the medication they need from a pharmacy they trust. I encourage everyone who takes medication or loves someone who takes medication to learn more about Medicare for All and to support the candidates who will fight for it.

Within the first three to four months of the COVID-19 pandemic, an estimated 186,000 workers in Illinois and their families lost their health insurance coverage due to job losses. Nationwide estimates in June 2020 suggest as many as 7.7 million workers and 6.9 million of their dependents lost employer-sponsored insurance (ESI) when they lost their jobs during the pandemic-induced recession. And while Illinois has more state-run programs and support available than many other states, many individuals and families losing coverage do not qualify for Medicaid, and many can’t afford other so-called low-cost plans. Even those who are able to obtain alternate health insurance may be left with gaps in their coverage. We know from pre-pandemic data that having a gap in coverage more than doubles the likelihood that someone will forego filling a prescription. Additionally, for individuals or families that have not lost their ESI, but for whom a meaningful portion of their household income was variable – for example restaurant servers, bartenders, hair stylists, or nail technicians who earnings may be dramatically impacted by tips – the same ESI plan that was previously sufficient may now leave them underinsured. The definition of underinsurance varies somewhat between studies, but generally this refers to an insured person or family facing out-of-pocket costs (ex. premiums, deductibles, and / or copayments) at such a high proportion of total household income that health care is not affordable, or is only able to be procured at the expense of other basic necessities.

Pharmacists have been observing the impact of this health insurance crisis from the front lines. Other health care professionals may not know the reason why a patient cancels an appointment or delays care. It could be cost, fear of COVID-19, a scheduling conflict, difficulty securing transportation, or one of so many other variables or barriers. But pharmacists, and in particular community pharmacists, often talk to patients who are struggling with tough decisions between a basket of groceries and a prescription refill. The pandemic has increased the frequency of these interactions in a country that was already leading our peer nations in numbers of uninsured and underinsured residents. And people make these difficult decisions between medications and other necessities monthly. Perhaps an annual screening or well check-up can be deferred without major issues in some situations, but delaying a prescription refill has a clear, visible consequence: running out of medication. And while missing only a few days of a medication for high blood pressure, for example, may not directly and immediately lead to a stroke for everyone, there are certain medications that do have serious, predictable consequences. A person with Type I diabetes can develop life-threatening complications within hours to days of running out of insulin.

Earlier in the pandemic, roughly May to June, I remember a scramble as many of the patients I worked with at the specialty pharmacy were no longer able to afford their high-cost medications. The pharmacy technicians and I were frantically filling out patient assistance program applications or grant fund applications to try and obtain medication for patients via limited free drug programs offered by drug manufacturers or charitable organizations whose funds were vanishing as quickly as they could be repleted by donors. I struggled to answer questions with no good answers for my patients: What should I do if the monthly cost of COBRA coverage for my family is the same as our total budget for the month, that is meant to include groceries and gas to get to the few shifts of work that are still available? Should I consider getting legally divorced so either my spouse or I might qualify for health coverage based on our individual income? What happens if I miss a week of this medication, if I know I have nothing in my debit account today, but I’m expecting a deposit on the 1st or the 15th of the next month? What will happen to me?

While the economic impacts of the COVID-19 pandemic have been felt globally, the idea of losing health insurance and prescription drug coverage as a consequence of this pandemic-induced economic downturn is almost uniquely American. Other high-income countries have single-payer systems that guarantee health care as a human right to their citizens. People there may be fearful of contracting COVID-19, but not because the cost of care will bankrupt them, as it could here in the United States.

We know controlling the spread of the virus will be crucial to getting our economy back on track. We should also consider the impact of our health care system on our ability to fight this virus. Now is the time to tell our elected representatives that we demand at a minimum universal coverage of a COVID-19 vaccine, and also universal health care coverage, period. It has never been more important to protect each other.

The notion that the “free market” is the most efficient way to spur biomedical innovation has been largely undermined by the COVID-19 pandemic, particularly with regards to the new antiviral remdesivir. First, the government has always played a major role in financing drug discovery through taxpayer dollars. Remdesivir (formerly, GS-5734), a compound originally identified in the wake of the 2014 Ebola virus outbreak, emerged from a collaborative research effort between Gilead Sciences and public institutions, costing tens of millions in taxpayer dollars. Despite significant public financing, patent law effectively grants Gilead a monopoly on remdesivir, inflating its price far above what would be expected in a true “free market”. Thus, remdesivir is priced at over $3,000 for a five-day treatment course, despite production costs estimated to be as low as $1 per vial. Reliance on the free market is particularly problematic for anti-infective drugs when research is undertaken in response to an outbreak or pandemic. The SARS and MERS coronavirus outbreaks of 2002 and 2012, respectively, demonstrate how reliance on the market has led to a predictable surge in research and funding at the start of an outbreak, which inevitably fades as infections wane. This leaves researchers playing catch-up when the next outbreak comes, as is the case with the current SARS-CoV-2 outbreak. The above points highlight the need for an alternative mechanism of financing anti-infective drug research and development. Hundreds of billions of taxpayer dollars are dedicated to the “war on terror” and the “war on drugs''. What about the “war on bugs”?

With May 31 marking the end of Mental Health Awareness Month, it is imperative to reflect on the state of mental health care in this country beyond just last month. Mental health in the United States is the midst of a crisis, and the recent pandemic has only exacerbated the situation.

According to Czeisler et al,¹ 40.9% of Americans reported having a mental health or behavioral health condition as of June 2020, which went up from 20.6% in 2019² and 17.7% in 2008.² In a comparison with 2019, Leeb et al³ reported that hospital emergency departments treated 14% more cases of drug overdose, 6% more patients after a suicidal attempt, 24% more children, and 31% more adolescents experiencing a mental health crisis in 2020.

Anxiety and depression spiked drastically in 2020, nearly three times and four times higher respectively, than 2019. The suicide hotline run by Substance Abuse and Mental Health Services Administration received 891% more calls in March 2020 compared to March 2019.⁴

The root cause of the mental health crisis in this country lies deep within our health care infrastructure. Even though mental health illnesses are exceptionally disabling, many people cannot access health care or choose to opt out because of incremental costs. Millions of people who are uninsured or underinsured in this country shed light to the fact that health care is simply not affordable.^5,6

The national average for a premium benchmark marketplace plan in 2021 is $452 per month, which increased from $273 in 2014 (66% increase).⁷ According to the National Alliance on Mental Illness,⁸ 60% of youth with depression did not receive any mental health treatment in 2017-2018.

People suffering from mental health illness are less likely to have health insurance than those without mental health problems.⁹ Pearson et al¹⁰ found that the odds of having health insurance were 40% lower for people with serious psychological distress (SPD) than those without. Even though the Affordable Care Act has improved access to health care, similar findings were reported by Novak et al.¹¹

People with SPD from low-income families were more likely to be uninsured, and to report delaying, foregoing, or being unable to afford mental health compared to their non-low-income peers with SPD.

Commercial insurance companies have their own mechanisms in place to deprive mental health patients of the care they desperately need. The continued trend toward increased cost sharing among the insured with mental disorders has led to substantial out-of-pocket expenditures that in many cases exceed 20% of family income annually.¹²

Commercial insurance plans are also notorious for paying mental health providers far less than other health care providers. In 2017, commercial preferred provider organizations paid in-network mental health providers 24% less for office visits than they paid other primary providers.

Payment disparities force mental health providers to withdraw from insurance contracts. Only 62% of psychiatrists accepted new, privately insured patients compared to 90% of other physicians participating in one or several insurance networks.^14,15

Mental health provider shortage exists throughout the country. Outside of the core metropolitan areas, 80% of US counties have no psychiatrist, 61% have no psychologists, and 91% have no psychiatric nurse.¹⁶

This means patients with mental health disorders are encountering more out-of-network (OON) providers in inpatient (15.6 times higher) and outpatient (5.7 times higher) settings compared to patients with other chronic disease states (ie, diabetes and congestive heart failure).^13,17

How does it translate to health care dollars? Patients with mental health conditions are spending $341 more for OON care compared to those with diabetes. Individuals with drug use disorders and alcohol use disorders had much higher cost-sharing payments for OON providers ($1242 and $1138) when compared to individuals with diabetes.

Furthermore, even if you happen to live in a metropolitan area with in-network mental health providers, it can be excruciatingly difficult to get an appointment in a timely manner. In a 2015 study by Malowney et al,¹⁸ investigators posed as patients attempted to schedule appointments with psychiatrists (N=360) within the network of the largest commercial insurance in three major cities (Boston, Houston, Chicago).

Researchers were successful only about 26% of the time in making an appointment with a provider in the network directory. In a 2017 study of providers listed as in-network with Blue Cross Blue Shield, Cama et al¹⁹ were able to secure appointments with only 17% of the child psychiatrists (out of 312) and 40% of pediatricians (out of 601).

Incorrect provider lists (commonly referred to as ghost/phantom network) and/or office phone numbers are often cited as the most common reasons for failure to secure an appointment.²⁰ Commercial insurance companies have other tricks up their sleeves to restrict, limit, or simply deny crucial care to patients with mental illnesses.

A 2015 study showed that insurance claims regarding mental conditions were deemed “not medically necessary” twice as much as other medical conditions.²¹ Commercial plans tend to follow such stringent guidelines to deny necessary mental health and substance use treatment that courts have routinely forced insurance companies to reprocess previously denied claims.²²

The verdict from multiple court cases have highlighted the fact that insurance companies are denying medically necessary coverage because of financial reasons alone.

Mental health parity is long overdue in this country and the implementation of a single-payer system (SPS) is the only way to achieve it.Apart from eliminating corporate greed and administrative waste, SPS will expand people’s access to health care and most importantly improve patient outcomes.

This is evident from a study conducted by the University of Minnesota. Publicly insured patients had greater access to care than those who were privately insured.²³

SPS will provide the ultimate freedom to patients with mental illnesses to pick their own providers as every provider will be in-network. This means patients may have access to providers other than psychiatrists (ie, clinical social workers, licensed mental health counselors, psychologists, licensed marriage and family therapists).

If SPS is implemented on a fee-for-service principle, pharmacists may qualify for reimbursements based on clinical services provided. Pharmacy does have its own set of challenges when it comes to mental health care.

As pharmacy professionals battle with their own challenges regarding mental health, the optimal role of psychiatric pharmacists is yet to be defined.^24-26 Pharmacy professionals need to actively work toward improving health care outcomes for their patients with mental illnesses.

This means engaging in health care legislation that constructs the SPS and ensures patients have access to health care. Without the voice of pharmacy, mental health parity will continue to remain a distant dream.

References

1. Czeisler MÉ, Lane RI, Wiley JF, Czeisler CA, Howard ME, Rajaratnam SMW. Follow-up Survey of US Adult Reports of Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic, September 2020. JAMA Netw Open. 2021;4(2):e2037665. doi:10.1001/jamanetworkopen.2020.37665

2. Substance Abuse and Mental Health Services Administration. (2020). Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP20-07-01-001). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR1PDFW090120.pdf

3.Leeb RT, Bitsko RH, Radhakrishnan L, Martinez P, Njai R, Holland KM. Mental Health-Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic - United States, January 1-October 17, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(45):1675-1680. Published 2020 Nov 13. doi:10.15585/mmwr.mm6945a3

4.Levine, M. (2020, April 7). ABC News. Calls to US helpline jump 891%, as White House is warned of a mental health crisis. https://abcnews.go.com/Politics/calls-us-helpline-jump-891-white-house-warned/story?id=70010113.

5. United States Census Bureau. Annual estimates of the resident population for selected age groups by sex for the United States, States, Counties, and Puerto Rico Commonwealth and Municipios: April 1, 2010 to July 1, 2017 2017 population estimates. Feb 18, 2018. https://factfinder.census.gov/bkmk/table/1·0/en/PEP/2017/ PEPAGESEX (accessed Jan 4, 2020).

6. Collins SR, Gunja MZ, Doty MM. How well does health coverage protect consumers from costs? Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016. Oct 11, 2017 http://www.commonwealthfund.org/~/media/files/publications/ issue-brief/2017/oct/collins_underinsured_biennial_ib.pdf (accessed jan 4, 2020).

7. KaiserFamilyFoundation. Marketplace Average Benchmark Premiums | KFF.

https://www.kff.org/health-reform/state-indicator/marketplace-average-benchmark-premiums currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%7D. Accessed April 28, 2021

8. Mental Health By the Numbers. National Alliance on Mental Illness. (2021, March 21). https://www.nami.org/mhstats.

9. Garfield RL, Zuvekas SH, Lave JR, Donohue JM. The impact of national health care reform on adults with severe mental disorders. Am J Psychiatry. 2011;168(5):486-494. doi:10.1176/appi.ajp.2010.10060792

10. Pearson WS, Dhingra SS, Strine TW, Liang YW, Berry JT, Mokdad AH. Relationships between serious psychological distress and the use of health services in the United States: findings from the Behavioral Risk Factor Surveillance System. Int J Public Health. 2009;54(Suppl 1):S23–9.

11. Novak P, Anderson AC, Chen J. Changes in Health Insurance Coverage and Barriers to Health Care Access Among Individuals with Serious Psychological Distress Following the Affordable Care Act. Adm Policy Ment Health. 2018;45(6):924-932. doi:10.1007/s10488-018-0875-9

12. Cunningham, PJ. Chronic burdens: the persistently high out-of-pocket health care expenses faced by many Americans with chronic conditions [Internet]. New York (NY): Commonwealth Fund; 2009 Jul.

13. PR Newswire. Milliman Report: Analyzing Disparities in Network Use and Provider Reimbursement Rates. PR Newswire US. November 30, 2017. Accessed May 16, 2021. https://search-ebscohost-com.libnet.swosu.edu/login.aspx?direct=true&db=n5h&AN=201711301306PR.NEWS.USPR.DC58702&site=ehost-live score=site

14. Holgash K, Heberlein M Physician acceptance of new Medicaid patients: what matters and what doesn’t. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20190401.678690/full/. Published April 10, 2019. Accessed May 7, 2019.

15. Bishop TF, Press MJ, Keyhani S, Pincus HA. Acceptance of Insurance by Psychiatrists and the Implications for Access to Mental Health Care. JAMA Psychiatry. 2014;71(2):176–181. doi:10.1001/jamapsychiatry.2013.2862

16. Andrilla CHA, Patterson DG, Garberson LA, Coulthard C, Larson EH. Geographic Variation in the Supply of Selected Behavioral Health Providers. Am J Prev Med. 2018;54(6 Suppl 3):S199-S207. doi:10.1016/j.amepre.2018.01.004

17. Xu WY, Song C, Li Y, Retchin SM. Cost-Sharing Disparities for Out-of-Network Care for Adults With Behavioral Health Conditions. JAMA Netw Open. 2019;2(11):e1914554. Published 2019 Nov 1. doi:10.1001/jamanetworkopen.2019.14554

18. Malowney M, Keltz S, Fischer D, Boyd JW. Availability of outpatient care from psychiatrists: a simulated-patient study in three U.S. cities. Psychiatr Serv. 2015;66(1):94-96. doi:10.1176/appi.ps.201400051

19. Cama S, Malowney M, Smith AJB, et al. Availability of Outpatient Mental Health Care by Pediatricians and Child Psychiatrists in Five U.S. Cities. International Journal of Health Services. 2017;47(4):621-635. doi:10.1177/0020731417707492

20. Holstein R, Paul DP 3rd. 'Phantom networks' of managed behavioral health providers: an empirical study of their existence and effect on patients in two New Jersey counties. Hosp Top. 2012;90(3):65-73. doi:10.1080/00185868.2012.714689

21. A Long Road Ahead--Achieving True Parity in Mental Health and Substance Use Care. Medical Benefits. 2015;32(15):12. Accessed May 19, 2021. https://search-ebscohost-com.libnet.swosu.edu/login.aspx?direct=true&db=bth&AN=108626904&site=ehost-live&scope=site

22. Highlights. ParityTrack. (n.d.). https://www.paritytrack.org/legal-cases/highlights/.

23. Rowan K, McAlpine DD, Blewett LA. Access and cost barriers to mental health care, by insurance status, 1999-2010. Health Aff (Millwood). 2013;32(10):1723-1730. doi:10.1377/hlthaff.2013.0133

24. Mospan CM, Gillette C. Student Pharmacists' Attitudes Toward Suicide and the Perceived Role of Community Pharmacists in Suicidal Ideation Assessment. Am J Pharm Educ. 2020;84(5):7588. doi:10.5688/ajpe7588

25. Douglass M, Moy B. Evaluation of the impact of a social media-focused intervention on reducing mental health stigma among pharmacy students. Ment Health Clin. 2019;9(3):110-115. Published 2019 May 10. doi:10.9740/mhc.2019.05.110

26. Silvia RJ, Lee KC, Bostwick JR, et al. Assessment of the current practice of psychiatric pharmacists in the United States. Ment Health Clin. 2020;10(6):346-353. Published 2020 Nov 5. doi:10.9740/mhc.2020.11.346

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.