Wednesday, September 16, 2009

It's crystal clear: doctors support a public option LIKE MEDICARE

According to a study published yesterday in the New England Journal of Medicine, 63% of doctors support expanding health insurance coverage through both private and public options. NPR reported on this survey with the headline, “poll finds most doctors support public option,” and immediately elicited comment from the American Medical Association, since the organization has equivocated on support of the public option in its public statements, while the study explicitly demonstrated support for the public option among AMA members (62%). Not surprisingly Dr. James Rohack, the president of the AMA (who has previously made confusing comments about the public health insurance option implying that subsidized private plans could be considered a public option), challenged the meaning of the findings, “[the public option] means different things to different people, kind of like the Rorschach ink blot test.” However, his attempts to obfuscate only further emphasize that the official positions of the American Medical Association do not represent the viewpoint of most American doctors (or apparently in some cases even AMA members).

While it is true that there are different versions of the public health insurance option described in the bills coming out of the House, the Senate HELP committee, and the framework envisioned by Jacob Hacker, the findings of this study are not up for interpretation. A Rorschach test is purposely subjective so a clinician can interpret a patients' psychological state. Conversely, good researchers ask precise questions and describe their methods in detail so that their findings can be reproduced. The reputation and influence of peer reviewed journals, like the New England Journal of Medicine, is dependent on publishing quality research.

The consistency and reliability of the research demonstrating doctors’ support for public health insurance similar to Medicare should relieve us all of the fear mongering around “socialized medicine." Ironically, conservative politicians fear "government bureaucrats standing in between them and their doctors," while their doctors do not. The evidence is crystal clear.

In 2003, Ronald Ackerman and Aaron Carroll asked 3188 randomly sampled physicians, “In principle, do you support or oppose government legislation to establish national health insurance?” At that time 49% supported this type of legislation and 40 % opposed.

In 2008, the authors repeated the study, this time with 59% agreeing and only 32% opposing national health insurance. They also asked, “do you support achieving universal coverage through more incremental reform?” 55% supported and 25% opposed this type of proposal.

And now, with the study by Keyhani and Federman we have another question directly relevant to the current health care debate:

Respondents were asked to indicate which of three options they would most strongly support:

1. Public and Private Options: Provide people under age 65 the choice of enrolling in a new public health insurance plan (like Medicare) or in private plans.

2. Private Options Only: Provide people with tax credits or
low-income subsidies to buy private insurance coverage (without
creating a public plan option).

3. Public Option Only: Eliminate private insurance and cover everyone in a single public plan like Medicare.

63% of doctors chose option #1 - the public and private options.
It is not clear to me how Dr. Rohack could be unsure what the public option means in this context. It's right there in the study's methods.

These research findings are robust and consistent: doctors support national health insurance (i.e. Single Payer); but when asked specifically about a public health insurance option similar to Medicare and available to everyone below 65, they overwhelmingly support it. There even seems to be a trend developing where a greater percentage of doctors support public health insurance.

Doctors are not afraid of government health insurance bureaucrats – we already have private insurance companies' utilization reviewers to contend with. The study's findings may be a surprise to some, since doctors tend to be conservative as a whole, but the truth is that most doctors are sick of fighting with insurance companies. The average physician spends 43 minutes per day and $65,000 per year on interactions with health plans; there have already been multimillion dollar class action lawsuits against Aetna, Cigna, Humana, Blue Cross Blue Shield, and others for underpaying doctors (among other charges), and ultimately we have yielded too much decision making capacity to managed care companies.

So when we talk about a public health insurance option, we mean a plan modeled on Medicare. We do not mean a co-op; we do not include a trigger option; and we don't want expanded coverage limited to public subsidies for private plans. The data is there in black and white - in the shape of a bar graph, not an ink blot.

Aaron Fox, MD
NPA - NYC Local Action Network

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