2020 Voter’s Guide: Healthcare

This year, every U.S. citizen has an important job to do—vote.

In November, we will all get the chance to participate in electing not only the next president of the United States but also our senators, congressional representatives, governors, judges and other local government officials. With the Pennsylvania primary election quickly approaching, now is the best time to get educated on the issues that may affect your health and wellbeing. (The Nexus will cover additional crucial voter issues this fall.)

To help inform you on issues surrounding healthcare in politics, some of the leading voices in the Philadelphia medical community have answered a few questions to consider for the upcoming primary and general elections.

David B. Nash, MD, MBA, is the founding dean emeritus and the Dr. Raymond C. and Doris N. Grandon Professor of Health Policy at the Jefferson College of Population Health. He is also a board-certified internist who’s internationally recognized for his work in public accountability for outcomes, physician leadership development and quality-of-care improvement.

Rosie Frasso, PhD, MSc, MSc, CPH, is the program director of public health and associate professor at Jefferson College of Population Health. She is currently researching health disparities, housing insecurity, health literacy and the integration of qualitative and quantitative methods in projects designed to improve population health, healthcare quality and access to physical and mental health services for vulnerable populations.

Mitchell Kaminski, MD, MBA, is the program director of population health and Navvis Associate Professor at the Jefferson College of Population Health. He is a family physician who has combined clinical practice and teaching with a career in healthcare leadership that has included private groups, hospital systems and academic institutions.

Alisha Maity, MD, is a recent graduate from Sidney Kimmel Medical College and will be starting her internal medicine residency at Lankenau Medical Center. In 2018, she co-founded JeffVotes, an initiative to assist hospitalized patients with voting in elections. Dr. Maity has interests in health policy, health advocacy, oncology and end-of-life care.

Stephen K. Klasko, MD, MBA, is an advocate for a transformation of health care and higher education. He has been a pioneer in using technology to build health assurance, not just sick care—especially as we emerge from the COVID-19 crisis. As president and CEO of Jefferson and Jefferson Health since 2013, he has led one of the nation’s fastest-growing academic health institutions based on his vision of reimagining health care and higher education.

What are the benefits of a healthcare system that provides universal coverage? Should private insurance still be involved?
Dr. Nash: Universal coverage without access to private healthcare would take the pernicious challenges for healthcare in general and exacerbate them. We need to expand Medicare Advantage plans. This means that private insurance companies would work managing Medicare dollars to offer more comprehensive care to patients. There is evidence that Medicare Advantage delivers a higher quality of care with a lower overall price.

Dr. Frasso: If we reflect on what is happening right now, we can see why universal healthcare coverage would be a great thing. Those who work in places like grocery stores, nursing homes and restaurants are far too often uninsured or underinsured and not paid for sick time. So, they go to work ill, and that is clearly problematic for everyone. If people cannot get treated and stay home when they get an infectious disease, then they spread it. It is simple. We’ve created a system that puts us all at risk because we’re not taking care of everyone.

Getting rid of the gap in healthcare will help our nation as a whole. Better access to preventive care would lead to healthier people and result in less spending on healthcare treatments for late-stage illnesses. So yes, we should have coverage that is available to everyone and is supported by the government. I do not think we are ready to replace private insurance; there would be far too much resistance to that and the needle would not move at all.

Dr. Kaminski: Most of us agree that universal health care coverage would be a good thing, whether because we believe it is a right, or that we, pragmatically, realize that we end up paying for patients’ healthcare whether they have insurance or not. Having healthcare coverage allows us to encourage everybody to get care upstream before they get sick—through preventive screenings, such as mammograms and colon cancer screenings to avoid getting cancer, or treating chronic diseases, such as hypertension or diabetes before they cause heart attacks, strokes and kidney failure.

Replacing private insurance altogether is more hotly debated. The reality is that the private health insurance industry is huge in our country. A highly profitable segment of our economy would suffer from a system without private insurance; many of the healthcare systems would shrink, and many providers and employees would lose jobs.

Dr. Maity: The main issue with our current healthcare system is the shocking amount of money that is being made within the medical-industrial complex. One of the major benefits of switching to a publicly run system is that it would hypothetically eliminate “middlemen” in the system and result in dramatic decreases in administrative costs, overhead expenses, payouts to shareholders and procedure costs while creating standardized care for all Americans. The argument for private insurance is that a competitive marketplace lowers costs and improves care—however, it is clear that our current implementation of this system struggles to achieve either of these goals.

What should be covered under a universal healthcare system?
Dr. Frasso: There are a lot of things that aren’t currently covered under Medicare, like dental care and mental health treatment. We need to expand our definition of what healthcare is and take a more holistic look at what defines good health. Vision care, hearing aids, dental care and mental health all impact a person’s wellbeing and quality of life. It seems pretty obvious that those should be covered. But it is time to think broader than all that. What about access to food and safe housing?

Dr. Maity: As it stands, Medicare covers any treatments that are “medically necessary and reasonable.” However, the decision on which treatments fit the definition of “reasonable” is up to interpretation. For example, there have been recent breakthroughs in experimental cancer treatments such as CAR-T cell therapy, which offer patients with late-stage cancer incredible outcomes that were not possible in the past. But these treatments are very expensive. The implementation of a universal healthcare system would require a closer examination of these types of high-cost, yet effective, treatments.

Dr. Klasko: The pandemic unveiled the biggest crisis in this country—that we have the best healthcare in the world, but only for about 25% of our population. I don’t believe anyone should run for office who isn’t willing to tackle how we fix a system that is embarrassing, confusing, fragmented and inequitable. Those who call for universal healthcare have diagnosed the system accurately, but have not yet proposed a solution that has a chance of working. The real question is: Are you ready to develop a workable approach to end of life, the cost of pharmaceuticals, the separation of payers from providers, the closings of hospitals, and the bizarre inequities of payments to specialists that sees family physicians earn a fraction of what plastic surgeons make. Those major policy questions will do more than universal coverage to free up money for expanded access to healthcare.

How would moving away from the Affordable Care Act (Obamacare) affect healthcare coverage for people with pre-existing conditions?
Dr. Nash: Instead of moving away from the Affordable Care Act, we need to expand it so it can do what it was intended to do. When we improve access to healthcare, we improve health overall. Before the COVID-19 pandemic, about 20% of the U.S. population was uninsured or underinsured. Now, more people are losing coverage because of the rise in unemployment due to COVID-19. For those with pre-existing conditions especially, it’s important to have access to healthcare outside of their employers so they can get treatment if they become ill.

Dr. Kaminski: Patients with pre-existing conditions could find themselves in the same boat they were in before the Affordable Care Act became law. If they lose their insurance, they could have a very difficult time being accepted by another insurance plan because of their pre-existing conditions. Many would become uninsured and won’t be able to afford the high cost of treatments out of pocket.

Should the government be responsible for regulating the high price of medication in the U.S.?
Dr. Frasso: The public health response is yes, but it would be difficult to achieve—this is a profit-driven industry. Right now, there are people that cannot afford life-saving medications for chronic illnesses. In fact, they’re resorting to buying medication in unsafe venues (like Craigslist). In pharma, innovation and profits are pretty intertwined and it would be hard, though not impossible, to disentangle them in the U.S.

The other issue around unregulated drug prices is the availability of treatments for uncommon illnesses. There are people who are motivated to discover treatments for these illnesses, but the industry is not willing to promote or distribute something that does not pay off. We’re so insistent that capitalism is the only thing that motivates innovation, but that’s not the case. Science rests on innovation and scientists are wired to innovate. It is not always about the money.

Dr. Kaminski: The unregulated pricing of medications results in a marketing approach to selling medications; pharmaceutical companies want to maximize their profits to share with their stakeholders. That is the basis of American capitalism. So insurance companies, the government and, ultimately, all of us have to pay for drugs that are priced much higher than in other advanced countries. How do those countries keep their drug prices more reasonable? Most often they have a single-payer system, which provides healthcare for all of their citizens, and they negotiate more reasonable prices with the drug companies.

Dr. Maity: Yes. Big Pharma is one of the most problematic sectors of the American healthcare system. The Food and Drug Administration (FDA) is one of the only organizations of its kind worldwide that does not use price or cost-effectiveness as a metric in its method for approving new drugs. Additionally, rather than comparing new drugs to other similar drugs on the market, they are approved on a measure of whether they are “safe and effective” compared to a placebo. Many of the FDA’s rules have been finessed by the pharmaceutical industry, a sector that has a vested interest in keeping drug prices high.

Frederick Banting famously licensed the patent for insulin for a dollar in the 1920s. But nowadays, stories about patients rationing their supply or traveling to Canada to pay for insulin are commonplace. Recently, Eli Lilly, one of the companies that manufacture insulin, announced that it would enable a $35 per month insulin copay due to the effects of COVID-19. Many have observed that this price cap could be extended permanently.

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What regulations need to be updated or put in place by the government to protect privacy under new technology advances and improvements within the healthcare system?
Dr. Nash: Patients should own their own healthcare information. They should be the ones to give permission to the healthcare system to gain access to and share their information.

Dr. Frasso: Large hospital systems certainly have the capacity to adopt electronic medical records that could respond to current privacy challenges. But we need to make sure that we’re rolling out technology requirements in a universally feasible way. We don’t want to put the small rural providers out of business because it’s difficult for them to keep up with regulations. Some patients would lose access to healthcare altogether.

Privacy is also a huge issue in the genetics space. If healthcare providers can use genetics to predict who might cost the insurers more money, insurers will only want to cover those who are at lower risk of illness.

Dr. Maity: Now that the majority of healthcare providers use electronic medical records, patients’ privacy has become even harder to keep protected. Ensuring that hospitals are using proper encryption methods is important as well as continuing to train healthcare workers to practice in a way that is HIPAA compliant.

Dr. Klasko: The core regulations for medical privacy, called HIPAA, were written before the internet existed. They cover hospitals, but not tech companies, which can collect massive databases about anyone, using consent forms that would take hours to read.

As all of the economy shifts to digital tools for everything—the Fourth Industrial Revolution—it is clear we have the responsibility to do this right. Ethics must be the first consideration as companies develop new products—not the last thing when marketing suddenly has to make that product trustworthy.

The pandemic unveiled the biggest crisis in this country—that we have the best healthcare in the world, but only for about 25% of our population. —Dr. Stephen Klasko

How should our next president best address a global health crisis like the COVID-19 pandemic?
Dr. Nash: Presidents set a broad vision. I would argue that whatever your political leaning, what we need is a vision for health. How do we make America healthier? If we decided four years ago that America needed to be healthier, we would be seeing a much lower death rate from COVID-19. Instead of building another bariatric surgery operating room, why don’t we focus on better nutrition at the start? In this way, the problem is a missed allocation of resources.

Dr. Frasso: The next president has to look very critically at how we responded to this pandemic. We have to spread the science, not the virus. Too much information is being disseminated by people who are not public health or medical professionals because the pandemic response team was dismantled after the last election. We wasted a lot of time at the beginning, we did not respond quickly and we did not collaborate to present a united message to the nation. Lots of mistakes were made—some were completely unavoidable and others were not. A good leader would be able to look at their administration’s approach, examine what went wrong and learn from it.

Dr. Kaminski: We will no doubt learn from COVID-19 and be better prepared for the next global health crisis. Our next president needs to be thinking ahead about these types of potential crises. As we have seen, preparing for a pandemic requires respect for and trust of what our public health professionals recommend. It requires leaders who are public servants whose first priority is the health and well-being of the people under their governance. Our president needs to have a team composed of leaders with experience and the demonstrated ability to promote effective government.

Dr. Maity: This pandemic is exposing the many cracks in our healthcare system and drawing attention toward other countries’ more equitable systems. There is a lack of national coordination, people are (even more so than usual) having trouble affording their medications and hospital bills, and hospital systems that operate near capacity on a regular basis do not have space for more patients. Our next president must be able to act swiftly, take advice from healthcare experts, provide necessary resources for all essential workers and benefits for furloughed and unemployed workers, and feel comfortable allowing scientists to have the spotlight.

Should the government act to cut back on the rise of healthcare spending? Should healthcare systems work to slow down or redistribute their spending?
Dr. Kaminski: The government has and must continue to cut back on the rise of healthcare spending. But a greater rise in spending is occurring in the private insurance industry. As mentioned before, it is hard to cut back on spending in a country where healthcare is a profit-driven business. You can’t simply ask a healthcare system to “reduce their profits.” But there should be programs and regulations in place to reduce wasteful and unnecessary care and unreasonable price increases.

Dr. Maity: Absolutely. The government should have a vested interest in lowering healthcare costs while boosting programs that improve health outcomes. One example of an area of medicine ripe for a redistribution of spending is within the American Medical Association’s Relative Value Scale Update Committee (RUC). The RUC is a multispecialty committee that determines the Medicare fee system for procedures and office visits—essentially how much physicians should be paid. This committee is biased toward interventionists—physicians whose specialties involve complicated procedures—and is responsible for the substantial income gap between subspecialists and primary care providers. Adjusting the value placed on procedures and emphasizing preventative care is one way to redistribute spending appropriately.

Dr. Klasko: The sad reality is that 5% of people account for 50% of the nation’s healthcare costs. At Jefferson, we’re leading the way in teaching what’s called “hotspotting,” using data to identify those people, and then intervening in what can be very low-cost ways. What we’ve learned: The lack of investment in mental health services costs the United States dearly in emergency room visits. The single best way to reduce that bill is to help people with complex needs, including their social and mental health.

The next president should focus on reframing the whole notion of healthcare as health promotion. Universal coverage is absolutely key to achieving this. —Dr. Rosemary Frasso

Should there be federal support in addressing the shortage of primary care physicians in the U.S.? What policy changes should be put in place to address this issue?
Dr. Frasso: 
The cost of medical education has become so high that it disincentivizes physicians from going into primary care because of the huge salary difference from specialists. We need to make sure that the provision of primary care is as rewarding and feasible financially as going the route of a specialist. A different license structure may solve this problem. Another solution is loan forgiveness for those who choose primary care.

Dr. Kaminski: The U.S. has only half of the primary care providers as other advanced countries. Incentives to go into higher-paying specialties are hard to resist for medical students who are leaving medical school with $300,000 to $400,000 in debt. Increasing the number of primary care physicians, as well as providers like nurse practitioners and physician assistants, will help bring affordable care to all Americans and place more emphasis on comprehensive preventive care before emergency procedures and invasive testing. Loan forgiveness and salaries closer in range to those for dermatologists, ophthalmologists and radiologists would provide our country with more primary care.

Dr. Klasko: The shortage of primary care physicians is not new and will not be changed easily. In fact, it’s already yesterday’s issue—nurses and advanced practice nurses have already taken over the role of primary care in America. We need to practice what we teach at Jefferson’s Center for Interprofessional Development—that healthcare depends on a team. I have never supported limitations on the scope of practice of nursing and other clinical providers.

What should be the top healthcare priority for the next president?
Dr. Nash: 
The priority of our president should be getting a vaccine for COVID-19 approved and distributed quickly and equitably.

Dr. Frasso: The next president should focus on reframing the whole notion of healthcare as health promotion. Universal coverage is absolutely key to achieving this. We need to make sure that people can live, learn, work and play in places that don’t create a burden to their health. The biggest threat to health in our nation is poverty, low education and unsafe environments. Universal access to healthcare would allow everyone to have access to preventive care and treatments to keep them healthy before a crisis, whether it be personal or global.

Dr. Kaminski: The next president should prioritize the improvement of overall health and wellness of the American people. This would include universal health care coverage at affordable prices and a system that addresses poverty, poor education, unhealthy and unsafe environments, and raising the living standard for all poor and low-middle income Americans.

Dr. Maity: One of the areas most suitable for improvement within the American healthcare landscape is the pharmaceutical industry and the FDA. Rethinking what we consider to be effective and affordable treatment is important if we want to improve health outcomes in the U.S. Secondly, the president should re-examine hospital systems’ bottom line and whether it is aligned with patients’ best interests. While they should work to provide insurance coverage for all Americans, insurance is not useful without functional access to care. Therefore, in addition to expanding insurance coverage, creating an equitable healthcare system will also rely on addressing socioeconomic determinants of health via data-driven solutions.

Dr. Klasko: Mass unemployment is a public health crisis. The virus itself has hit African-Americans disproportionately, and the loss of jobs and businesses has hit underserved communities the hardest. My first question for candidates: How will you tackle the second great crisis of 2020—the loss of well-being, the catastrophic effects of COVID-19 on those who can afford it least?

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