Uro groups offer takes on Medicare for All

Medicare for All has become the battle cry for many of the multitude of candidates for the Democratic presidential nomination as they declare that every American should have easy access to affordable health care and should not have to choose between going to the doctor and putting food on the table.

“Health care should be a right, not a privilege,” they say.

But what about a huge segment of the population that would be dramatically affected by such a massive revamping of our health care system: the nation’s doctors? What do they think about the idea? How about urologists?

AMA nearly changes stance on single-payer

Traditionally, organized medicine has opposed any sort of single-payer system. However, in June, the American Medical Association’s House of Delegates nearly voted to overturn that position. When the votes were counted, 47% favored eliminating the AMA’s official opposition to single-payer, while 53% voted to maintain it.

Within urology, there is continuing debate about the implications of Medicare for All, recognizing, of course, that while the main focus is on legislation sponsored by Sen. Bernie Sanders (D-VT) and endorsed by Sens. Elizabeth Warren (D-MA) and Kamala Harris (D-CA) among other Democratic presidential candidates, many iterations are likely to take place before they would ever actually be considered by Congress.

Asked for the views of LUGPA, Mara Holton, MD, LUGPA health policy committee vice chair, replied with caution.

“LUGPA, as an organization, has been stalwart in its role as an advocate for the preservation of patient access to high-quality, cost-efficient, and integrated genitourinary care in the independent practice setting,” she said.

“While, in general, LUGPA would support any initiative that would improve or expand access to these resources, the organization has not evaluated any proposal in enough detail to determine its effectiveness at achieving that goal or its potential impact on member practices,” she added.

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Dr. Holton stressed that “LUGPA remains committed to working with regulatory agencies and policymakers to enhance the quality and access to care for patients impacted by genitourinary disease and will carefully analyze any proposal put forth from that precept.”

Asked for his comments, Neal Shore, MD, past president of LUGPA, pointed out possible positive aspects of Medicare for All, but said there was still much to learn.

“In addition to enhancing coverage for more people and reducing preauthorizations and arbitrary commercial insurance denials, the concept has great appeal,” he said. “However, I have not read any prudent economic analysis to convince me of its implementation and sustainability.”

But Mark Edney, MD, president of the American Association of Clinical Urologists (AACU), was less circumspect.

“I think it’s a terrible idea,” he said flatly. “In the most rigid proposal (Sanders’), it would mean the elimination of private insurance and that would be disastrous for American health care” and would “change the face of American medicine.”

He pointed out that physicians often deliver medical services to Medicare and Medicaid patients at a loss, and to compensate they must rely on patients with commercial health insurance with its higher payment rates.

“We’ve seen a socialistic bent in this crop of candidates,” Dr. Edney said. “They really want to move to a government-controlled and -owned health care infrastructure.”

Moreover, he said, if the most extreme proposals (Sanders’ and Warren’s) were enacted, Medicare would have to be expanded from its current 80% coverage level to 100%, since private insurance would no longer be available for supplemental coverage.

“Nobody talks about the cost of that,” he added. “It would be exorbitant.”

Advocates contend that doctors’ administrative overhead and headaches resulting from onerous paperwork and preauthorization requirements, limited formularies, narrow networks, and high-deductible insurance plans of many patients would be reduced or eliminated under Medicare for All, providing incentives for physician support.

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In a March 15, 2019 commentary published by the conservative think tank The Heritage Foundation, Senior Fellow Robert E. Moffit, PhD, contended that enacting such a plan would worsen the growing physician shortage largely because it would depress physicians’ income.

He pointed out that American general physicians earn an average annual salary of $218,173 compared to $146,286 for their counterparts in Canada, with its government-run health care system. Combining a mammoth pay cut with the abolition of private-sector alternatives would hurt morale and accelerate the shrinkage of the medical work force, Moffit said.

That has been a major concern for urology, as the AUA warns that as practicing urologists continue to age and retire, and with inadequate financial support for graduate medical education, the pipeline of urologists continues to thin.

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According to the 2018 AUA Census, the number of urologists per capita has declined by more than 10% over the past 20 years. The median age of a urologist is 56 years, so many are approaching retirement. Complicating that situation is that training for urologists following medical school graduation is a minimum of 5 years and often longer.

Thus, if physician compensation is sharply reduced as a result of implementation of Medicare for All, it stands to reason that the already low number of urologists in the nation would be further reduced.

When contacted for this article, an AUA spokesperson said the organization does not have a position on Medicare for All.