Healthcare is a deeply personal issue for me. My daughter was first diagnosed with brain cancer at the age of 4, but the quality care that the American people provided my family through the military gave her a chance to beat the disease. When Alex’s cancer came back last year, more than a decade later, we were fortunate to have the same medical heroes who had saved her once, save her again — including a doctor who came out of retirement to perform the intricate brain surgery. I’m running for President so that one day soon all Americans will be able to feel the same sense of gratitude and good fortune my family feels when we think of my daughter’s care and treatment. We must finally make healthcare a right, not a privilege.
As a Congressman, I was proud to vote for the Patient Protection and Affordable Care Act (ACA) in order to increase access to quality care, reform the broken health insurance industry, and save lives. By every metric, the ACA was successful at providing more and better healthcare coverage and in lowering costs: more than 20 million previously uninsured Americans now have insurance; average health insurance premiums per family have been reduced by $4,000 per year; insurance companies must now cover pre-existing conditions; parents can keep their children on their health plan until age 26; and overall healthcare spending has kept below pre-ACA projections by a staggering $2.3 trillion dollars over just the first seven years of the program.
Yet not all Americans benefit from the successes of the ACA, for a variety of reasons. Many Americans can only afford high-deductible plans, employees are now covering more of the costs of their own insurance (their share of premium costs has gone up some 32% since 2012), and the costs of prescription drugs and copays continue to climb. In the run-up to the final passage of the ACA, I was also proud to vote for a public health option, though unfortunately it was removed from the bill in the Senate — which refused to stand up to the health insurance industry — and the resulting law was weaker for it. I still believe a public option would further reduce costs across the board. It would create competition in local markets where one or two health insurance companies enjoy a monopoly. It would allow the government to negotiate with hospitals and pharmaceutical companies to save patients money. And, importantly, having a choice in the public option could have ultimately served as a testbed for a transition to a single-payer health system. That is why I support immediately creating a public option plan to expand access to many more uninsured people and cut costs for everyone.
I believe that the public option is one part of a transition of choice to a universal healthcare system. Creating such a system will not be easy, but I know our country can rise to the challenge, particularly if there are milestones to measure the credibility of transitioning to a single-payer system. Beginning the transition process with a public option would provide credible proof and lessons learned that a single payer system can work. Actually, there should be multiple public options among a basket of health insurance choices that can demonstrate better access, lower costs and better medical care than the alternatives (these options will be subsidized for people who cannot afford insurance, especially those in states that refused the Medicaid expansion in the ACA). Then, as the public options prove themselves — and therefore attract more individual enrollees — the transition toward a universal health care system, eliminating the unnecessary middleman of the health insurance industry, will continue. Such a deliberate effort is necessary because there are 255 million Americans who currently have private health insurance — including Medicare Advantage or Medicaid-managed plans — supporting them and their families in some way, and they should not have concern that suddenly the provision of their healthcare will be mandated to change at what may well be a very difficult time in their lives. My family’s own experience in this regard is with my daughter’s care: I know how upset I would have been if the government suddenly mandated we had to change from the medical heroes who had saved my daughter’s life once, when she was four years old and fighting brain cancer, and did it again through the same health care plan over the past year. If the government had suddenly directed a change to our plan in the midst of her life-saving care, it would have been devastating to our family.
There are two reasonable possibilities for achieving universal healthcare toward this transition of choice which the testbeds of several public options will likely lead us to: a national healthcare system modeled on the Veterans Health Administration (VHA) where the hospitals and doctors are all government-provided; or a Medicare-for-All system where the government pays directly to private hospitals and doctors. I believe we should be studying the feasibility of both options, and walk down both paths to determine the best choice — because as I learned in the Navy: “piss-poor planning produces piss-poor execution” — and we must get this right first before the full implementation of a single-payer system.
I know from my experiences visiting our wounded warriors at VHA facilities across the country that this type of system can work — indeed, it already is working for our veterans. The VHA directly provides high-quality medical services to over 9 million people at some 1,250 facilities, employing over 300,000 healthcare professionals. It is the country’s largest integrated healthcare system, providing comprehensive care to its patients whether they walk into a Vet Center in Fairbanks, Alaska, or a VA hospital in San Juan, Puerto Rico. And while there have been a few unfortunate scandals at the VA, overall health outcomes are actually as good as or better than other healthcare providers (this has been found consistently by sources from the New England Journal of Medicine to the Rand Corporation to the Journal of the American Medical Association). It is not a perfect system — and I offer some solutions to the challenges it faces in the Veterans policy paper — but it is remarkably effective at providing quality care for millions of Americans. Ultimately, I believe that the VHA model will prove to be most useful for developing public hospitals or clinics in underserved rural or urban communities — where hospitals have been rapidly closing due to the lack of profitability — permitting a cost-effective and quality care healthcare system to always be available for such communities, because no community can grow and thrive after its only hospital shuts down.
That said, the key to reforming our healthcare system — and why a single-payer system is so attractive — is cutting out the middlemen of private insurance companies. It simply makes no sense to have a layer of bureaucracy between doctors and patients seeking to squeeze profits out of both. During my daughter’s treatment, a life-saving drug was denied by the insurance company, leaving us liable for a $300,000 bill. That drug had not been approved for brain cancer before, but it was the best means to save her life — and as part of her overall treatment plan, it did. If my wife and I had not had the wherewithal to appeal their decision and fight on our daughter’s behalf, along with her doctors, we would have had to bear that necessary cost to save our daughter. Thankfully, we won the appeal, the insurance company covered the cost, and Alex beat the odds.
With that in mind, the second path toward a universal system would resemble Medicare-for-All. I believe this will eventually prove to be the best route to comprehensive and integrated care for everyone. Such a system should keep the best parts of the private market — especially the world-leading innovation of institutions like Johns Hopkins University, the Mayo Clinic, and the University of Pennsylvania — while expanding access to quality care to all Americans at better cost (which will necessarily be proven during the transition period). This eliminates private health insurance, except for those who wish to continue paying for it — in the UK some 10% of people maintain private insurance, and Canadians spend billions annually on supplemental private insurance — but the bulk of medical care in the United States would be paid for directly by the government. The large risk pool of patients will allow the government to negotiate prices with doctors, hospitals, and pharmaceutical companies, and thereby help control costs. We certainly must use milestones along the way to determine what is working and what is not; but if the milestones are being met, and the goals of better access, lower cost and higher quality care are being achieved, we can then move to a more compulsory, comprehensive system with different groups of Americans added over time, but within a set period of time. Most critically, we need to provide adequate time for doctors, hospitals, patients, and families to understand what changes are coming down the pike so they can do what they need to do to ensure a smooth transition. But the bottom line is that healthcare is a right, not a privilege, and therefore our healthcare system should not be profit-driven, like any ordinary industry. It must be mission-driven.
While the ACA has gone a long way toward stabilizing costs, the overall cost of healthcare remains a burden for millions of American families and individuals. I believe Congress and the President should take immediate action to lower costs further. One solution to skyrocketing costs of prescription drugs is to allow the importation of cheaper drugs from Canada where our own pharmaceutical firms often sell the same drugs for lower prices. For years the state of Maine permitted citizens to reimport drugs from Canada — often saving individuals thousands of dollars each year — until a federal court struck down their law in 2013. Now Vermont has passed a law to allow wholesalers to import drugs from Canada, but it is still arguing for the approval of federal government and so has yet to come into effect. To give just one example, Canadians pay just $29 per month on a Nasonex prescription, while in the US we pay $105.
The pharmaceutical companies argue that they need to charge as much as possible to pursue critical research, but I cannot accept that argument when the same drug companies spent $27 billion a year on marketing drugs. That’s enough to buy more than 5,000 Super Bowl ads. Meanwhile, Americans pay more for insulin than people in any other country — $6000 per year — and that price inexplicably doubled between 2012 and 2016. Such profiteering by drug companies must end. One way to force drug prices down is to allow Medicare to bargain directly with drug makers — as Medicaid and the VA already do, saving over $15 billion every year. Another is stopping the “pay-for-delay” practice that costs $3.5 billion annually by allowing pharmaceutical firms to pay generic drug manufacturers not to go to market after their brand-name drug patent expires. We could also use the so-called “march-in rights” granted to the federal government under the Bayh-Dole Act of 1980 to seize patent licenses for prescription drugs developed with public funding when the patent-holder refuses to offer them under reasonable terms. That would allow us to distribute those licenses to other manufacturers that would agree to offer them for a lower price. If all of these efforts fail to control the costs of drugs, I would be open to the creation of an entity in the United States akin to Canada’s Patented Medicine Prices Review Board, which has authority to determine maximum prices for patented prescription drugs in Canada, and is part of the reason why Canadians pay so much less than we do.
Finally, we must shore up our entire medical system by taking action against the increasingly dangerous shortage of doctors and nurses in our country. The Association of American Medical Colleges projects that by 2030 we could face a doctor shortage of 120,000, with roughly one-third of them primary care physicians. Especially as we move toward an integrated national healthcare system, primary care physicians play a critical role in our health system as the gatekeepers to specialist care. We can redistribute the $13 billion America’s teaching hospitals receive in federal subsidies toward more primary care residencies, with financial incentives for rural area follow-on assignments, and generally fund additional residency slots. We must also strengthen federal incentives and programs like the National Health Service Corps, the Conrad 30 Waiver Program, Public Service Loan Forgiveness, and Title VII/VIII workforce development and diversity programs which aim to recruit a diverse medical workforce and stimulate doctors to take up specialties with particular doctor shortages and to practice in underserved communities. The nursing shortage can be addressed by increasing training and educational opportunities (such as through fellowships and loan forgiveness for future nurse educators who commit to teaching in underserved communities), and by incentivizing healthcare organizations to conduct internal reviews about policies regarding nursing staff and implement solutions to prevent burnout and turnover.
Too often mental health is considered an issue apart from our broader healthcare system. But we know that mental health is critical to overall health and well being. We also know that our mental health system is failing. While some 43 million Americans suffer from a mental health condition, only 43% of them have received some form of treatment, according to a report from Mental Health America (MHA). The same report found that over 76% of youth with severe depression — some 1.7 million kids — do not get the treatment they need. It’s no wonder that both suicidal ideation and major depressive episodes among our youth are increasing.
Shockingly, nearly half of all psychiatrists refuse to accept Medicare or Medicaid patients, or even patients with private health insurance, instead preferring to see only cash-paying patients. While this is their right, it is incumbent on policymakers at the state and federal level to provide incentives to mental health professionals to do the right thing and take on the patients who need their help the most. We must also increase the number of hospital beds available for inpatient psychiatric treatment, currently at the same level as it was in the 1850s.
The federal government is already required to play a role in assuring that mental health and addiction are covered by health insurers under the Mental Health Parity and Addiction Equity Act (MHPAE) — which requires that restrictions and insurer’s requirements for coverage of mental health and substance use disorders are no more restrictive or onerous than those set for other medical and surgical benefits — but the Act is largely unenforced. Unfortunately it was written without a mechanism to monitor and evaluate its effective implementation, so it must be amended and updated as soon as possible — and then we must enforce it, with the federal government having a significant role in overseeing the enforcement by the states of equity between mental and physical healthcare. The ACA did improve coverage for behavioral health patients, but the parity protections of the MHPAE do not extend to Medicare, traditional Medicaid, or certain bare-bones catastrophic coverage plans currently offered. We must extend parity protections so that people in such plans are also able to access mental health and substance abuse treatment.
Finally, we must mobilize as a nation to address the crisis of opiate addiction. According to the data published by the Department of Health and Human Services, some 11.4 million people misused prescription opioids in 2016. Some 2.1 million people had an opioid use disorder. Tragically, nearly 50,000 people died from an opioid overdose. The federal government should be leading a multi-pronged approach to dealing with opioid addiction. We need states to rework their Medicaid programs to boost reimbursements paid to providers of addiction treatment services — as Virginia has implemented with their Addiction and Recovery Treatment Services program — because addiction treatment providers are generally underpaid by health insurers. We need to increase funding for training programs to help clinicians better understand the complexities of addiction care, and we need prisons to improve access to addiction treatment, including all available medications. We need to increase access to addiction treatment for everyone. Furthermore, the national database on opiate distribution should be made better available to law enforcement agencies that need to start utilizing it to better determine where to focus their limited resources. And we should permit federal law to allow doctors and scientists to expand research into the potential of certain controlled drugs to assess their value for treating substance abuse and for other mental health treatment.
We need states to rework their Medicaid programs to boost reimbursements paid to providers of addiction treatment services — as Virginia has implemented with their Addiction and Recovery Treatment Services program — because addiction treatment providers are generally underpaid by health insurers. We also need prisons to improve access to addiction treatment, including all available medications, and we need to increase funding for training programs to help doctors better understand the complexities of addiction care. We should permit federal law to allow doctors and scientists to expand research into the potential of certain controlled drugs to assess their value for treating substance abuse and other mental health treatment.
Perhaps most critically, we need to hold corporations accountable for their role in the epidemic, and then we need to use fines levied against them to fund drug treatment programs and increase federal support for mental health programs. We also need to deal with the corruption that has largely seen the Justice Department fail to pursue criminal charges against pharmaceutical company executives and drug distributors. The revolving door between the Justice Department and the Drug Enforcement Agency, and the pharmaceutical companies and their lobbyists, has resulted in law enforcement decision-makers going easy on corporate executives so they can maintain their chances of scoring a lucrative job with the corporations once they leave government. I therefore support a new division in the Justice Department to be called the Office of Public and Corporate Accountability to deal with exactly this kind of insidious and thus far intractable subversion of the rule of law — and not only through levying fines, but through criminal prosecutions. People are dying in our streets. It’s time those responsible — be they doctors, pharmacists, drug company executives, distributors, lobbyists, law enforcement agents, or other government officials — are held accountable.