The News:

Hillary Clinton, the 2016 Democratic nominee, said last Wednesday she hoped for a return to “boring, normal times” after the 2020 election, voicing skepticism of her party’s populist wing and predicting that Sen. Elizabeth Warren’s (MA) proposal for single-payer Health care would never get enacted.

At The New York Times DealBook conference in New York, Mrs. Clinton said she saw two of the biggest policies embraced by the left in the 2020 Democratic primary–Medicare for All-style health care and a tax on the assets of the very wealthy–as “unworkable or politically impractical.”

She said Democrats should pursue the goal of universal health coverage, but through other means. A longtime leader of her party’s moderate wing, Mrs. Clinton was most blunt about Ms. Warren’s proposal to replace private health insurance with a single-payer system.

Asked if she thought Warren’s proposal could get passed into law, Mrs. Clinton answered in the negative.

“No, I don’t — I don’t,” she said. “But the goal is the right goal.”

Mrs. Clinton did not criticize either Ms. Warren or Sen. Bernie Sanders (VT), the liberal populist who challenged Mrs. Clinton in the 2016 primary and who also supports Medicare for All, in harsh or personal terms. But she suggested that the approach to health care favored by both was misguided, saying that “the smarter approach is to build on what we have” by adding the option of a public healthcare plan to the offerings of the Affordable Care Act. It is not a surprising preference for Mrs. Clinton: In the 2016 campaign, she supported introducing a public health insurance option but consistently rejected Sanders’ calls for single-payer health care.

Speaking last Thursday at North Carolina A&T State University in Greensboro, Ms. Warren was asked about Mrs. Clinton’s remarks.

“I’m saying, you don’t get what you don’t fight for,” she said in response. “You know, you’ve got to be willing to get out there and fight.”

Mrs. Clinton’s comments suggest she remains skeptical of the populist forces on the rise in Democratic politics. While she did not endorse a candidate, she indicated a clear preference in one of the largest debates raging in the Democratic Party: whether to nominate a candidate who would make sweeping changes to the country’s government and economy, or someone who would restore something like “normalcy in Washington.”

Steve’s Take:

Alright. Hillary Clinton doesn’t care for Elizabeth Warren’s Medicare for All. That’s understandable considering Mrs. Clinton certainly provided input to President Barack Obama’s Affordable Care Act. But Medscape’s Alicia Ault reports that many doctors are angry and “feel undervalued by Warren’s health plan.”

The Massachusetts Democrat’s proposal to help pay for Medicare for All by curbing physician fees is mostly drawing the ire and outright shock from doctors, although some continue to support the notion of creating a single-payer, government-run health system, first proposed by Sen. Bernie Sanders leading up to the 2016 election. Much of organized medicine has been on record as opposing a single-payer system, and now many doctors have taken to Twitter and other social media platforms–some to voice their contempt for Warren’s plan, others to voice their doubt.

Warren announced in her plan that was released on November 1 that she’d hold physician fees to roughly what Medicare pays and increase primary-care physician pay while decreasing pay of many specialists. The plan is based on a report prepared for the Medicare Payment Advisory Commission in January 2019 titled, Analysis of Disparities in Physician Compensation.

“Does she not calculate the massive egress of physicians from the field with such a pay cut?” queried radiologist Stephen Poole, MD, in commenting on a story by Medscape about the Warren proposal. “If such a plan were enacted, those close to retirement would retire en masse,” he commented.

Speaking in his role as a Fox News medical correspondent, internist Marc Siegel, MD, of NYU Langone, New York City, said during a recent interview on the network that:

“doctors will be paid up to 40% less, many will leave the profession, there will be an enormous doctor shortage.”

Michael McClurkin, MD, MPP, a psychiatry resident at Yale University, tweeted that he was a Medicare for All supporter but that:

“if physicians take a pay cut across the board, medical school/residency should be restructured to reduce debt burden.”

In a tweet response, Philip A. Verhoef, MD, PhD, FACP, FAAP, a board member of Physicians for a National Health Program, called McClurkin’s proposal:

“a nice idea,” adding, “but there’s no reason to think physicians would take a ‘pay cut across the board.’” Verhoef claimed that physician pay would “not be compromised under Medicare for All,” and added that “Canada’s docs get paid more on average than US docs.”

One of the specialties targeted as “overpaid” by Warren is neurosurgery. Neurosurgeons have high practice expenses–including some $250,000 per year in malpractice premiums–and significant debt, accumulated during the average 15 years it takes to become board certified, said Katie O. Orrico, director of the Washington office of the American Academy of Neurological Surgeons (AANS).

Two thirds of respondents to a recent yet-to-be-published AANS survey said that if they had to accept Medicare rates for all their patients, they wouldn’t be able to cover practice expenses. A quarter said they weren’t sure if the rates would be enough to cover expenses, and only 7% said they’d be able to cover costs, Orrico told Medscape.

Reimbursement for all patients at the Medicare rates “would be significantly problematic” for the AANS membership, she added. The AANS wouldn’t comment specifically on Warren’s proposal but has been on record since 2009 as being opposed to a single-payer plan, Orrico said.

Similarly, a spokesman for the American College of Radiology (ACR)–another “overvalued” specialty–told Medscape the organization would not comment on the Warren plan. But he noted that the ACR is a member of the Partnership for America’s Healthcare Future, which is against a single-payer system. After Warren gave details on how she would pay for Medicare for all, the Partnership called it unaffordable.

“Lawmakers should build and improve upon what’s working and come together to fix what’s broken–not start over from scratch with an unaffordable one-size-fits-all system controlled by politicians that forces Americans to pay more and wait longer for lower-quality care,” said Lauren Crawford Shaver, ACR’s executive director, in a statement.

The American Academy of Orthopedic Surgeons (AAOS)–yet another overpaid specialty, according to Warren’s plan–also opposes single-payer plans but would not comment on Warren’s proposal. The AAOS backs wider, affordable access, and said in its position statement on health reform that “it is important that policymakers avoid creating new unaffordable programs that repeat past mistakes.”

The AAOS noted that Medicare, Medicaid, and the State Children’s Health Insurance Program (SCHIP) all have problems with respect to sustainability that have led “policymakers to erect bureaucratic impediments to care and reimbursement rates that make it difficult for providers to cover the cost of care.”

Because Warren has laid out a specific payment plan for Medicare for all–one that targets multiple constituencies through higher taxes–it seems to have received more attention than the Medicare for All program backed by candidate Sanders. To some in Washington, Medicare for All seems destined for failure, in part because it would represent such a monumental upheaval.

“I have to believe that Elizabeth Warren is smart enough to know that this doesn’t have a chance,” Robert Laszewski, of Washington-based Health Policy and Strategy Associates, told Medscape.

Writing on Medium.com, candidate Joe Biden, in an apparent, thinly veiled reference to Warren, called her approach, “representative of an elitism that working and middle class people do not share: ‘We know best; you know nothing. If you were only as smart as I am, you would agree with me.’” Biden said he had “proposed the most progressive, transformational ideas in this campaign.”

Sanders told ABC News that his plan was more progressive than Warren’s, in part, he said, because her payment proposal would hurt job creation. The Hill quoted several Democratic senators as saying they did not support Medicare for All and that they doubted such legislation would receive a vote if Warren was president.

“I’m for universal coverage, I’m for building on the Affordable Care Act,” said Ben Cardin (D-MD). But, he added, “My preference is to move forward on a public option.”

Public support for Medicare for All also appears to be fading. From a high of 59% in 2018, support fell to 51% in October, according to recent data from the Kaiser Family Foundation. The nonprofit’s President and CEO Drew Altman, PhD, however, said in a November 6 column for Axios that “it’s still a powerful idea among many Democrats.”

Bottom Line:

Within all the contentious issues fomenting among the Democratic presidential candidates, health care, sadly, also falls into the predominantly “take it, or leave it,” categories. And, of course, there are the similarly polarized Republican/Democratic-parties’ overarching and entrenched positions on health care. That’s why Democrats, if they really hope to win the 2020 election–whether or not Donald Trump is the Republican candidate–sorely need a “moderate.”

And Joe Biden is the closets to being that–at least at present. As appealing as the slogan Medicare for All might seem, building on Obamacare is the more “moderate” position and perhaps makes the most sense toward providing actual universal healthcare coverage–in our lifetime. Isn’t that the ultimate goal, no matter whose side you’re on?