There are certain commonalities that are relevant to state proposed single-payer plans. Of interest to natural medicine are those features that pertain to private practice physicians and primary care providers, definitions which generally fit naturopathic physicians (NDs) in states that offer NDs licensing.
In states that do not offer licensing to naturopathic physicians some of the definitions would not apply and hence the impact of single-payer on natural medicine in unlicensed states would be somewhat less conspicuous than it would be in licensed states. However, even in unlicensed states, the passage and steps leading towards the enactment and execution of single-payer legislation would be expected to allow for more movement in a direction that favors licensure in states that elect to adopt a single-player model.
In licensed states, the consequences of single-payer plans for natural medicine and NDs can be predicted to vary according to how that state views NDs in terms of the definition ‘primary care physician’ and how that state viewed NDs and natural medicine prior to single-payer legislation. It would also depend on the number of primary care physicians per person in that state as well as the degree of involvement of NDs in state single-payer grass roots movements.
The remainder of this article will focus on how the implementation of single-payer legislation in licensed states like Washington State could potentially allow for positive changes for NDs and natural medicine.
The WHST Could Increase Patient Access to NDs and Natural Medicine beyond that of the ACA’s Medicaid Expansion
As licensed health care practitioners, naturopathic physicians are included in the Washington State single-payer bill HB 1085, Washington Health Security Trust (WHST).
In Washington State, at present, only substances or treatments obtainable via prescription are covered by Medicare and Medicaid. Only Medicaid covers naturopathic physicians, but neither Medicare nor Medicaid reimburses for the majority of natural therapies. The Medicaid expansion could increase the ND patient pool for NDs who accept Medicaid.
However, ACA’s Medicaid expansion alone does not positively alter Medicaid reimbursement rates.
Not all NDs will be able to afford to accept Medicaid. A single-payer plan could enhance reimbursement rates to primary care physicians, further incentivizing ND acceptance of Medicaid payment and thereby increase access of the economically challenged to ND services.
A single payer system enhances the odds that natural medicines would be made more available and more affordable to those who currently find these treatments beyond their reach.
Single-Payer Plans Seek to Remedy the Shortage of Primary Care Providers
This health care program’s emphasis on meeting the need to fill the current shortage of primary care physicians includes loan forgiveness programs for graduating medical students agreeing to enter primary care residencies and/or to work in underserved areas. It also increases funding for graduate medical education teaching programs in primary care.
In states like Washington and other licensed states, naturopathic physicians could help meet the need for more primary care providers and loan forgiveness programs may help naturopathic physicians set up practices or work in underserved areas which could help decrease ND student loan debt while at the same time allowing more patients greater access and freedom to have naturopathic physicians as their primary care providers.1
Single-Payer Plans Tends to Favor Pay Parity for Primary Care Physicians
Despite the similarity in the number of years of education, the type of training and amount of educational debt ND reimbursement rates from third party payers are typically 15-50% less than those for MDs performing identical services.2
Projections have indicated that implementation of a single-payer system would result in increased pay parity for primary care physicians with specialists.3 This may also decrease the need for NDs to specify a niche/unofficial specialty in order to maintain financial solvency in urban areas where NDs are more concentrated.
Single-Payer Plans Put an End to Haggling with Insurance Companies Who Refuse to Cover Natural Treatments or Pay Providers in a Timely Manner
Doctors today are often hamstrung by the limited formulary and set of modalities that insurers will cover as well as the added infrastructure necessary to collect their reimbursement from private insurers. At present, the status of health care as a for-profit endeavor results in decreased availability of certain types of providers and treatments, such as naturopathic physicians and natural treatments that may actually be superior and less expensive in many cases than actions that private insurers typically reimburse. The added billing expense forced on physicians by the private insurance system takes resources away from the quality of care and the affordability of that care patients receive.
Under a Medicare style single-payer system, the number and variety of treatments available to patients is predicted to substantially increase and doctors and patients rather than insurance companies would have a greater say in what treatment a patient can access.
(See full article for more on potential impact to patients who submit their own claims.)
Potential for Increased Research Funding to Encourage the Use of Cost-Effective Natural Therapies
In addition to fostering policy decision making via participatory democratic process, one of single-payer’s aims is to control costs. For example, increased research funding could be offered to encourage the use of cost-effective therapies such as efficacious natural therapies that are not patentable but may be less likely to lead to costly iatrogenic disease down the road.
A number of natural therapies are frequently safer than certain drugs with high side-effect profiles currently used to treat the same conditions. Many of these treatment options are often preferred by both physicians and patients but are not reimbursed under the current private insurance system.
Single-payer’s accent on democratic decision-making and cost control could allow for coverage of many natural treatments that naturopathic physicians recommend to their patients who currently must pay out of pocket for these treatments, making these therapies more accessible to many more patients.4
Selection of Covered Treatments under a Single-Payer Health Plan
At the national level, single-payer proponents such as Physicians for a National Health Program (PNHP) have proposed that “In general, coverage decisions will be made by the health care planning board or another public body. New kinds of treatments will be added to the benefits package over time as they are shown to be effective, including ‘alternative’ treatments.”5 PNHP further proposes that the decision making body, the health planning board, would be a “public body with representatives of patients and medical experts.”6, 7, 8
Proposed Decision Making Bodies Could Include the Board of Naturopathy
On the state level, the Western Washington Physicians for a National Health Program (PNHP-WW) have set forth principles as part of their Washington State Alliance for Health Care as a Human Right objectives. One of these principles, states that: “Health care policy-making is decided through a participatory democratic process at all governmental levels.” 9
Therefore, based on both the national and state democratic framework, it has been suggested that representatives from the Washington State Department of Health Board of Naturopathy could be included in our state’s health care planning board, the board responsible for making coverage as well as other policy decisions. It is also possible that Washingtonians could elect or have influence via appointment of elected officials regarding the representatives that could potentially be included in Washington State’s health care planning board.
Click here to learn more about the potential impact of increased participation of the natural medicine community.
The Term ‘Evidenced-based’ could be defined by the Health Care Planning Board
The lack of coverage of natural therapies is often based on the presumption that these therapies are not “evidenced-based” or that natural therapies are “experimental”. This presumption is based on the lack of phase I-III randomized placebo controlled trials (RPCTs) or FDA clinical trials which are the standard by which drug therapies are “proved” to be “evidence-based” under the existing system. However, natural treatments currently have an unfair disadvantage compared to their pharmaceutical counterparts; namely, the fact that only the pharmaceutical and medical device industries can afford to finance the enormous costs of the RPCT, FDA studies.
Further exacerbating the disadvantage of natural treatments as compared to pharmaceuticals is the erroneous assumption that off-label use of drugs is an evidence-based practice. Despite the RPCT standard, off-label uses of pharmaceuticals that are based only on conjecture concerning mechanisms or anecdotal evidence alone is extremely widespread, making up a significant proportion of conventional treatments. Yet, there is no parity for natural non-patentable treatments that are supported by a body of research data demonstrating their efficacy.
Citing JAMA, Martin A. Makary MD, MPH reports that 25% of conventional medical practice is evidence-based and the other 75% is “discretionary”.10
At present, single-payer principles in Washington State also emphasize the use of ‘evidence-based’ medicine, but this term has not been rigidly defined as yet.11 Under a single-payer plan the term ‘evidence-based’ could be defined in any number of ways based on the determination of the health care planning board. Click to view full article’s examples of how the term ‘evidence-based’ could be defined under a single-payer health care plan.
A very strict definition of phase I-III FDA CTs would mean that the health care planning board would have to eliminate coverage of thousands of off-label use pharmaceuticals. Based on the likelihood of the selection of an alternative definition of the term ‘evidence-based’, under a single-payer plan, there would be a strong argument to increase NIH funding to phase I-III CTs for promising natural therapies.
The more naturopathic physicians and natural medicine proponents become involved in single-payer advocacy, the more likely that the definition of the term ‘evidence-based’ would be defined to reflect descriptions that encompass natural, non-patentable therapies and the more probable that these therapies would be to be covered.
The possibility for NDs to participate in board decision-making could help to integrate conventional and naturopathic medicine under one roof, as different flavors of the same discipline, that of medicine.
Dose Response Relationship: Conclusion of the 3-Part Series
There is a dose-response relationship between the level of understanding that naturopathic physicians and all people living in this country have regarding the basic concepts involving our health care crisis and our ability to solve our health care system problems. The more we learn about this issue the more able we will be to trust our diagnosis of the problem including its causes and its prospective cures.
Single-payer systems could benefit physicians and patients who use natural medicines in the following ways: click here to view summary of potential benefits.
We have already taken the first step on the road to health. That step is ‘docere’ or doctor as teacher. By having tuned in to absorb the information in this 3-part article, we have all become the doctors of our own destiny; we have all become healers of the crisis in American health care. ∎
Special Thanks to: Sherry Weinberg, MD, Don Bunger MEd, Helen Thorsen CDP, David McLanahan, MD, Jim Squire, MD, Don Mitchell, MD, Marti Schmidt, JD, Betty Capehart, MSc, Dana Iorio, ARNP, Kathleen Myers, DDS, Kathleen Randall, MA, all my patients.
References available here.