The Uninsured Are the Symptom, Not the Disease

April 28, 2009 · Posted By · Filed Under Covering the Uninsured 

I was invited to join the health care reform debate by addressing a set of questions falling under the general theme “Covering the Uninsured.” The problem is that to answer these questions I have to challenge fundamental assumptions underlying them — if one asks the wrong question or misunderstands the nature of a problem, the chances of getting the right answer or solving the problem are slim.

And this is precisely what happens with the three questions I was asked, namely, should all Americans be required to purchase health insurance; what options for coverage should the uninsured and underinsured have; and how do you assess when coverage is affordable. They all assume that the problem is the uninsured or the underinsured. But these are only the “symptom”. The real “disease” is the financial organization of our system.

In all industrialized economies, but ours, individuals do not “purchase” insurance as you “purchase” shoes or cell phone plans. Rather, they contribute to a system whose goal is to eliminate financial barriers to health care. Those systems, to varying degrees, pool risks and are financed by compulsory cooperative contributions.

What does this mean? Well, pooling risk simply means putting everybody into large pools, the bigger the better, and budgeting for people’s medical needs in the same way families budget for their members’ nutritional or educational needs. And why would they do this? They do this because given that the goal of the system is to eliminate financial barriers to care universally and according to medical need, these systems seek to optimize the use of members’ money.

And pooling risk does so in three ways. First, it allows the system to cross-subsidize, which means that at any given moment the healthy or least costly majority pays for the medical care of the less healthy and most costly minority. Cross subsidizing is critical for any insurance system to be sustainable: if a system includes only sick people it will quickly go bankrupt (this, incidentally, is the problem of our American Medicare, because it enrolls only the elderly, who tend to have higher medical costs, and the disabled, whose costs are the greatest. This problem would be resolved by putting all of us into Medicare, and of course getting rid of all the private middle-men that have corrupted it, e.g. “private fee for service Medicare”, “part D”, etc.).

The second thing that pooling risk does is to dramatically reduce administrative overhead, i.e., waste that comes from pushing paper around — to separate people into plans, to market those plans, or to underwrite policies (essentially to deny paying for care). While paper-pushing is the lifeblood of private or liability insurance, because it helps it achieve its ultimate goal, which is not to provide a social service but to make a profit, from the point of view of systems whose goal is to eliminate financial barriers to healthcare paper-pushing is waste.

Third and last, pooling risks gives those systems important market leverage, precisely the leverage Americans lack, which is why we pay the highest prices on the planet for services and goods (e.g. pharmaceuticals) that cost a fraction elsewhere. (And don’t worry: doctors and pharmaceutical companies elsewhere do just fine!).

What about cooperative compulsory financing? Well, this means that participation is not optional and is based on cooperation, or solidarity, if you will. And by making participation compulsory those systems have a guaranteed supply of money. But the cooperative dimension means that nobody is forced to pay what they cannot afford, because that would defeat the very purpose of the system. So contributions are a proportion of income, a mix of taxes or payroll deductions, and align, more or less, with the World Health Organization (WHO)’s requirement pertaining to “financial fairness”. For the WHO, a system that forces you to forego healthcare, or to have to choose between healthcare, rent or food, or that pushes you to bankruptcy (as we do) is decidedly unfair. The rule of thumb is that any system into which people pay over 10% of their income in medical bills (including monthly contributions and out of pocket, extra costs) is “financially unfair”. And mind you, we pay at least that much to finance an extremely dysfunctional system, even this system leaves you on the cold when you need health care (Remember that your taxes foot the bill of all public programs, for the elderly, the disabled, or those who qualify as “poor”, even before you are eligible for any services yourself. In truth, you are “cleaning” the market of “bad customers” and leaving all the “good customers” to the private health insurance sector).

But what about the questions posed by KQED? Well, let me rephrase them.
Should Americans be required to purchase health insurance? As I said, the concept of “purchase” does not fit the systems I just described, which is the one I believe we should have in America, because people elsewhere do not “purchase” health insurance the way we do.

And what “options” should the uninsured and underinsured have? Again, others do not “shop around” for “options”, which implies that you need to second guess if you will need an appendectomy, diabetes care, or one week rather than two days in a given operation. Whatever expenses others have for care that the system has considered “medically necessary” will be paid for out of the common pot. If they want over and above that, they pay for it as you do for that pair of shoes that no reasonable person considers is your “right” to have, or is a “basic human need” (especially if like me, you have more than you will ever be able to wear!).

And last, how do you assess your coverage is affordable? Well, if you consider that unpaid medical bills are our first cause of personal bankruptcy, you know where we stand in that one.

Last, will the Obama plan solve our mess? I wish I could believe so, but I do not. For one, it sticks to the wrong conception about how to finance a health care system, assuming of course that the goal of the system is to eliminate financial barriers to health care universally rather than to create a profitable “illness market” or appease the folks who finance your political campaigns. And any system that sends people “shopping around” for policies while leaving the for-profit motive at the center of the system intact is likely to fail. It has repeatedly, for reasons studied ad-infinitum (yes, health policy is not rocket science!) and we have no reason in the world to believe it will be different this time.

Comments

37 Responses to “The Uninsured Are the Symptom, Not the Disease”

  1. margaret wheeler md on May 1st, 2009 1:13 pm

    I couldn’t agree more with Claudia. The terms of the debate– even well-intentioned ones like KQED’s “Californian’s Weigh In on Health Care Reform”– can obfuscate the issues. The BIGGEST cause for health care ( not health ) disparities is lack of access; key to cost containment is ridding our system of its overwhelming administrative costs and lack of market leverage; key to quality are integrated delivery systems and coverage that can not be lost with a new diagnosis or loss of a job. There is a clear-cut, fairly simple, unified solution to all these problems– a single payer system. I depair that the influence wielded by big pharma and insurance companies will continue to keep single payer, the only truly comprehensive solution to our health care crisis, off the table.

  2. claudia on May 1st, 2009 6:46 pm

    thank you, margaret, for your comment. it is really heartbreaking to see how successful the politics of obfuscation is, that it confuses even well-intentioned people, while so many people are suffering. and as you pointed out, single payer options like SB810 in California or HR676 at the federal level are the only bills that meet the two very simple policy principles i stated above, and the only ones that will control costs and will allow us to work on increasing quality (which of course will not happen automatically, but getting the financing and the system of incentives right is critical).

    and beware of those who tout switzerland or holland as models of “successful private insurance systems”. while the topic is a complex enough so that i cannot explain in a sound bite, let me just say that confusing switzerland’s private insurers with ours is like saying that birds and butterflies belong to the same biological species only because both have wings –sheer nonsense.

    so yes, we will keep having the same debate until american grassroots and ordinary americans gather the steam to push for single payer, and to demand from their representatives that they do the job they were hired to do.

  3. Bart Woolery on May 3rd, 2009 9:32 pm

    Excellent explanation of the problem with the questions and the system. Even those who do not like a system based on a social contract such as universal single-payer (for political reasons) have to admit that it by far the best way to finance healthcare in an affordable, comprehensive, and equitable way. Our antiquated way of financing healthcare must change, and what is so far being proposed at the federal level is not change but more of the same on steroids. The will of the people bends towards a social contract in which everyone contributes and everyone benefits – when will the politicians accept this fact?

  4. Claudia on May 4th, 2009 8:29 am

    Thank you, Bart. And in reply to your last question, politicians will accept this fact when ordinary people like us let them know that we will withdraw our vote if they fail to do so. While lobbyists’ money has its attractions, it loses at least some of it if it does not get politicians the vote.

    And we can learn this much from history: no movement for greater social equity ever succeeded without a strong and vocal grassroots, so we probably should not expect the one for greater health care equity to be any different. So every time somebody says “Americans are not ready for blah blah blah”, we need to publicly let them know that we are ready indeed, and that we will settle for no less than true social health insurance.

    On a side note, the first social health insurance system was fostered by Otto Von Bismark, first chancellor of the German Empire, in the early 1880s, not because he was a socialist, but because he wanted to stop the advance of socialism. He had seen the 1848 socialist revolutions and the 1870 Paris Commune, and realized that workers meant business. And history shows us that he succeeded quite well.

    I like your comment about current federal level proposals being “more of the same on steroids”. I might borrow it in the future if you don’t mind :-)

  5. Bart Woolery on May 4th, 2009 8:51 am

    You are welcome to steal/borrow anything I say if it will further the cause. I am deeply involved in the grassroots movement towards effective healthcare financing. I think a critical component is how we frame the issue (you might enjoy my diary on the subject at http://www.dailykos.com/storyonly/2009/2/21/699597/-Framing-the-Healthcare-Financing-Issue , or not). Your comment about Von Bismark, which is news to me, gives us an excellent frame for the debate which will largely center on political issues and not the facts surrounding the efficacy of publicly funded universal healthcare financing which are essentially unimpugnable.

  6. Claudia on May 4th, 2009 11:25 am

    I will borrow your expression indeed :-)

    Equitable health care reform, I believe, is really a team effort. I very quickly checked your diary by the way. Let me just add to your argument that this is indeed about values, but it is one case where good morals and good economics go together.

    What I mean is that single payer/social insurance is the way to go from a moral point of view, but also the best from an economic point of view — unless, of course, one owns shares in the private insurance sector, and expects their kids, grand-kids, friends, etc. to so do too, or does not care about them!

  7. RL on May 11th, 2009 11:42 am

    While philosophically I agree with everything that was said in this article, my practical side is saying so what? If the administration has taken a single payer system off the table, how do we make sure that the reform that is happening today takes us closer to our goals and not farther away? Do you feel like an individual mandate or a public pool are steps in the right direction? Is there any language or provisions that we can advocate for that will lay a foundation?

  8. Claudia on May 11th, 2009 1:03 pm

    RL,

    Thank you for your reply. You say “if the administration has taken single payer off the table” bear a big “if”, which is why we need to question. We (the people) are their boss and pay their salaries, not health care corporations. At least that is what a democracy is all about. Obama is an elected official, and so are legislators. They are not Louis XIV, the Sun King, and should not behave as such. If they are confused about their proper behavior, then that’s the problem and we need to change it.

    In a variety of polls, the majority of Americans, including physicians, prefer single payer over any other option (I will write about the “public option” in my next posting, so stay tuned…).

    So single payer is not only what demonstrably works, from a policy perspective, to eliminate financial barriers to health care for a suffering population, already batted by phony wars, rising unemployment, loss of houses, and bank bailouts, but what the people want.

    Last week, a group of 8 brave folks, including physicians, were dragged out of the Senate Finance Committee because they “dared” demand that single payer be on the table. When one of the doctors said “we need single payer”, Senator Max Baucus, chair of the Committee, laughingly replied “we need more police”, and dragged her and others out, while the rest of the audience laughed as well.

    Take a look at two links, featuring The Ed Show and the Real News network reporting on the event, all but ignored by the major, corporate media (you can copy and paste the links into your browser, or Google them up). You would never know that single payer exists not even by reading the New York Times, presumably “liberal” paper, let alone the Wall Street Journal.

    The 10 minute video clips are worth every minute, and are worth circulating as well.

    Ed Show:
    http://crooksandliars.com/susie-madrak/ed-schultz-insurance-companies-are-ta

    Real News:
    http://therealnews.com/t/index.php?option=com_content&task=view&id=31&Itemid=74&jumival=3665&updaterx=2009-05-07+17%3A10%3A43

    We cannot allow this to continue to happen. If we do, shame on us. And bear in mind that they cannot throw all of us in jail….

    I hope this helps.

  9. JG on May 12th, 2009 11:06 am

    Claudia,

    I just found about:

    http://singlepayeraction.org/

    It looks like the right organization to push the points you made. Do you know about them?

  10. Claudia on May 12th, 2009 12:53 pm

    Hi JG,

    It is very good, and one of the many very good ones out there (there are also the “pseudo” or “aiming at” universal folks, including a public plan as an “option” (stay tuned for my next posting).

    Other organizations are Health Care for All California (major force in California), Single Payer Now (San Francisco based but goes to all rallies in California and buses people to D.C. as well), and Physicians for a National Health Program, which also rallies and organizes everybody, not exclusively physicians.

    Every person counts! :-)

  11. RL on May 12th, 2009 3:49 pm

    Thanks for the quick response. I don’t want to be confrontational, but do you really think a single payer system is politically feasible in during the administration? My experience with California’s latest run in with health care reform, as well as the fact that neither Obama nor Kennedy are even willing to broach the subject – tells me no.
    In this current political climate I’m wondering what is the best role for single payer advocates? I know we need to fight the long term battle, but how can we balance this vision with current realities and the millions of Americans that need health care today?

  12. Claudia on May 12th, 2009 4:01 pm

    I understand your concern, RL. Check my second post for a fully developed answer to your question. In the meantime, the short answer is, what is “politically feasible” is what ordinary people fight it to be, especially, albeit not exclusively, in a democracy.

    Political feasibility is not a “law of nature”, like, say, gravity (and even this you can “defy” by developing technologies that work “around it”, e.g. airplanes that take us through the skies). And the argument that X is not politically feasible because special interests make it politically unfeasible, as you can see, is circular.

    Ordinary people, masses, are a huge political force, whose effects, as history shows, we can barely imagine. Back in 1883, Otto Von Bismark, first Chancellor of the German Empire, created the first social insurance system (and the foundation of Germany’s wonderful current healthcare system), not because he was a radical concerned with workers’ rights or well being, but because he realized that, in his own words, “the social insecurity of the worker is the real cause of their being a peril to the state”.

    In my view, political feasibility is politicians’ problem. It is they, not us, who want to be re-elected. Ordinary people ought to be concerned with equity, and go for it.

    (Well, longer than what I intended :-))

  13. Bart Woolery on May 12th, 2009 7:38 pm

    In terms of political feasibility, what we are taking on here is really approaching the magnitude of the civil rights movement. Clearly nothing would have happened in that movement without the massive popular uprising that it fomented. We too are about fomenting a massive popular uprising, person by person. The leaders will follow, dragging along their political feasibility with them. The current leadership needs to be shamed for locking a popular concept out of the discussion. That process pulls in more discussion of the issue in the media.

  14. Claudia on May 12th, 2009 7:46 pm

    Bart, I could not have said it better. We need people like you :-)

  15. metropolitical on May 13th, 2009 9:02 am

    I agree with the basic philosophical conclusions of the author, but wonder how the dramatic changes envisioned in our healthcare system could be accomplished. There are a number of business realities which threaten to block any of the real changes hinted by the author.

    First, the current combination of pay-for-procedure incentives and fear of medical liability create an unholy economy that benefits doctors and lawyers, but not patients who are subjected to unnecessary “defensive” medical procedures. Pay-for-procedure is all doctors have known, and the fear-mongering spread by trial lawyers provides a legitimate excuse to overtreat and thereby increase profitability under a halo of pseudo-ethical righteousness. It is very profitable, for lawyers primarily, but despite the loathing of it, doctors also profit from it.

    Secondly, for decades, doctors incomes have risen faster than the rate of inflation. Ultimately, this diverging trend can not be reconciled with broadening the access to health care for most people who are barely keeping up with inflation. Now it may be possible that modern doctors are treating more patients daily than their predecessors, through productivity increases, thereby inflating their incomes disproportionately in an agreeable way, but I have not seen much evidence of that. Doctors today generally treat as many patients as before in the same 1 to 1 relationship that existed in years past. Moreover, if productivity was really increased then more people proportionately would be benefiting from medical care, not fewer. The fact is, people pay disproportionately more of their incomes for medical care. For the most part, the inflation probably stems from passing along the increasing costs of dealing with the proliferating insurance company paperwork on behalf of patients, from the aforementioned rise in overtreatment (justified as defensive medicine), as well as simple disproportionate expectations of income, otherwise known as greed.

    Despite appearences, I don’t mean to single out doctors with culpability. Medicine is a very complex business entity, and the sum of all its parts, as each part vies to maximize its own profit, will cause all of medicine to become bloated with cost. It is an economy unto itself. The more parts, the higher the probability some of those parts will find a way to disproportionately extract a greater share for itself, but because of each part’s subordinate role, rarely reach the attention it deserves when looking for a spot to apply an economic torniquet. Ultimately though, doctors are the ones who have to pass along those costs.

    A consumer can not be expected to know medicine as thoroughly as a doctor, and even doctors have trouble deciding if a treatment modality has an impractical cost/benefit ratio. Moreover, if they do question it, often trade groups with vested interests politick to bend the standard of care their way. Doctors therefore really have little choice but to pass on whatever comes down the pike, and thereby become the primary aggregators of disproportionate price increases throughout the medical economy.

    Food, housing, and medical care are critical necessities to survive in any economy, and even more so in one as demanding as ours. For some reason food prices have been kept reasonable over the years, but not housing or medical costs. Although the current economic crisis seems to be partially addressing housing affordability, medical costs have not been affected as much. Both housing and medicine have been absorbing a greater proportion of people’s incomes over several decades. Most people won’t even know how much damage is being done until they realize how age really affects them, and then it will be too late. There seem to be too many vested interests in keeping both housing and medical prices inflated. Any real change will have to fundamentally alter the way business is done over a wide spectrum of businesses associated with medicine, and that seems improbable to me.

  16. Bart Woolery on May 13th, 2009 11:23 am

    A few points about single-payer. First, single-payer primarily addresses the issue of healthcare financing, that is, how do we pay for what we get, whatever that is. There is plenty that can be done on the delivery side in any system. That said, single-payer does enable certain beneficial aspects that help ameliorate, for example, the problem of defensive medicine (and more importantly, clinical waste in general). As the bulk of malpractice awards are for the future healthcare requirements of the victim, and this is removed from the equation with single-payer, not only will malpractice awards and premiums go down, so will the lawsuits.

    Overall, malpractice costs are less than 1/2 of one percent of all healthcare costs, not a very significant factor in the big picture but something that will definitely improve with single-payer universal healthcare financing.

    Second, there is no doubt that vested interests, including some doctors, would be averse to supporting single-payer. However, the majority of doctors, and especially younger doctors, support single-payer. Overall, doctors support it by about 60%, in line with the general populace.

  17. Claudia on May 13th, 2009 1:01 pm

    hi folks,

    in my opinion, metropolitical has a point (or two!), but, what is the option? just give up? i can get far, far worse, unless we (i.e., the people) push for the right kind of financing, which as i have argued is social insurance, in our case single payer (we do not have the history of mutual funds that led the germans to a multipayer system, even if non profit).

    on the other hand, this is to metropoltical, doctors in america are not worse than doctors elsewhere, neither are political forces elsewhere non-existent. so even if i think you (metropolitical) have some points, i am not sure what we should be doing, other than advocating for what is good for us (again, the people, not private interests).

    my two cents :-)

  18. Dr. Rob on May 18th, 2009 7:07 pm

    Now I see why I was invited to this discussion. This is exactly what I posted about: http://distractible.org/2009/05/12/mandated-morphine/ It is just like giving morphine to a person with chest pain. It takes away the symptoms briefly, but does nothing for the underlying problem. In fact, it will temporarily make you forget about the things that are so bad that they are making having no insurance the most reasonable alternative.

    This approach is simplistic: No insurance? We can fix that! Shazam! You have insurance now! Yet it does nothing to bring down cost. I believe this law is just so some legislators can campaign that they voted to get rid of the uninsured.

  19. Claudia on May 19th, 2009 11:10 am

    Rob, I am not sure I understand your point…are you stating that the mandate to purchase insurance, currently discussed in Congress as the “solution” to uninsurance, is a scam? If so, I could no more than agree.

    In my lectures, I often use a cartoon which I purchased from the Cartoon bank of the New York Times, which shows a doctor, who, with a very straight face (as he looks at a patient’s insurance card), tells his very sick patient: “Sorry, but your plan does not cover illness”.

    Put another way, the “problem” of uninsurance will be resolved with a piece of paper, and you will be billed for it. And as you comparative shop you will have to make sure that you read the fine print because the plan you settle down for, however affordable, may not protect you from the financial burden of disease. This is what is being “cooked” for us.

    And yet, how to provide health care equitably to a population is not that difficult. The Germans figured it out over 100 years ago: the answer was putting everybody in large (better single) risk pool, banning profit from shuffling paper around and passing the buck from patients to providers, and compel everybody to participate depending not on their disease state but on their ability to pay. The rest, as we say, is history. And the industrialized world, sooner or later, followed through — Canada, the UK, etc — except for us, of course…

    We (rather some on everybody’s behalf) created an “illness market” whose main purpose is to avoid the sick and make a buck at the expense of the healthy (so long as they remain healthy, otherwise they will get dumped, at best on the public programs paid for by taxpayers). So nobody should be surprised that medical bills are the first cause of personal bankruptcy, and that three quarters of those who went bankrupt had insurance when they filed! Others look at us and thing we’ve all gone crazy…

    And now the same sectors that created the mess have pledged to make things better, to shave off a billion or two (maybe…). With respect to what? Not with respect to a reasonable alternative, mind you, but with respect to the disastrous system that we would otherwise continue to have if nothing is done about it! A true insult to our intelligence, in my opinion.

    Unless, of course, we have a massive mobilization and ordinary people do something about it. And I understand that the point of this KQED sponsored debate is that ordinary Americans become more informed and involved in making history.

  20. metropolitical on May 19th, 2009 11:37 am

    Bart Woolery: “Overall, malpractice costs are less than 1/2 of one percent of all healthcare costs,…”

    Ok I stand corrected: doctors are in fact the primary economic beneficiaries of malpractice fear, not lawyers. They benefit by overtreating for a statistically non-existant threat.

    However, it is also beside the point. As implied by Dr. Rob, the cost of healthcare is increasing disproportionately relative to the overall economic productivity of the majority of the population. It is the fundamental problem, and it is unsustainable unless, (1) the rate of healthcare cost increases are reduced to fall in line with inflation, or (2) more tax money is used to redistribute wealth and subsidize the disproportionate increase in health care costs.

    From 1960 to 1990 the number of physicians per capita rose at a fairly steady rate, but between 1990 and 2000 that rate nearly doubled. Simple economic theory would suggest that the increased competitiion would drive prices down, yet the opposite has occured. Although demographic issues like doctor maldistribution, increasing demand for care, or more expensive types of treatment may be in part behind the paradox, whatever the reason, costs have escalated faster than inflation.

    Another possible issue here is that doctors have traditionally been in the upper quintile of wage earners, the one demographic group whose incomes actually did better than inflation over the last few decades. Healthcare costs are therefore, at least in part, another casualty of the wage gap issue which still is unresolved. Although doctor’s wages represent only about 20% of the total cost of healthcare, it is nevertheless a piece of the social dilemma: how can a necessary expense of the majority be paid when the income expectations those being paid are rising faster than those who must pay. Is it any wonder there are more phycisians per capita today than 10 years ago?

    For pragmatic reasons, mass production can not be easily integrated into healthcare, and to the extent to which it can be done, probably has already been implemented. Electronic records certainly will help reduce errors, and thereby reduce retreatment, but I am not sure if that will increase productivity much once the initial productivity increase is absorbed. Trimming administrative costs, will also just restore a fixed percentage in efficiency costs, and even then such costs now only take up about 5% of healthcare costs. So where are the long term savings going to come from?

    As long as doctors cling to being a part of that upper income minority, and as long income expectations diverge as they have been between the economic majority and upper-income minority, none of the fixed percentage changes in healthcare efficiency will be sustainable once doctor’s income expectations catch up to the savings.

  21. Claudia on May 19th, 2009 11:45 am

    Here is a contribution to the “public option” debate, from the national organization of physicians (to which i belong) that supports single payer universal health care. I think it is very instructive. I hope you find it useful.

    Health Policy Q & A with PNHP Co-founders Drs. David Himmelstein and Steffie Woolhandler

    Q: Should PNHP support a public Medicare-like option in a market of private plans?

    A: PNHP should tell the truth: The “public plan option” won’t work to fix the health care system for two reasons.

    1. It foregoes at least 84% of the administrative savings available through single payer. The public plan option would do nothing to streamline the administrative tasks (and costs) of hospitals, physicians offices, and nursing homes. They would still contend with multiple payers, and hence still need the complex cost tracking and billing apparatus that drives administrative costs. These unnecessary provider administrative costs account for the vast majority of bureaucratic waste. Hence, even if 95% of Americans who are currently privately insured were to join a public plan (and it had overhead costs at current Medicare levels), the savings on insurance overhead would amount to only 16% of the roughly $400 billion annually achievable through single payer.

    2. A quarter century of experience with public/private competition in the Medicare program demonstrates that the private plans will not allow a level playing field. Despite strict regulation, private insurers have successfully cherry picked healthier seniors, and have exploited regional health spending differences to their advantage. They have progressively undermined the public plan – which started as the single payer for seniors and has now become a funding mechanism for HMOs, and a place for them to dump the unprofitably ill. A public plan option does not lead toward single payer, but toward the segregation of patients; with profitable ones in private plans and unprofit able ones in the public plan.

    Would a public plan option stabilize the health care system, or even be a major step forward?
    The evidence is strong that such reform would have at best a modest and temporary positive impact – a view that is widely shared within PNHP. Indeed, we remain concerned that a public plan option as an element of reform might well be shaped in a manner to effectively subsidize private insurers by requiring patients to purchase coverage while relieving private insurance of the highest risk individuals, stabilizing private insurers for some time and reinforcing their control of the health care system.

    Given the above, is it advisable to spend significant effort advocating for inclusion of such reform?
    No, for two reasons:

    1. We are doctors, not politicians. We are obligated to tell the truth, and must answer for the veracity of our stance to our patients and colleagues over many years. Ours is a very different time horizon and set of responsibilities than politicians’. Falling in line with a consensus that attempts to mislead the public may gain us a seat at the debate table, but abdicates our ethical obligations.

    2. The best way to gain a half a pie is to demand the whole thing.

    Is fundamental reform possible?
    We remain optimistic that real reform is quite possible, but only if we and our many allies continue to insist on it.

  22. Bart Woolery on May 19th, 2009 7:54 pm

    I for one really don’t care to argue one way or another about the earnings of doctors, as this is primarily a delivery issue and not a financing issue. Single-payer addresses how we pay for what we get, whatever that is, and all evidence supports that it is the best way to pay for healthcare. I am all for reducing costs on the delivery side wherever possible and prudent. I am very suspicious of claims that our healthcare woes are largely, or even substantially, a result of the greedy doctors, but I am open to hearing the fact-based evidence. The beauty of single-payer is that it moves competition in healthcare from being price-driven to being quality-driven. Only good things can come from that.

  23. Claudia on May 19th, 2009 8:39 pm

    Right on, Bart, once again :-)

    You make an excellent point distinguishing financing from delivery, that even presumably talented and prestigious health care commentators miss. Stay tuned for the last posting. Maybe you can help me figure out what is in the mind of one such commentator 😉

  24. Eugene on May 21st, 2009 9:37 pm

    I’ll be brief. The problems of rising costs come from the virtual monopoly insurance companies have over the medical costs. Forbid the “networks” and prices will get to a normal competitive level. Note that I am not vouching for eliminating health insurance – they can still bet on my health. But disallow them to do price fixing.

  25. Bart Woolery on May 21st, 2009 10:36 pm

    I’ll be longwinded 😉
    The basic problem with multi-tiered system is not competition, but adverse selection. What is that? Think about it this way: a person who is relatively healthy will look at the insurance market and say, meh, I’ll just pass. This removes them from the risk pool and thus increases premiums for the remaining participants. Now even more people look at the price and say, meh, I’ll just pass. This positive feedback effectively encourages the insurers to offer even more convoluted plans in an attempt to garner participants, and to offload as much of their costs as possible to their clients to dissuade them from actually using their products and thereby costing them money (what they call “medical losses”).
    The solution? A single plan into which everyone contributes to the best of their ability, and everyone benefits according to their needs. Universal single-payer is by far the best way to finance healthcare. Price competition yields the predictable and bad results we see in our fragmented “system”.

  26. Claudia on May 21st, 2009 10:38 pm

    Dear Eugene,

    I will try to be creative and not repeat myself, even if I cannot be brief.

    Health care is not a “good” that behaves like designer shoes. For markets to work competitively and bring prices down as you suggest you need at least: 1) rough equality of power between buyers and sellers; 2) ability to walk away from a deal if it is not good enough, and 3) transparency of information (and ability to figure it out). I did not invent that. It is basic economics and it also makes sense.

    Yet you have none of this medical care, and you cannot have it for complex reasons too long to lay out here, any more than you do with national security, protection of the air you breathe, communications, transportation, the drinkability of your water, the edibility of your food, the safety of the drugs you consume, etc.

    Which is why these things are organized, monitored, and financed, collectively.

    With all due respect, you made a claim yet did not support it with an argument. You simply say: “do such or so and prices of policies will come down”. They will not, or rather, for the reasons I have given, if prices of policies do come down that does not mean that your medical needs will be paid for by those cheap policies. But of course that is the whole point. You care about having affordable policies only if they will protect you from the financial burden of health care. Otherwise, a policy is worse than worthless.

    We are so behind in health care when compared to the rest of the industrialized world that our debates would be laughable if our situation did not cause unspeakable, and avoidable, suffering to millions of people. I happen to think that it is a disgrace, but even if somebody does not, they will have to agree that it is not a good thing.

    Yet we have folks who still believe that we have “the best health care in the world” and that the rest of the world has hell, but they won’t even bother look at the evidence.

    Here is a video clip that you might enjoy, showing some of this:

    http://therealnews.com/t/index.php?option=com_content&task=view&id=31&Itemid=74&jumival=2677

    We don’t need private insurers making money from connecting health providers and patients, even if we do need a system that connects us. This is what a single payer system does. It is not the only option (Germany and others do it slightly differently) but it is the best option.

    The bottom line is, there is no such thing as no government in complex societies. The question is who are you going to make government work for, and which rules are going to regulate what.

    Now the rules are slanted towards corporate insurance interests. I personally would rather see them work for people who need health care, namely, all of us sooner or later.

  27. Claudia on May 21st, 2009 10:44 pm

    I just got a comment from Bart, but cannot find it here…it’s about adverse risk selection. Right on, again :-)

    Can I take you as my teaching assistant to my course in comparative health care policies?

    Just kidding. I am sure you can teach the class yourself 😉

  28. Double Barrel on May 22nd, 2009 9:02 am

    Highly infectious newly emerging diseases like MORGELLONS DISEASE will spread to the rich from the poor if the poor do not have adequate medical care. Morgellons diseases’ plastic root-like fibers grew all around the base of my friend’s spine, all that tissue had to be cut-out so he could walk again. In Australia, his country, everyone has free Medicare: it cost him $1000, the total cost was $3000. Here, it would cost $30,000-45,000, his pay depends on his insurance, or lack of it. He could’ve had private insurance on top of the free medicare, and he would’ve paid even less. Morgellons disease, the fibers disease, biosynthetic plastic fibers growing like roots throughout a person’s body, highly infectious through indirect contact, is a warning of things to come. It’s spreading silently: over 13,000 American FAMILIES have it. Coming to a school near you: MORGELLONS DISEASE.

  29. Claudia on May 22nd, 2009 11:22 am

    Thanks Double Barrell, one more good reason to pass single payer I did not know about :-)

    Incidentally, back in the 19th century, the Public Health movement in Europe gained steam precisely because of these fears, at the time with infectious diseases, and also at the recognition that for capitalism to work (and nation states to afford strong armies), the “populace” had to be maintained healthy.

    But if whatever motives bring us single payer universal health care are welcome! 😉

    By the way, I have written two more postings but have not heard from readers’ yet…no complaint if they keep coming to the first, but in these others you might find other relevant points and information.

  30. Allan Hotti on May 25th, 2009 10:25 am

    I STRONGLY support single payer, social financing, of health care.
    Leaving the health insurance industry in charge will only aggravate the mess we are in now.
    … Insurance Industry “profit motive” is not appropriate in health care delivery; it logically leads to denial of care!
    … Private insurance leads to excessive administrative costs that only diminishes the care that could otherwise be delivered.
    … The health insurance industry is too large and is not accountable to any one, not the people, not the patients, not the providers and certainly not to Sen. Baucus and fellow legislators.
    … Health care cost cannot and will not be curtailed by Insurance companies. Greed is their overall operating principle. Look at recent history.
    … We must get back to ethical behavior, “do no harm and provide the greatest good to the greatest number”. Private insurance entities cannot behave ethically. They have done harm to the vast majority of Americans. Greedy behavior cannot produce ethical results.
    … Health care costs the economy too much now; the Industry promises, to reduce expenditures, are empty. They control costs by denying care and cherry picking enrollee’s, leaving 40+% of Americans without access to proper preventative and therapeutic care. They have added to costs with huge administrative overburdens. The denial of care and lack of access to 40% of Americans only adds to the drain on the economy.
    … Some form of cost control has to be applied, as health care is a “bottomless pit” of demand and costs (largely driven by advances in technology and ageing of the population). Preventative care, better managed care, self involvement in care and queuing for minor non-urgent care are preferable cost control mechanisms, to leaving 40+% of people without appropriate access to care, heath care bankruptcies and poor national health care outcomes! (See Canadian experience)
    … If Senator Baucus and Congress do the right thing for Americans now, they won’t need the Health Care lobby money to help with their re-election. The voters will recognize when Congress enacts legislation that is beneficial to ordinary citizens and will support them at the ballot box.
    … A transition to a single payer social health insurance system (not “socialized medicine”) will be disruptive to no one but the HC Insurance Industry. Look at the Canadian experience. The transition was irritating but effective.
    No system is perfect. There are shortfalls and problems with a single payer system, but they will be mere irritations when compared to the egregious, inhumane behavior of our current privatized insurance system.
    … In a single payer system, the providers must remain in the private sector and not become civil servants.
    … We must urge President Obama and the Congress to do the “right thing”; resist the Insurance Industry and initiate a single payer system!

  31. Claudia on May 26th, 2009 11:38 am

    That’s right, Allan. We need more people like you putting pressure.

    Writing or better still, visiting legislators and demanding that they do their job (presumably protecting your interests) works…

  32. Kate Frankel on June 1st, 2009 5:50 pm

    I am delighted to read these exchanges. Thank you Claudia. And Bart.
    I will add that I am currently sending post cards to all my representatives 3 or 4 times a week.
    I also reply to any solicitations for money that I will not provide any until they manage to include single payer in the current discussions.
    I was recently — well, before the current crisis, but — solicited by a financial managing firm.. great investment: health care and drugs pay 25 to 30%.
    I find it obscene to make money on someone’s illness.
    Bill Moyers Journal, May 22 (which can still be downloaded, or watched online) had doctors who reported that more than half of the current physicians are members of an activist organization supporting Single Payer, and they feel near 70% would prefer it.
    Doctor do not want to spend time and money on insurance forms, or fighting with insurance companies.

    katefrankel@earthlink.net

  33. Bart Woolery on June 1st, 2009 8:42 pm

    Good for you! I saw the Moyer’s program and am actually using it in a presentation at our library. I would suggest that most likely 90% or more of people would support single-payer (as they do in Canada) if they only knew what it was, and spreading the word is our job!

  34. Claudia on June 2nd, 2009 2:07 pm

    Let us make it “not politically feasible” for legislators NOT to discuss, and choose, single payer. Germans did this in the 19th century, and the last in line were the Taiwanese. Had the party in power not passed single payer it would have been voted out of office!

  35. How long are the waiting lines with US health care? at The Social Medicine Portal on September 24th, 2009 7:10 pm

    […] day, 1,850 among whom had health insurance) who file for bankruptcy for medical reasons. And, as I have argued elsewhere, the uninsured are not the “disease”, but the […]

  36. claudia on December 30th, 2010 9:47 pm

    Arden, thank you very much for your kind words. I would be more than happy to recommend additional, excellent reading material for you and your daughter.

    The only thing that can move our country in the right direction, i.e., in a way that serves the needs of ordinary Americans rather than that of special interest groups is an educated citizenry demanding that our representatives do the job they are being paid of, by us.

    For now, let me suggest to websites with plenty of information of extraordinary quality:

    http://pnhpcalifornia.org/
    http://www.healthcare-now.org/

    Take care.
    Claudia

  37. michael kors crossbody on May 11th, 2013 10:57 pm

    The main character is a man named Daniel. When you look at his eyes, you’re looking into the eyes of a man who has seen Hell. There are moments when he looks like he’s about to begin screaming at any second, and never stop. The first time you see this is in episode one, when he’s about to leave the prison. The guard is treating him like a human being, and it’s evident this hasn’t happened in an extremely long time. You see the confusion on his face as he wrestles with suddenly being treated decently by the same people who have treated him like an animal for years. He can’t quite process it. I know that look well. As he’s about to leave the prison, the guard helps him tie his necktie, as he can no longer remember how to do it himself.

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