Health Care Reform

So, I'm going to break team here a little and post on a directly political issue (as opposed to clinical or regulatory/insurance concerns).

This is not intended to be a personal soap box on politics in general; I am simply getting a lot of questions on this lately, and I presume it is due to the national-level debate in the setting of the upcoming Presidential elections in November.

What is Health Care Reform?

That being said, let's clarify some terms. Part of the problem is the overuse, misuse or misunderstanding of some words used in public debate on health care in our country.

"Socialized Medicine"

Right off the bat, no one is proposing "socialized" medicine. Period. If we accept the definition of socialism here as advocating government ownership and administration of the means of providing medical services, then you may notice that no one in our debate is suggesting that the federal government should outright own all the hospitals and medical practices and that all doctors should be employees of the federal government. This would approximate the National Health Service in the U.K.

So: throw away "socialized medicine". No one. Repeat, no one is suggesting this. The motives of politicians using this term to stifle debate, or arouse anxiety or anger should be questioned.

"Universal Health Care"

"Universal health care" is a nebulous catch-all phrase that has no specific definition, save that it is meant to mean all things to all people. Generally, the term is used where improving the availability of health insurance and decreasing the number of people in our country who have no insurance is intended.

While no one could reasonably object to any genuine effort to make health insurance more available to more people, you may notice that any such proposal typically includes specific actions like tax credits for purchasing medical insurance, negotiating with health insurance companies at the table, or offering more incentives to HMO's.

Unfortunately, none of these ideas really addresses the underlying causes of our problems with insurance costs or health care costs. Certainly, including insurance companies as equal partners in any planning is like including the foxes in round-table discussions concerning the security of the chicken coop.

The insurance companies are the only interested party who is satisfied with the status quo, because they are the only interested party who is making serious profits at this, and are the only ones who are distinctly for-profit only in their fullest intent and by definition. (Yes, doctors make a profit. We do have bills to pay, kids to put through college and such. However, the ethical and professional mission of the doctor or hospital or clinic is to provide the best possible medical care for its patients.) Patients, doctors, hospitals and politicians all want substantial change.

So: IMHO, any "universal coverage" plan that includes the insurance companies as equal partners and tries to keep their role as close to the status quo as possible without upsetting their apple cart is doomed from the outset to represent little to nothing in the way or substantial and meaningful improvement and change.

"Single Payer"

"Single-payer insurance" or "national health insurance", or "MediCare for all" is advocated by many (disclaimer: including me- more on that later). This would approximate France or Germany's (or. to a lesser extent Canada's) style of health care. Actually, it would approximate the way health care is administered in virtually every developed nation on the planet except ours.

This would mean that all citizens are entitled by right (and not by bought privilege) to a basic level of health insurance from birth to death. This would typically be through a single large insurance pool composed of all citizens and administered by a single large insurer, which is usually the federal government. The State of Oregon has a roughly similar State administered health plan.

"MediCare for all" is a term used to mean the same thing, but in a way that may convey more meaning than the technically accurate but confusing "single payer". Let's face it, the only folks who use the term "payer" here are medical professionals, insurance people and policy wonks. Average folks think "insurance company". MediCare provides for doctor visits, annual exams, cancer screening, care of acute and chronic medical problems, labs, tests, ER, hospitalization and surgery. If you want and can afford more coverage, then you are free to buy it from whoever you choose. Thus, "MediCare for all" is meant to convey the idea of such insurance being extended by the federal government to all citizens, and not just those who are over 65 or disabled.

As is already practiced in many of the other developed countries of the world, the federal government could administer a publicly funded or supported health insurance that would cover the same things that MediCare covers (as described above) and extended to such care appropriate for children, as well. Insurance companies (through employer-based means or otherwise) would fill the niche in the marketplace for those who want to buy more coverage such as improved drug, durable medical equipment or long-term care coverage, or perhaps as specific riders in the same way you can buy homeowners insurance riders on your cameras or jewelry or computers if their value exceeds the basic plan coverage.

So, what do you think about health care reform?

Again, I get asked this a lot by patients in my office, hence this post. I have tried to define all terms as accurately as possible though I'm sure it's evident that I feel the best plan would be for our government to adopt a single-payer model that mirrors every other developed country in the world.

I see no sense in doing so just because everyone else is doing it. I feel we should do so because of the following facts (repeat, facts: not opinions, facts):

• We do not have the world's best medical system, we have the world's 37th best medical system.
• We do moderately well in terms of measurable health quality (24th best), but
• we do very poorly in terms of being able to care for all our people (55th best), though
• we excel (1st best) in emergency care.
• We spend twice as much money per person for this level of performance.
• Unfortunately, one must wonder whether this translates as follows: we have the best emergency care in the world because we have to, since so many people have no other way to get medical care they go to the ER for it or wait until they're crashing and burning to show up, and thus our overall levels of infant death, lifespan and disease occurrence and care suffer for it.
• Economic models prove that having health insurance where you split the pool of people who are insured as we do will lead to exactly the problems we face where people often find that no one will insure them, or they cannot afford available insurance. (Harford, T. 2006. The Undercover Economist, Oxford University Press, pp. 109-110, 113-16, 119-23.)

Additionally, I myself have moral and ethical qualms with the status quo.

• I think it is wrong to have to change doctors because of your insurance or your job.
  
• I think it's stupid to put the entire choice of your insurance in the hands of your boss (not because your boss is necessarily mean, but because your boss has the most incentive of any player in the game to keep the cost as low as possible).
• I think it's wrong for 47 million fellow Americans to have no health insurance. That's 16% of our entire country! That's 1 of every 6 men, women and children! Note that this doesn't even count people who are on MedicAid or MediCal which has so few doctors who will accept it you may as well be uninsured in many respects (these folks are referred to as "under-insured").
• I think it's wrong for the most common cause of personal bankruptcy in our country to be unpayable medical bills. Half of all personal BK's are because of this, and 76% of these BK's involved households that already had medical insurance at the time of the illness.
• I think it makes bad business sense to not significantly change a business model that costs twice as much as other businesses in the marketplace, and in which you are the 37th best producer. Personally, I aim to be the best and not settle for Top 40. Let's stop saying "Thank goodness for Slovenia (#38)!" No offense to Slovenia, I just expect better for the amount of money we're spending.
  
• I think adequate medical care should be a right, and not a privilege that you have to purchase. I do not believe that it is acceptable for those of us who are less wealthy to be left to die younger. ("[i]nasmuch as you did it to one of the least of these My brethren, you did it to Me", if I may make so bold.)
  
• Yes, I put my money where my mouth is. MediCare, TriCARE, MediCal, Workers' Comp and union commercial insurers typically pay quite poorly. However, I have patients on all these insurances because I think you should have a doctor and get medical care regardless of whether or not you are old, a veteran, poor, injured on the job, or are a labor union member. (Mea culpa. If I were a baseball fan, I guess I wouldn't be a Yankees fan. Besides, I'm from Pittsburgh. I still remember Roberto Clemente!)

So, frankly I hope to eventually see a single health insurance in our country that covers all our citizens from cradle to grave and still has doctors and hospitals in the private sector where competition will still create incentives to do the best possible job of providing professional medical care.

Even though some of my previous posts reflect some apprehension on my part with the federal government administering the insurance, it really makes the most sense for them to do so. At least, it makes as much sense as calling the police and the police responding as an arm of the state, and not as the result of several calls to local and competing privately owned security companies.

Even if a 10% increase in income taxes had to occur to fund this (tax is to government as income is to your household), would you still be ahead? Certainly, I would. Given the cost to me of insuring my family and my employees I'd still be cash ahead. That doesn't even begin to include the other costs and savings in not having to pay a billing service and freeing up my registered nurse to work with patients and not dicker with their insurances.

Mind you, some proposals suggest this level of tax increase. Others propose that the costs of providing a national health insurance would be more than offset by savings in doing so (The Physicians' Working Group for Single-Payer National Health Insurance, 2003. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance, Journal of the American Medical Association, 200 (6). 798.).

What about you? Run the numbers, do the math. Compare an increase in 10% on your income tax against the costs of your health insurance premiums or deductions from your pay for this, the amount you spend on deductibles and co-pays. Heck, add in the lost income and vehicle maintenance and fuel costs of going to Folsom or Sac for this if you have Kaiser or some HMO. If those costs are higher than a 10% income tax increase for you, let me know.

But, also add in other factors and hidden costs.

What if...

• Every neighborhood had an after hours clinic that would even do house calls?
• You got pregnant and didn't get refused health insurance because your pregancy is a pre-existing medical condition? Hey, what if actually your insurance included more maternity and paternity leave and home care after the delivery?
• What if when you were diagnosed with a really serious disease like cancer, it meant that your insurance stepped up and covered more of the costs when you most needed it?
• What if everyone had insurance, but it didn't affect your choice?
  
• Would it mean maybe we could do better at preventing deaths that are preventable with good medical care? That would be nice, since right now we are 19th best in this out of all 19 major industrialized countries.
• Hey, for that matter, what if better coverage didn't come with higher taxes?

Just sayin'...