Tuesday, September 27. 2011
Op-ed in the Wichita Eagle this morning, by Dr. Margaret Flowers: Medicare for all would save lives and money. Flowers is co-chair of the Maryland chapter of Physicians for a National Health Program (PNHP), a minor celebrity for getting arrested protesting in Washington trying to get single-payer back on the Democrats' agenda. (See her interview by Bill Moyers). She's in Wichita today, to give a talk at the Murdoch Theater tonight.
I'm going to quote the whole piece below, but break it up so I can get some words in edgewise. What she has to say is fundamentally right but incomplete and inadequate, so I want to build on that.
I believe the "37th" figure is rank based on average longevity -- one of many measures where the US has mediocre performance. The rub there is "average" given how inequitably health care services are distributed among Americans. Of course, most Americans think they're well above average, and they're right that the stats are distorted by those who aren't. It's just that they have trouble understanding how easily, and how arbitrarily, one can slip and fall into the other. Reminds me of the DC sniper story: one moment you're out on a routine shopping trip, next you're cut down by an invisible assassin's bullet. Isolated individuals can get fired, lose their insurance, suffer a debilitating illness or accident, go bankrupt, almost as suddenly.
Last time I checked, the health care sector accounted for 18% of GDP, with 20% projected not too far off. Back when Clinton tried to pass his scheme in 1993-94 the number was 14%. It's a bit simplistic to translate these figure to the current budget quandry -- only part of the total health care bill goes to the government, and most of that goes to Medicare and Medicaid which are funded on a different set of books -- but the longterm prognosis is bleak: the industry is set on a path to devour the economy, and while it's not clear where the choke point is, it's clear that something has to give sooner or later. You can't sustain infinite growth indefinitely, yet the logic of the investors demands that they try.
It's worth noting that until 1990 Switzerland had virtually the same health care cost structure that the US had, with both pulling away from the rest of the world. But where the US continued on its profit-seeking path, Switzerland clamped down and forced its private insurance companies to be run as non-profits, and that simple act stabilized their cost structure. Switzerland still has the world's second most expensive health care system, but as a percentage of GDP is is virtually the same as it was in 1990. As T.R. Reid shows in The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, there are lots of ways to manage health care costs without giving up progress and quality, but the essential element of all of them is to limit profit-seeking.
The ACA does provide some measure of cost controls -- enough to claim to be revenue-neutral while providing insurance for many more people than are currently covered. (I don't know where this "23 million uninsured through 2019" figure comes from -- that's way more than I had been led to believe, although it's always been clear that the ACA scheme wouldn't provide universal coverage.) The main problem is that by leaving most people without any sort of non-profit health insurance option the profit-seeking private insurance companies will have no competition and therefore very little restraint on their ability to increase costs.
There are various approaches to containing Medicare/Medicaid costs -- all unpopular with vendors who are conditioned to feel the pinch even before it arrives -- but the most serious attacks on Medicare have been schemes to increase costs, mostly by pushing Medicare recipients into private insurance plans. The so-called Medicare Advantage plans were a prime example. Obama's offer to raise the eligibility age for Medicare is even more ominous. The rationale there is to move costs off the federal budget and onto people who will wind up paying much more -- in their lives even more than money.
Medicare does bear some responsibility for rising health care costs, especially early in its history from 1965 into the 1980s: by agreeing to pay "customary" fees to hospitals and doctors they basically handed out blank checks, which vendors took advantage of to constantly roll up prices much faster than the inflation rate. By the 1980s, prices had risen so much that the government started to impose restraints. At the same time, the industry was becoming more profit-seeking, with vendors working persistently to game their way around the rules.
On the other hand, Medicare is vastly more efficient than private insurance companies, imposing much less overhead -- close to 3% vs. 30% for private insurance companies.
There's no doubt that a single-payer insurance system would be the single most effective way to improve our current health care industry, and that it would be the single most important step to solving the longterm problems endemic to the current system. As we generally understand the term, it also represents an important commitment to universal health care, and all that implies -- the sense that as a people we share responsibility for each other's welfare, and that as a democracy we believe that the government exists to serve the people and take purposeful collective action for our behalf.
That last sentence, of course, is anathema to the faction of the American people known as Republicans. They've lately been obsessed with disempowering people -- with scaring poor people away from the polls (where they might vote their self-interest), with busting unions, with preventing people from appealing to the regulators and/or the courts for protection from corporate abuses. They're upset that banks should be limited from scamming customers, or each other. And they'd rather die than cramp the freedom of the health care industry to price gouge, overtreat, undertreat, or commit the occasional malpractice. They won't even allow Medicare to negotiate the price of drugs -- just send more blank checks.
The biggest advantage of single-payer is simplification: everyone gets the same insurance, so nobody has to market a bunch of differences; every vendor gets paid filing out one standard set of forms, instead of having to work up different coding schemes one for each separate insurance company each with its own schedules and formularies and pencil pushers dedicated to the easiest way to improve the company's bottom line: by denying benefits. You also get rid of the collection agencies pursuing bills the insurance companies denied, and the bankruptcy lawyers. This also eliminates the need for vendors to overcharge paying customers for those who don't pay, which starts to bring prices back in line with costs.
Universal coverage also solves a lot of problems. It means, for instance, when when you're wheeled into the emergency room, the first person you see is someone trying to help you, rather than trying to pick your pocket. (A big problem now is emergency rooms dodging patients so they don't get stuck with the bill.) It means that your car insurance costs will drop since one can safely assume that future medical costs will be covered. It means that malpractice damages will be reduced (for the same reason, although not having to cover the lawyer's premium is a bonus). It means that people can move more freely from job to job, can retire early, or can afford to start new businesses without worrying about losing their coverage.
So single-payer insurance with universal coverage would produce an enormous cost savings right from the start. It would also eliminate one of the main forces behind the persistent inflation of costs -- the private profit-seeking insurance companies -- and it would provide the basis for negotiating fair and manageable compensation for the vendors. But to get there, we have to get past the political obstacles, which is mostly the desire of a certain political party (and a few of its admirers in the "loyal opposition") to preserve a system of larcenous capitalism exploiting our deepest health fears, and their key ploys: that everyone should pay their own way, that no one (other than the companies) should organize, that progress is magically linked to free enterprise, that trampling on the prerogatives of billionaires will destroy "our way of life," that your democratically elected government is set on killing you first chance they get. It shouldn't take much thought to realize that all this is nonsense -- which is a good part of the reason they work so hard to keep you from thinking.
I meant to get the above done and posted before the lecture, but ran out of time. Big crowd. Bottom floor was about 80% full when we got there, so we went up to the balcony, which wound up about 30% full. Flowers dispelled most of my reservations. She advocated something more than current Medicare for all, calling for an Expanded & Improved Medicare which among other things would dispense with the co-payments and limits of the current program. (Those seem to be carved out mostly to support private secondary insurance programs. People who buy such insurance often feel like they're paying for their own insurance when they're actually just tipping a company that assumes virtually no risk.) Especially when reformers talk about cost control, people get nervous that their benefits will be cut -- ignoring that the cost controls of private insurance companies are far more restrictive, and much harder to appeal, than anything Medicare might do. Still, my recommendation is to pitch single-payer less as a way to manage costs and provide universal coverage than as the essential way to improve health care quality.
Flowers actually did a pretty good job of explaining why this is so. She pointed out that under the current system many people are overtreated, many are undertreated, and many are mistreated. A single-payer system would provide more consistent coverage, more consistently in line with evidence-based best practices, with greater transparency. She called for efforts to realign doctors' incentives with better outcomes -- no simple task, but the focus should be less on paying doctors more for the desired results than on disinteresting doctors from the financial impact of their treatment options. She called for better resource planning, noting that it is more effective to have centers in a given area specialize than to have them compete across the board, adding excess capacity which they then have a stake in filling up. She fielded a question on malpractice, correctly noting (as I did above) that bad outcomes wouldn't have to be budgeted ahead of time, and that there were other ways to limit the expense. She suggested paying centers to maintain a given level of capacity regardless of utilization instead of having them risk overbuilding then have to figure out how to make it pay off.
Someone asked about high technology driving costs up, and she covered various aspects of this, especially how patentability distorts pharmaceutical research. She pointed out that most of the real research is public-funded, especially by NIH. She didn't go as far as I would in eliminating patents and promoting more competitive sourcing, and she didn't point out how proprietary research has been used to hide drug defects, and how this in turn has led to massive class action suits that have cost companies billions of dollars (as well as patients thousands of lives -- another area where reform promises to improve quality).
She also pointed out that the health care industry, huge as it is, only affects a limited aspect of public health: much more important is a clean environment, safe workplaces, education, good food, security from crime and violence, the sense of shared responsibility that comes with an equitable society -- not her phrasing but that's the gist of it. So a political system that has been captured by corporate profiteers has not only turned health care into a system for reaping enormous profits but has done so by corrupting the very nature of democracy. Change the latter and fixing the health care system becomes easy; fail to do so and the system will lurch on until it falls apart, to our great horror.
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