American Academy of Ophthalmology
American Medical Association (Medical Student Section)
American Podiatric Medical Association
American Podiatric Medical Students' Association
American Physician Scientist Association
Institute for Healthcare Improvement
International Federation of Medical Students' Associations
McGill Journal of Medicine
National Community Pharmacists Association
National Register of Health Service Providers in Psychology
National Society for Nontraditional Medical Students
Pre-Medical Student Osteopathic Medical AssociationNational Health Insurance!?
Posted on August 19, 2008
Filed Under Health Care Policy and the Student Doctor, Medical (MD, DO)
A review and interview with the author of Do Not Resuscitate, the controversial book about the current status of America’s health insurance system.
by Lee Burnett
A recognized pioneer and leader in family medicine, John Geyman, MD has written a number of articles and books on American healthcare. He has just released his latest book on the health insurance system, Do Not Resuscitate.
Dr. Geyman’s books are known for detailed research and facts. Do Not Resuscitate is a natural follow-up to his earlier texts, deftly tackling the latest and most complex data and concepts and distilling them into a captivating and quick read.
This book could be compared to the writings of Noam Chomsky with Dr. Geyman delivering a searing indictment of today’s health insurance companies and the US Government. This book has a single point: the insurance industry has failed America and it should be replaced with a single-payer nonprofit fund.
The book starts with a fascinating historical review of the development of health insurance and how it evolved from a nonprofit enterprise to a massive for-profit industry. Most interesting is why the United States is the only western country without national universal healthcare. He then analyses industry tactics such as risk avoidance through cherry picking, policy cancellation, denial of coverage, and deceptive and even fraudulent marketing practices.
Dr. Geyman presents compelling data illustrating tactics the insurance companies use to perpetuate the status quo and retain control in the face of increasing calls for comprehensive change. He details how the insurance industry is dying and demonstrates that incremental reforms will not save it. The book concludes by showing how national single-payer health insurance could work for the US.
Being that the topic of healthcare reform is very timely in this campaign year, I would highly recommend Do Not Resuscitate to students going on interviews.
The Student Doctor Network spoke with Dr. Geyman, who lives on San Juan Island near Seattle, Washington.
Why is the U. S. the only western nation without single-payer health care?
For a number of historic, cultural and economic reasons, the U. S. is the “odd man out” among industrialized countries around the world in not having some kind of public financing system for its population.
The idea of national health insurance (NHI), however, is not new. It was first raised by Teddy Roosevelt and the Progressive Party in 1912. After a bitter fight it was finally defeated in 1917 by an alliance between employers and organized medicine.
Since then, American worship of open markets, our culture of individualism, and the political power of private stakeholders in what has become a medical-industrial complex, have successfully opposed publicly financed universal coverage on the basis of claimed American exceptionalism.
Although public opinion for more than 60 years has favored NHI, an ongoing coalition between market stakeholders, an increasingly powerful, largely investor-owned insurance industry, and most of organized medicine continues to oppose NHI.
The AMA fought hard against Medicare and Medicaid during the mid-1960s, It was marginalized politically, however, when the American Hospital Association joined forces with Blue Cross (which as an intermediary would process all claims for hospital services) to assure passage by Congress of these public programs. The AMA then quickly switched to profit from these programs as poor and elderly Americans became consistently paying patients.
Private stakeholders in our deregulated market-based system use their political power and money to preserve open markets against public will on the basis of claimed market “efficiencies”(untrue) and the threat of “socialism” if NHI were to be implemented (also untrue, since NHI is social insurance combined with a private delivery system).
It is claimed that the U. S. has the best health care system in the world. Why would we want to change this for-profit model?
It is pure mythology that we have the best health care system in the world.
Many cross-national studies show the opposite, as these examples show:
- 42nd in life expectancy, 41st in infant mortality
- last among 19 OECD countries in mortality from amenable causes (deaths that could be avoided by timely and effective care)
- 15th out of 25 countries for such indicators as disability-adjusted life expectancy and child survival to five years
- 11th out of 11 industrialized nations on 11 criteria for performance of its primary care base
We do have the most expensive and bureaucratic system in the world. One that siphons off 31 percent of the health care dollar on administration, overhead and profits.
The profit motive distorts incentives, encouraging many providers to deliver inappropriate and unnecessary services. It is well documented that the more specialists there are in higher reimbursed parts of the country, the more unnecessary care is provided with worse outcomes.
Investor-owned care has been demonstrated to cost more and to be of lower quality, whether hospitals, HMO’s, nursing homes, dialysis centers, or mental health facilities.
With NHI, we can transition to a not-for-profit system which assures universal access to necessary and cost-effective care of higher quality and greater accountability, which still incorporates the strengths of a private delivery system.
What about the for-profit pharmaceutical and medical device companies?
There is not anywhere near as much competition in our health care system as market advocates would have us believe.
The drug and medical device industries, as well as other medically-related industries, have wide latitude to set prices at what the market will bear, and lobby strongly to defend their price-setting prerogatives and avoid price controls.
They claim that any effort by the government to constrain costs by bulk purchasing (as the Veterans Administration does so effectively in gaining discounts on prescription drugs of about 45 percent), would stifle innovation. This is a false argument.
Most current medical research is publicly financed through the National Institutes of Health. The drug industry spends two or three times as much on marketing as it does on R and D. Many new technological advances have been made abroad by countries with national health systems (egs., CT scanning in England, laparoscopic cholecystectomy in Canada).
Manufacturers know that most demand for health care is not price-sensitive. Chemotherapy for cancer gives us a classic example of inelastic demand. Driven by hope, cancer patients will spend enormous amounts of money on chemotherapy drugs (some now costing $50,000 to $100,000 a year), even for those of questionable or marginal clinical benefit.
Many new drugs have no competition until their patents expire. As an example of predatory price-setting, Ovation Pharmaceuticals raised the price of Cosmegen, its drug for Wilms’ tumor in children, by 3,436 percent (not a typo!) in 2006.
What happens to physician income and quality of life if there is a single-payer system?
The growing gap between procedure-based reimbursement and cognitive, time-intensive physician services has led to serious specialty maldistribution of physicians in this country. We now have an oversupply in many procedure-oriented specialties and critical shortages of physicians in primary care, geriatrics, and psychiatry.
NHI can provide a structure for reimbursement reform based on system needs. Physician incomes in family medicine, general internal medicine, general pediatrics, geriatrics, psychiatry and other shortage fields will see increased incomes, while those in surplus specialties are likely to be reduced, especially if providing inappropriate or unnecessary services.
When Canada went to its single-payer system, physician incomes changed little. Today, generalist physicians in England are better paid than their counterparts in the U. S.
Physicians’ quality of life will improve with NHI. With simplified billing through single-payer, their overhead and administrative hassles will be much reduced. Their time will be mostly involved with direct patient care, what they went into medicine for and were trained to do, and they will have more clinical autonomy.
The intrusive bureaucracy of 1,300 private payers, with their different requirements, will be a thing of the past.
Do you hold much hope that single-payer health insurance can be implemented within the current political system?
The current political system is a challenge, but many forces are gathering that give me optimism that single-payer NHI can be finally enacted in this country. Here are some data points that point in that direction:
The present health care system is falling apart - fast. Access is getting worse, costs are becoming unaffordable for much of the middle class, quality of care is spotty, many of the services being provided are either inappropriate or unnecessary (some even harmful), and all incremental attempts to reform system problems have been failing.
Our market-based system is not self-correcting, as its proponents claim. The private insurance industry is on a death march, and has demonstrated its obsolescence in these ways:
- inefficiencies compared to public financing
- fragments risk pool by medical underwriting
- increasing epidemic of underinsurance
- excessive administrative and overhead costs
- profiteering - shareholders trump patients
- pricing itself out of the market
- unsustainable and resists regulation
So, as things get worse, as they are, the pressure for real reform of health care can only increase. Here are some signs that this is underway:
- the crisis in health care costs and access now affects at least one half of our population
- a sizable majority of the public has favored publicly-financed universal coverage for 60 years
- the electorate is changing, with many across party lines seeing the failures of conservative policies of the last 30 year
- the mismatch of the business model of health insurance with the public interest is raising concerns of sustainability among industry insiders and some Wall Street analysts
- with the exception of privatization in recent years, the overall success of Original Medicare since 1965 shows that publicly-financed health care works
- organized Labor is rapidly getting behind single-payer NHI; employers may not be far behind, as shown by the economic difficulties of many employers (eg., the auto industry) in competing abroad with countries with social insurance
- there are now 92 co-sponsors of HR 676 in Congress, a bill for NHI as a “hidden solution in plain view” for the failures of our health care system
- recent studies are now showing that a majority of physicians support NHI (egs., 59 percent of 2,200-plus physicians in a national sample this year; over 60 percent of physicians in Massachusetts and Minnesota)
The 2008 elections are likely to alter the political landscape with probable control by Democrats of Congress and the White House
Although organized medicine, as exemplified by the AMA, has been a reactionary and often marginalized player in the national debate over health care for 90 years, this was not always so. It is of historical interest that the social insurance committee of the AMA passed a resolution in 1917 calling for serious study of various forms of social insurance in order to avoid “ leaving the profession in a position of helplessness as the rising tide of social development sweeps over it.”
The new generation of physicians can play an important role in reversing the reactionary mode of organized medicine and moving it to one of leadership toward a health care system that meets the needs of the country.
Rather than have government create the single-payer system, do you see any other options such as a government-backed for-profit insurance company (along the lines of Fannie Mae and mortgage lending)?
The possible role of a government-backed for-profit insurance company along the lines of Fannie Mae and mortgage lending is discredited by recent events.
The business model doesn’t work as a way to finance health care. Original Medicare operates with an overhead of about 3 percent, while the average overhead for commercial insurers is 18 percent and 26.5 percent for investor-owned Blues. High overhead costs just take money away from direct patient care.
Experience has shown that the health insurance industry cannot be effectively regulated. Although some states (eg., Massachusetts) try to regulate health insurers through such requirements as guaranteed issue and community rating, public not-for-profit financing still offers more value and reliability to enrollees, as demonstrated by Original Medicare.
The insurance industry has successfully avoided regulation for many years. It maintains a very large lobbying presence in state capitols across the country, often with revolving doors and conflicts of interest with state legislatures.
All self-insured employee benefit programs (ie., most large employers) are exempted from state regulations by the Employee Income and Security Act of 1974 (ERISA). If insurers don’t like regulatory policies in one state, they just move to a friendlier state. Another approach being touted by the industry and conservative policymakers involves association health plans (AHP’s), which are exempt in most states from state rate-setting regulations.
Private and institutional shareholders of for-profit insurance companies would not take kindly to the idea of national healthcare. How do you address their concerns?
This is true, but the policy goal should not be to prop up a failing industry through government subsidies. Instead, the goal should be to build a health care system that best meets the needs of our entire population for affordable coverage of necessary health care of good quality.
The NHI program includes a major effort in retraining and job placement for many administrative and insurance worker positions displaced by NHI. There will be new needs for many to become involved in expanded programs in home care, public health, and other areas.
John Geyman, MD is Professor Emeritus of Family Medicine at the University of Washington School of Medicine in Seattle, serving as Chairman of the department from 1976 to 1990. He served as founding editor of the Journal of Family Practice (1973 – 2000) and editor of the Journal of the American Board of Family Practice from 1990 to 2003.
Comments
53 Responses to “National Health Insurance!?”
Leave a Reply
Current SDN Poll
Loading ...
Subscribe in a reader
Very interesting article; thanks!
Hopefully, this is not an endorsement by the administration of SDN of this book. I disagree with many of the points in this article and would strongly advise that if SDN is to post leftist viewpoints as articles then they should post the opposing view if they don’t wish to convey the impression that they have an agenda. Two thumbs down on this one.
Very interesting and useful. I will look for your book.
If Canada and Europe have such great systems, why do canadians often come to America for care and many areas in Europe are importing physicians?
Something has to be done but you can have universal care without single payor, which creates MANY problems of its own. The reason single payor doesn’t work is:
1) there is little incentive to work hard for providers - why see 30 patients a day when you can see 10?
2) the single payor will eventually pay as little as it possibly can without providers quitting (if they are the only game in town, they can reimburse as little as they want) - hasn’t happened with medicare yet cause theres still private insurance and providers can refuse to see medicare - ie look at what happened to medicaid.
3) Other countries a) fund their healthcare provider educations almost fully b) are way less litigious - are we willing to give up suing our providers when we decrease their salaries? c) willing to wait 6 months for elective procedures
The solution is to implement industry wide computer/ billing systems; make pre-exisiting health insurance exclusions illegal; make health insurance portable and direct-to-consumer (not related to employers- instead a payroll tax); REGULATE not eliminate insurance; reduce the incentive to order unneccesary tests (ie defensive medicine and self-referals); get rid of malpractice trial-by-jury and amulance chasing lawyers; limit drug/device company advertising
Very inspiring, and I truly hope this sort of message will catch on in Congress. It’s time for us doctors, med students and the like to start thinking about the next 100 years & not just the next $100 grand. It’s exciting to think that I am a part of the generation of medical workers who really might do the right thing for the common good with my work. I know there are plenty of people who don’t want our health system to change, but I’m yet to hear an argument from that other side which isn’t at heart self-focused.
Good post above about the difference between single-payor and universal coverage. I agree 100%
One thing Dr. Geyman got right is that private insurers waste a TON of money with administrative overhead, advertising, paying the CEO a 50 million bonus etc.
I’m wondering why he thinks primary care doctors should make a similar amount as specialists in the US. As I understand things, the specialists have more years of training and the more qualified top students go into specialties. Shouldn’t they be reimbursed more?
I think the point wasn’t that all specialities suffer by lower salaries, but rather that the specialities that are crowded with unneccessary amounts of doctors will have lower salaries. This means that (for those of us who are pro laissez-faire, the demands of the market will cause the supply to match it at the price it should be. The surplus specialists will find that there is less work for them and will be better off serving the public as general practitioners. Then we won’t have unnecessary CT scans and MRIs done, etc etc. There are plenty of specialities (I think he mentions a few) that really need doctors, but nobody is willing to work in those fields because they pay so poorly (ultimately because they have such poor profit-margins for stakeholders).
I agree with Casey. SDN administration should not endorse any viewpoints on universal healthcare, which are bound to be politicized. If SDN wants to maintain credibility among medical establishment, it should provide similar exposure to views opposite that of Dr. Geyman.
The leftist premeds on SDN are spreading fallacies. US ranks low on infant mortality because of aggressive measures taken here to rescue premies. Other countries don’t deliver and try to maintain life at 26 weeks GA, we do. Deaths of premature infants are the prime contributors to high infant mortality. See http://www.ncbi.nlm.nih.gov/pubmed/17015548?ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
US has the best healthcare in the world. Ask Ted Kennedy why he didn’t go to Canada to have his tumor removed.
Lies - damned lies - and statistics.
I couldn’t agree more with Casey’s post above. SDN should not be in the business of promoting a political agenda, that is this far left; and I am saying this as a neutral independent.
The one inherent farce that is used multiple times in Geyman’s arguments, is that we have a free market medical system. This is entirely not the case. In a free market system, the consumer has price transparency and in effect, they set the prices. With insurance the way it is, consumers don’t know or care about the price of services provided. So when Geyman advocates a single-payer system, using the current “Free market” failures as an example (i.e “American worship of open markets, our culture of individualism”), he is basing his argument on a fallacy; we do not have a free market system.
“Most interesting is why the United States is the only western country without national universal healthcare.” SDN, you dropped the ball here. There is no explanation or even worse, no questioning of the other side. What is so interesting about the US being the only industrialized or western nation without national universal healthcare? What about the oh-so important idea that the US is the most advanced of the industrialized nations due to our free markets? Being the “Odd man out”, has never been a problem in the US rising to the top. The question of why would we want to become more like these other countries, was never asked. Again SDN, you dropped the ball.
During the course of his “fascinating”, “Chomskey-like”, and “searing indictment” rhetoric, cost analysis is never fully addressed. Where will this insurance be paid from? Currently, Medicare is approximately 18% of our entire tax revenues. How will this program be financed? Who will pick up the bill? Will he suggest that the wealthy pick up the tab? We have a tax revenue system that is already in turmoil. The top 10% of income earners, pay 70% of all income tax revenues and the top 1% pays 40% of income tax revenues. The bottom 50% (i.e half of the country), pays into the tax revenues less than 3% of the entire collection. This number has been shrinking by the year. The point is, we have an increasing amount of net-consumers and a decreasing amount of net-producers. It is important to note that, although we have a smaller number of net-producers, they are earning more and more. The definition of a net-consumer, is one that receives more from the system than they put in, strictly speaking of monetary contributions. So with the number of net-consumers increasing, healthcare getting more exensive, individuals living longer, and the flood-gates that will open for healthcare access; I ask the question again, how will this program be financed without causing our economy, which is based on free-markets, to crumble?
SDN-you dropped the ball. I expect more from you. I am not an advocate for our current system. It has a lot of kinks that have to be worked out with price transparency and litigation at the top of the list. But it is important that SDN does not endorse such a radical opinion. If SDN wants to address political perspective, then do so. Do not endorse one view over another because you represent students and doctors across the US with many differning opinions.
I agree that the government should form a NHI as soon as possible. I know a lot of people are afraid of it, comparing the system to socialism and a break from free market ideals, but medicine should not be measured by simple supply and demand. The fact is, people have a infinite demand for life. That is to say, every healthy minded person wants to live. As doctors we want to provide healthcare to all people who need it, and one of the obsitcals for us is this system leeching the time and energy from us and our patients.
The insurance companies are directly preventing us from delivering good healthcare to the people of this counrty, and because they dont see the patients die because of our system, they feel free from the moral gravity of their decisions.
There are many ways to pay for the system suggested.
#1. Insurance companies use far more resourses than they should. A NHI would save people far more money in the long term. The only people hurt by such a system are the people working at the insurance companies or investing in them.
#2. The military industrial complex that was left since the end of the cold war could be considered a massive pool of money to re-alocate to the medical system.
#3. If we factor in the price of research provided to discover new drugs, the government should claim a share of the profits and redirect the money into the NHI.
My point is, america still has powerful economy, we just need to rethink our investments.
In response to those requesting a debate on NHI, that was not the intent of this article.
This article is a review of a controversial book and interview with a thought leader on a topic important to SDN members.
Those who disagree with Dr. Geyman’s conclusion will still find the book well written and well researched.
However, based on the interest this article is generating, I’ll attempt to bring together leaders with different viewpoints for a detailed discussion.
I agree Dr. Geyman’s position is on the far left and he blurs the facts by saying “60%” of the public wants universal care into somehow saying they want his version of a single payor… I think EVERYONE theoretically wants universal care. That’s entirely separate from a single payor system.
Universal care CAN be realized if we eliminate the REAL problems in our system. As the astute poster above mentioned, this IS NOT a free market system… eliminate cherry picking, defensive medicine, phara advertising, employee based insurance etc. and introduce price transparency.
I agree with Dr. Geyman that insurance companies as they are structured now have to go, but his assertions about public support and the international facts behind single payor health systems are ludicrous. We need sweeping reform but those leftist ideas would destroy our healthcare all together.
National insurance would be great. I would work far less hours.
To get there, eliminate all tuition debt for doctors, the idea of malpractice for bad outcomes….not happening.
Too much money at stake.
The US government is already by far the greatest “payer” of health care in America. It already dictates what it wants to pay and what it deems as an appropriate level of care. Furthermore, private payers (insurance companies) negotiated rates are largely influenced by and for the most part based on “what the government would pay for the respective service”. Hence, one cannot assume that the “role” or “influence” of the US government in American health care would necessarily “increase” as a result of “universal health care”, given the fact that it is already the most influential player in the arena.
I have a hard time believing that any government or single payer system can provide a service more efficiently than private industry. Can anyone provide an example where they have done so?
One thing I know for certain is that their moral compass is not going to be any more true, and to suggest otherwise is wishful thinking.
Excellent point swartz23, has anyone advocating NHI been to a VA recently? Have any of you gone to government run welfare and food share offices lately? Ever had anything happen timely at the DMV? I may be a little sarcastic, but the point is salient: the government is not capable of running such things efficiently
Casey … seriously? Do you have any facts to back-up your statements.
If you have done any investigation you will know the VA does better on most outcomes and preventive care measures than elsewehre in the USA. Plus NHI is not government owned facilities … it is doctors being paid by a single organization (like medicare.) How is that any different than now, except less administrative bs?
I’ve worked at the VA, I have delt personally with both DMV and government run welfare and food share offices, and from my experience the “administrative BS” is fairly significant. Do you have any evidence to support your claim that there will be “less” administrative BS under NHI? The CMS runs medicare and medicaid, and CMS is a component of the Department of Health and Human Services. Did I say that the VA has poor medical outcomes? Did I say that the preventative care measures in the VA system are inadequate? The fact is that the people who work at the VA do great work with what they are given. The doctors and nurses don’t always have the latest technology, but they provide excellent and necessary care. Allow me to restate my point: I do not believe the government is capable of effeciently MANAGING a single payor system.
Does the cms do a bad job running medicare?
Wow, imagine the whole country being run like the VA:
a) impossible to get the nurses to do anything
b) have to get a preauth for common meds, WAY moreso than private insurance
c) oh, veterns have severely limited ability to sue their providers… gonna implement that everywhere?
d) providers get crappy salaries and many work as few hours as they can.
e) oh, residents cover call… there are plenty of them to cover every hospital in the nation *sarcasm*
Yeah the VA has good points- bargining power to get drugs cheap, single computer system etc but I shutter to imagine all of US healthcare a big VA with no checks from private hospitals.
While I agree with Gary’s points as far as some of the drawbacks of NHI, it is my assertion that the benefits significantly outweigh the current status of healthcare delivery in the US.
The staff issues, “impossible to get nurses to do anything” and “residents cover call” are both drawbacks most likely due to short staffing. Nurses may be “impossible” because they are already stretched thin as it is, I do not have data to back me up though it is an issue across the country and not just in the VA system. With NHI there is a much larger pool of resources to draw from. While some issues may persist as far as work ethic is concerned, the larger pool of resources should keep the nurse/patient ratio down and make the “impossible” possible. Larger pools of physicians may also solve your dilemma of residents covering call.
NHI may reduce the stigma of government jobs being for those people not willing to work hard, as it relates to the VA system. “Providers get crappy salaries and many work as few hours as possible” is a statement that perpetuates this stigma, and I would fathom to guess not true in most instances.
Typically countries with NHI will subsidize or pay completely for medical education. Many pre-meds and medical students cite student loan debt as a factor in choosing the specialty with higher pay. I will concede that students will most likely enjoy the specialty they are in, though they may have been equally as happy with IM, FP, OB if the salaries were equal. “Crappy” is a very relative term and I’m sure there are 46 million US residents without health insurance that believe what you consider “crappy” doesn’t justify their predicament.
Decreased financial burden will also bolster the field, if not in quantity then in quality of physicians. The current cost for medical school is astronomical. This creates a barrier to those who may aspire to go to medical school though lack the finances to afford the COA, not to mention now loans start being paid in residency. While those who get accepted are the best and brightest that apply, a larger pool of applicants may increase the quality of physicians produced.
The preauthorization issue is a necessary evil. Its a measure by which pharmaceuticals are used appropriately. I realize that this is a physicians forum and some may want to retaliate against me for this statement. Though if you look at the data, physicians are not exactly the best at knowing everything about pharma. If they did, they’d be pharmacists. Preauthorization is considered a barrier and I concede that it may seem like “administrative BS” as stated earlier, I assure you it is rooted in the patients best interest.
My last and very unscientific point refers to the lack of ability to litigate. Is this such a bad thing? Would we then have OB/GYNs? Litigation in medicine has gotten way out of hand, to say the least. That is one of the greatest points for NHI. Physicians being able to practice medicine, instead of practicing economolitigiomedicine (I said its unscientific so I can make up my own words!).
In conclusionthe VA system can work if expanded and given the proper resources. Most of the drawbacks that currently exist in the system can be fixed. I don’t believe we can right the ship overnight, though I do believe it can be done. The 46 million of our neighbors are depending on us.
Tim, 46 million minus 14 million illegal aliens, equals 32 million. I just reduced the burden from uninsured residents by 30%. Would you agree that part of righting the ship includes addressing this segment of the population? What are your thoughts?
Tim, in an ideal world I can concede that a VA-type system as a national model benefits outweigh problems. But in your argument you are assuming there will be *such* a sweeping change that:
1) Providers would work hard just cause… they are hardworking individuals. Sorry, but having worked at both the VA, university and private institutions people work for incentives, just like any other industry.
2) Americans would gladly eliminate their(constitutional) right to sue their providers
3) Not only will the gov’t pay for medical school, they will forgive the billions in loans of current graduates (the ones you don’t want to make bitter cause they are pioneering the new system).
4) You are going to defeat the most powerful and rich lobbies in the nation: insurance, phara and malpractice attorneys ALL AT ONCE.
Instead, you are going to get a bastardized system where the interests above make NHI a living *hell* for both patients and providers … worse care, lazy no-incentive staff, bitter providers with lower salaries AND stress from liability.
That’s why we have to eliminate these MAJOR problems FIRST before we attempt any form of universal care. Get rid of educational burden of debt, ambulance chasers/ defensive medicine, predatory pharma spending, insurance administrative waste THEN use the extra money to implement universal care in a incentivized, multi-payor system.
SDN is a private entity. The owners of this website have every right to publish whatever they want. It’s not a news organization but rather a social networking service.
Thanks for this excellent article.
For those you like or dislike this article, you can watch the DVD on this website named \SICKO\ http://vidics.com/media.php?id=1571
MaximusD, Aren’t news organizations also private? But you are right, SDN is a private service provider. They can tailor their service to best meet the needs of their constituency. In fact they are “forced” to meet our needs; otherwise, you and I are going somewhere else to chat about health care. Herein is the most important factor when considering system structure.
swartz23:
I agree that there will always be a segment of the population that will fall through the cracks. Whatever your political position is on the matter of illegal immigrants, they are here so lets account for them. There are approx 300 million people in the country, 15% (rounded for easy math) of which are uninsured (46million). While it is nearly impossible to account for every single man woman and child, 85% coverage is inadequate. By covering 32million of the uninsured, leaving 16 without coverage. Thats closer to 95% coverage. This is a statistic that will never happen under the current model. So yes, you have found 30% of the uninsured population that will most likely never pay into insurance. Until there is a political solution to this we can only work on the access for American citizens. I will take 95% over 85% coverage anyday.
I did like your post, way to think out of the box!
Gary,
I agree that the conditions must be perfect for the sweeping changes to be made. Incrimental change in healthcare has gotten us where we are today, which is in a bad place. Addressing your points one by one
1) I have worked in a large university setting as well as a smaller urban hospital and I do believe the marjority of people here are hard working. Incentives work for a short period of time, though have little to no staying power.
2.) (unscientific) Its the lawyers that got us into this. I believe that if there is true incompetence or negligence that litigation is ok. Mostly, though, I find that lawsuits involving medicine follow the “hot coffee” type lawsuits. (woman sued bc she spilled coffee in her lap and didn’t know it was going to be hot… this was before the iced coffee fad set in)
3) Incrimental increases in subsidization for student loans should work. Its not a gone one day, here the next.
4) What do you call 3000 lobbyists at the bottom of the ocean…
While i share your frustration, a “bastardized” version is not what I had intended. More then likely any type of legislation will be killed in either the senate or the house by the powerful lobbyists. I know they are there. They have picked the pocket of the American citizen for decades. Some represent groups that would otherwise not have a voice, others… (see #4)
You are incorrect in one point. Worse case scenario is we keep bending the current system until it breaks. A true market failure in this field is dangerous and should be taken more seriously by people that truly make decisions.
Your last paragraph is true. I do agree that work on the major problems first, whether it is multi-payor system vs VA, we need NHI coverage.
While I viewed it as incredibly negative, your post was well thought out and I guess not everyone can be as positive as me. Keep them coming, great discussion on a hot topic!
I thought I’d weigh in on a few points. I’m probably as left as Tim, but with a few libertarian leanings, so I’ll probably throw around a few thoughts for both sides.
(1) If the NHI is fee-for-service as most people are suggesting, it will be no different than Medicare. Therefore the incentive to work harder will be seeing more patients and getting more money for it, same as now. Reimbursements can be tweaked to provide PCP with better rates to help increase primary care.
(2) There’s no *constitutional* right to sue. I looked through the Constitution and didn’t see anything like that. I think most Americans agree that lawsuit levels are past ridiculous. E.g. Carol Ernst who was awarded $250 million after her 59 year old husband died possibly because of taking Vioxx. How many people think this is a fair judgment? Yes, certain clear cut negligence claims should be arbitrated, or people should be allowed to sue, but few people would argue the system is working perfectly well.
(3) I think paying for medical school could be part of the NHI bill when it is passed.
(4) The only argument I have for that is that other big business interests want NHI. All the big manufacturers lose out compared to NHI countries because that have to pay for such high health costs for their workers.
Finally, a point to swartz23. Illegal aliens are no good for America, I’ll give you that. But they’re here, and they’re staying, so I don’t understand how we can take them out of the equation. If a person goes to the ER with an acute MI (or car accident, or whatever), we have to treat them. So, someone (currently all the other paying hospital patients) is going to pay for them. It’s just a question of who we want to help pay the tab. Everyone working in America, or just the other hospital patients?
Currently, a decent number of illegal immigrants pay taxes. They give false Social Security numbers for their job, and the taxes are taken out by default, just like for a legal worker. The bonus for the U.S. Treasury, is that they never file their taxes and get a refund. Now this isn’t true for all illegal immigrants. Some work on a cash-based system which circumvents all taxes, but many are paying taxes like you or me. So, I don’t see the point of saying, “Let’s never pay for illegal immigrant care.” when it happens every day in hospitals all across the country. It won’t change. As a civilized society, we’ll never dump a bleeding, dying human on the curb, just because they can’t pay.
Let me re-phrase one sentence of my last post. I said “Illegal aliens are no good for America…” What I meant was, the status of illegal aliens is no good for America. I do think most illegal aliens give more to the country than they receive. They mostly work shitty jobs that many people wouldn’t even think about doing. Many pay taxes just like everyone else. The part that’s no good for America is their status. If America could more effectively incorporate them into society with driver’s licenses, insurance, IDs, etc., that would be better for everyone. That’s what I meant. Not that the people themselves are bad people or anything.
let’s move this discussion to the Topics in Healthcare Forum — much easier to follow posts there.
I am an American doing research in England at the moment. Before you decide we need government beaurocracy in one more industry sector come see what the NHS is like. Attendings round ONCE a week. Can you imagine? The hospitals, save for the few brand new ones, are run down and filthy… mine has roaches scurrying through the halls at night. Standard drugs like Lexipro are not available yet. Standard life saving treatments like TPA for stroke are not widely available yet… and even if they had TPA if you don’t stroke during normal business hours there will be no technicians to run the CT (assuming there is a CT in your town). The work week is 38 hours for nurses and techs and allied health. Nurses in Ireland had the nerve last year to even strike for a 35 hour work week (like in France) PLUS a 10% pay raise?!?! That type of entitlement is not in the best interest of our patients. Quality healthcare cannot be built upon flimsy infrastructure. It really makes me long for home. At least you can say one thing: everyone here has the opportunity to have the same mediocre health care as rest. It is a little telling that most of the rich folks and royals have PRIVATE healthcare. Also, be weary of the so-called data attacking the quality of American healthcare. Recognize, for instance, that the Commonwealth Fund which has provided much of the noise was founded by Jimmy Carter. Look at their so-called “benchmarks” which change with every new health care report card (likely to skew the results in their favor…). This is politics disguised as scientific data. Come to Europe to see the objective truth of nationalized healthcare. It’s not pretty.
Thanks for sharing your experience, Aloysius. Your comments reinforce my opinions that (1) statistics are vulnerable to manipulation, and (2) privatization is a good thing. This last point is important for all policy making and not just health care. Ask yourself this question and let common sense give the answer. Is any human being inherently good when no one is watching? Or is anyone unconditionally unselfish in every situation? From another angle, consider “mob rule” patterns of behavior evident at sporting events. Crazy fans will do anything if there’s no risk of them being singled out and held responsible for their actions. Government is no exception. Privatization is perhaps the best way to keep an industry sector honest. Our founding fathers understood this concept when they set up the checks and balances of the three branches of our United States government. As US citizens, let’s try to learn from history and prevent it from repeating.
Why aren’t we using the forum topic that was made for this?
It’s fun to comment on this stuff under a leftist article.
Why I never will agree with national insurance?
It’s not because someone who doesn’t deserve it getting it. It is because neither “I” nor “any doctor” should be someone’s fundamental right.
I hope physicians can stop this abuse of our services, and too bad for some, but everyone can’t get the same services.
Will farmers become my fundamental right too?
Dude, we owe NO one healthcare. If you don’t work and earn enough of a living, you don’t deserve healthcare.
Why should docs have to work for free when there are people sitting on their ass playing Wii all day?
How to solve this healthcare problem? More price transparency. Force people to know what the costs are by making them pay for it. Eliminate insurance period. You can’t afford it -> too bad.
There are not enough resources in the world for everyone to spend $1 million on a pre-emmie nor is there enough to spend $500k on prolonging life 6 months while the person lies in the hospital bed dying.
http://musefree.wordpress.com/2008/07/29/mandatory-health-insurance-does-not-work/
http://www.hoover.org/publications/digest/3459466.html
Terrible Article is an interesting name.
What you described is Consumer-Driven Healthcare. I wrote a paper on it and I agree with the basic principle of price transparecy. I do believe in government subsidy for those who cannot afford it. We do owe people healthcare, it is a basic necessity. Health in a population can be an indicator of income, education, etc. Health is a basic building block for a strong country.
There are enough resources for pre-emmies, and end of life care. You obviously hae not had either happen to you, so any logical argument will be lost.
“There are enough resources for pre-emmies, and end of life care. You obviously hae not had either happen to you, so any logical argument will be lost.”
Sounds like you mean “emotional” argument rather than a “logical” one. That’s the difference between libs and conservatives; libs can’t seperate their feelings from their thought processes.
Rusty,
It may sound like I mean emotional vs logical. But for those who have read anything about the subject, it is not a lack of resources, it is a lack of properly using the resources we have at our disposal.
And to be completely honest, I’m not a fan of responding intelligently to someone that will make statements and do not have the common courtesy to put their name behind it (Terrible Article).
And liberals versus conservatives? I cannot think of a statement that would be inferior as far as intelectual content. My political standpoint is actually middle of the road. I go where the data takes me.
Its been fun, but I believe I will just make statements on the message boards from here on in.
It almost makes me sick to see how money is wasted in our healthcare system. Anyone working in a hospital has seen it:
1. The 85 yo man with 50 medical problems sent on flight for life to another hospital’s ICU who’s life expectancy is measured in weeks. 100-200k right there.
2. The alcoholic found down that comes in like clockwork once a week with chest pain… Thats a Ct head, ekg, trops x 3, probably a telemetry bed and hoping he wont withdraw after… maybe 15,000 dollars a week.
3. The premie born 24 weeks has a 5% chance at a normal life, kept on support for weeks only to end up neurologically impaired and requiring disability for life… 5 million dollars.
Do you know these are COMMON occurances? The theme? Doctors don’t do these things cause they want to or they are stupid. They do them because otherwise they may be sued… in addition a generation of docs has been trained to do these things in order NOT to be sued. Defensive medicine is WAY underestimated in how much trouble it has caused. It’s messed up a generation of training and easily accounts for 50% of our *unneccessary* healthcare bill.
Interesting article. I dont believe the author of the book has anywhere near the beliefs of Noam Chomsky and sincerely wish people would stop comparing NHI with socialist/communist policies. We pay for everyone’s healthcare anyways, you cant just send someone away from the ER b/c they dont have insurance. The only issue is that they dont end up paying their bills. Guess who does? We do.
I agree that unnecessary lawsuits and procedures have significantly f’d up our healthcare system and contributes to rising costs. Tort reform is going on everywhere and I think everyone agrees that malpractice lawsuits are just as unnecessary as NHI is necessary. We are the wealthiest nation in the world and have no business having 50 million people uninsured and unprotected. Societies are judged by how they treat its most vulnerable. Elective procedures would be harder to get and this is the downfall of the national system. There is no way any system will go through without addressing tuition b/c its rising every day and is just going to push more docs into specialties. Who knows, if we keep going at this rate, maybe PA’s and NP’s will take over the primary care industry and docs will all specialize. It might be a great thing if this happens. However, we have to cut the fat. Tort reform and eliminating unnecessary procedures will help streamline the industry and make sure that there is penicillin and vaccinations for the poor instead of wasting ER’s and hospital beds for gangrenous feet that could have been nipped in the bud if the patient wasnt afraid to go to the hospital.
We need more than tort reform… we need an overhaul of the whole medical-legal system. It should be illegal (yes illegal) to sue a doctor for anything other than GROSS negligence (ie on purpose, drunk surgeon etc). At the same time, there should be a peer review system to penalize/eliminate doctors practicing well below the standard of care. Finally, there should be a compensation system (like sweden) to help *reasonably* take care for patients who get injured from honest or unavoidable medical outcomes/mistakes. Most of all, the greedy, scum-feeding lawyers need to be cut out of this. 40% cut of a patient’s take home and playing the lotto for a 20 million dollar payout is just plain idiotic. They are the leeches of the medical system and don’t do anything good.
Being neither a provider of medical care nor one who profits from the medical care industry, let me offer my observations:
First of all, in a moral and just society, everyone must have equal access to quality, affordable health care. Everyone!
Secondly, I believe that an overwhelming majority of health care providers (doctors, nurses, dentists, mental health practitioners, etc. etc.) all want to practice best medicine. Best medicine has zero to do with financing health care. The former is about medical care, and the latter is about money.
Thirdly, medical care providers must be justly compensated.
Purchasers of health care insurance are finding it increasingly difficult to afford ever-increasing premiums. (Currently, my daughter’s family spends about 25% of their net income on health insurance premiums). We all know the statistics relating to uninsured, underinsured, bankruptcies due to medical debt, and deaths due to inability to afford life saving care or prescription drugs…they are well documented.
As long as health care providers are adequately reimbursed for their services why would any of them care about the sources of their income, i.e., payments from for-profit insurance companies, and fees charged to patients, as opposed to national health insurance, which is an alternative to the current, horribly flawed system?
Providers who lament about a national health care plan appear more concerned with making money than they are about practicing best medicine.
HR 676, the United States National Health Insurance Act (also called “Expanded and Improved Medicare for All”) would guarantee full coverage for all medically-necessary care to every resident in our nation. Isn’t that what providers want? Of course! Anybody who practices medicine and who objects to national health insurance while alibiing that the uninsured are an unavoidable condition of our system would be well-advised to re-read the Hippocratic Oath.
HR 676 would provide fair and just compensation to providers. Doctors, etc., could continue private practice, but would be paid from a public fund, just like Medicare works. (That is the “single-payer” process.) The difference between current Medicare and HR 676 is that under HR 676 all medically-necessary needs would be covered, and providers would receive just compensation for their services.
HR 676 is a uniquely American plan. It is not *Canada’s or *Great Britain’s or *France’s or any other *nation’s. It is the “United States National Health Insurance Act”. HR 676 is a plan that would guarantee equal access for all medically necessary care to every resident in our nation, and would also provide just compensation to health care providers. Who can mount a moral argument against such a plan?
Lastly, we constantly hear corporations complain that health care costs for workers are too high in the U.S.; they require corporate America to charge more for goods and services in order to remain profitable, which in turn renders U.S. made goods more expensive (and less competitive) than those produced by foreign companies. HR 676 would remove that argument.
* Authenticated statistics show that the populations of these nations nonetheless have a longer life-expectancy than do U.S. residents.
Rich,
how exactly is HR 676 going to provide “just compensation” for healthcare providers? Medicare certainly doesn’t… whenever the gov’t is short of money they try to cut back on the largest programs- ie medicare. The only thing stopping medicare from paying overhead + minimal margin (like medicaid, which usually is even below overhead, which is why no one takes medicaid) is the fact that private insurance provides competition and providers can refuse to see medicare. So while it is *true* that universal care with “just” compensation would be good, it’s much harder said than done.
Imagine housing and food, which *are* basic needs for everyone being price-set by a single entity…
John –
First of all, the answer to your question is written into the actual bill (HR 676).
A short answer is that providers, patient advocates, and representatives of government, etc. would meet and negotiate just compensation.
HR 676, was partly written by providers. They saw the need to make sure doctors, nurses, and everyone else involved in providing medical care receive fair compensation. That is one of the reasons HR 676 is also called “Expanded and Improved Medicare for All”. Benefits are greatly expanded, and doctors receive improved compensation. No one single entity would set fees. Several groups would be involved, with providers having a significant say in the process.
I concede your point on current Medicare fees. The fault lies with Congress. Many are beholden to the medical profits industry and seek to shrink Medicare dollars in order to make private plans more attractive…to those fortunate enough to afford them. Under HR 676, for-profit health care would disappear. Doctors, etc. would be free of insurance company bureaucracy, mindless and endless paperwork, free of interference, and would simply bill one plan. The result would afford them much more time to do what they are trained and choose to do: provide health care.
With 300 million consumers, anyone in Congress that got in the way of maintaining a healthy national health care system would pay the price come election time. (If seniors knew the truth about some of the shenanigans that some members of Congress pull in the here and now, there would be a whole lot of new facers in the capital next year.) With 300 million people all rowing in the same direction, the charlatans would be kept at bay. I urge you to read the bill.
I read the bill and although there are some good ideas, there are major problems.
1. Although fees are negotiated, it seems the “global budget” given to entities such as hospitals, HMOs would be derived from a national total budget which is totally determined by the single payer.
2. “Negotiation” is really not negotiation when the director- who is an entity of the gov’t program - has the final say (see section 202 line 19).
3. There is no provision limiting liability of providers. There can be no national healthcare without addressing the insane malpractice and defensive medicine environment.
4. In entities such as HMOs who set salaries of providers, people will tend to be lazy and see as few patients as they can.
* Single payer always has the same problems in the end- it’s a monopoly and that entity has the final power to set prices no matter what pretty words are put into the bill.
I agree we need to overhaul private insurance and standardize electronic billing/ eliminate insane paperwork, but this bill, in my opinion, is the absolute wrong way.
It seems some may be losing sight of the SERVICE of medicine and forgetting that is should be a “patient first” medical world. Too many seem to be defending what they believe to be a “doctor first” program when in all reality it is a profit first. You can disagree with the arguments presented by this book, but as a physician you have a responsibility to advocate for universal health care. Until everyone has quality health care–we have a problem conservatives and liberals alike. Medical care is a fundamental right for all, not a privilege. If you disagree, go to business school.
James, your ideals are honorable but unfortunately naive. Get a few more years under your belt in the real world and revisit the issue.