Wednesday, June 24, 2009

Dear Senator Brownback: A letter my Kansas Senator

Dear Senator Brownback:

Thank you for the response to my letter urging your support for health reform, and particularly health reform based upon a single-payer mechanism, such as that proposed in the House’s “Improved and Enhanced Medicare for All” bill, HR 676, or Sen. Sanders’ “American Health Security Act”, S. 703. Although you disagree with this approach, you have indicated your clear desire to have the highest-quality health care, at the lowest possible cost, available to all Americans, so I know that we agree on the end goal. Therefore, I hoped to be able to discuss some of the issues that you raise, and perhaps explain why it seems to me (as well as to many others) that a single-payer system would be the best solution. It is my hope that by keeping the end goal in mind, and looking at the issue, we can transcend partisan positions. Or, if not, clarify the core areas on which we disagree rather than using “sound bite” statements that obfuscate them. The New York Times reports today (June 24, 2009) in the article “Baucus grabs pacesetter role on health bill” (, that Sen. Baucus is perceived (or perceives himself) as being able to reach across the aisle more toward Republicans; it also suggests he may not be trusted completely by stalwarts of either party. I do not know about this, this is your area and not mine, but I know you are a leading Republican, and my senator, so I would like to address what may be in the best interests of Kansans, as well as other Americans.

As you note, prevention and wellness are areas that need more focus – and more funding. The simple fact is that most of the money spent in health care (of the part that goes to health care, and not administrative overhead and profit) is spent on treatment, and often the most complex treatment. This means that physicians who do things to people, and particularly end-stage complex things to people, are much better reimbursed than those who care for people by doing prevention, screening, chronic disease management, and providing a medical home. Our health system is far too heavily overbalanced to sub-specialists, with only about 30% primary care physicians, instead of the needed 50%+. And, with scarcely over 20% of students entering the primary care specialties of family medicine, general internal medicine, and general pediatrics, we are never going to get there. And when the income differential is not a little, but 200%, 300%, 500% -- we are not going to get students, especially with their onerous loan burdens, to enter primary care.

And while preventing disease is a good thing for peoples’ health, but may not save money. If you really wanted to save money on health care, you’d ask everyone to eat a high fat diet, smoke, not exercise, and drop dead of a heart attack at 45 before they could get to the hospital. That would save money on health care, but be a bad thing for them and their families and their communities, and ultimately cost us all a great deal. Prevention is good – when it is evidence-based – because it prevents disease, not because it saves money.

I am afraid that consumer-directed health care and health savings accounts are fatally flawed because, while at any given time they may meet the needs of a majority of people, those are not the people who need health care and cost us money. An appropriate health system or financing plan must understand that it can’t be “majority rule”, but be based on a social approach. Only a small percentage of us are sick at any given time, and a smaller percent use most of the health care dollars. Five percent of the people account for 55% of health costs, and 10% for 70% of the costs. The costs are not managing your cold, or blood pressure, or bad knee, but for people with cancer, older people with multiple chronic problems who are frequently hospitalized, babies in NICUs, and young car-accident victims with multiple trauma surgeries, etc.

You are concerned about bureaucrats becoming involved in health care and getting in between the patient and physician in making health care decisions. So am I; in fact I am all too familiar with it, as this is what happens now. Bureaucrats have great influence over what health decisions will be made, but they are insurance company, not government, bureaucrats. People often do not get to keep their doctors, because often when an employer changes insurance plans, or the insurance plan changes their physician panel, they have to change. If a person changes his or her job, or (all too frequently especially recently) loses his or her job, they probably will have to change doctors, or may not have a doctor at all. I know that it is popular to “knock” government bureaucracy, but it has nothing on insurance company bureaucracy! One of the most important differences is that the government is at least supposed to work for us; at its best it does, it listens. Indeed, you, my senator, are the government, and are willing to listen to your constituents. For-profit insurance companies report only to their shareholders and no one pretends they need to answer to us – and they sure don’t! Currently, even “non-profit” insurers, like the Blues, behave in the same way in order to compete.

As you well know, in your role, it is easy for people to get confused when complex issues are involved. Therefore, when I say that I advocate single-payer I want to make clear two important distinctions. The first is that between being able to choose where you get your health care – who your doctor is, what hospital to go to (provided you live in an area where the choice exists), and having a choice of insurance companies. People care a lot about the first; no one (except the insurance companies, of course) cares one whit about the second. The only thing people care about with regard to their insurance is whether they are covered, what their co-payments and deductibles are, what their maximum costs are. Who that insurance company is has no relevance to them. Therefore, a single payer system that covers everyone the same, but allows people free choice of healthcare providers, meets that need.

The second distinction is between how much money is spent per capita by a health system and how it is distributed. First of all, stories about waits in other countries and lack of access to care are grossly overblown, and mostly come from the wealthy who, when you get down to it, really think that they should not have to stand in line with others. The data – rather than anecdotes – decisively demonstrate that the health of the population – not just those with insurance, but counting everyone – is better in every other industrialized country. But to the extent that there are waits in other countries, even if the outcomes are better for their population, that is a result of what they spend per capita, usually half to 2/3 of what we do. If, for example, the UK spent anywhere near what we spend per capita now but distributed it the way they do, there would be no waits and the health of the population would be even better. We spend more than we need to provide outstanding health care for all, but still have 47 million uninsured people and inadequate (and in some cases near third-world) health outcomes. Study after study, including the 2008 study done for the Kansas Health Policy Authority, show that single-payer would be the only system that would both cover everyone and save lots of money. That is a win-win. Instead, we are paying and not getting. Some of this is from the overuse of expensive tests and procedures, but much of it is insurance company profit and administrative waste.

Now, I understand that one person’s “waste” is another person’s income; I may say that insurance company profit is waste, but they like it, and they use it to lobby and make campaign contributions. However, that should not affect the legislative process. The American people care about having access to quality health care. They do not care about insurance companies. It would be grossly immoral for the Administration and Congress to pass a health plan predicated on maintaining the profits of insurance companies.

I have indicated that I favor single-payer, but I am willing to be convinced if there are other options that will cover everyone, provide for access to quality health care for everyone and save money. I will not accept that it has to save insurance companies, at least in the for-profit form. Many other countries use not-for-profit insurance companies to administer their health programs; maybe that would work. But issue number one, the sine qua non for a good health system, is the elimination of for-profit insurance companies. Only then can we work on the other areas of health care quality that need to be improved.

I encourage you, and all your colleagues in the Kansas delegation and in Congress, to pledge that only the interests of the health of the American people will affect your health reform decisions, and that you will give no consideration to maintaining the profits of the health insurance industry.

Thank you for your attention.

Joshua Freeman, MD
Kansas City, KS

No comments:

Total Pageviews