Monday, June 22, 2009

Government sponsored health coverage: The Good, the Cautionary, and the Ugly

The good news:
The recent New York Times/CBS News poll (June 21, 2009, demonstrates conclusively that, as the headline reads, there is “Wide Support for Government-Run Health”.

“The poll found that most Americans would be NY Times willing to pay higher taxes so everyone could have health insurance and that they said the government could do a better job of holding down health-care costs than the private sector…72 percent of those questioned supported a government-administered insurance plan — something like Medicare for those under 65 — that would compete for customers with private insurers.”

Sound like overwhelming support for a single-payer plan, especially one like that called for in the “Improved and Expanded Medicare for All Act”, HR 676, with 100 co-sponsors in the House of Representatives (

Sixty-four percent said they thought the federal government should guarantee coverage, a figure that has stayed steady all decade. Nearly 6 in 10 said they would be willing to pay higher taxes to make sure that all were insured, with 4 in 10 willing to pay as much as $500 more a year.” Despite the fact that “…only a fifth of those with insurance said the cost of their own medical care posed a hardship….One in four said that in the last 12 months they or someone in their household had cut back on medications because of the expense, and one in five said someone had skipped a recommended test.”

My goodness! Where are the self-centered Americans we keep hearing about? “…only a fourth said that keeping health costs down was a more urgent need than providing coverage for the country’s nearly 50 million uninsured.” People understand that we are all dependent upon one another. And that, while I might be insured through my place of work today, I might not be tomorrow. And, while I may be healthy today, I may not always be. Good for us!

The cautionary news is that “While the survey results depict a nation desperate for change, it also reveals a deep wariness of the possible consequences. Half to two-thirds of respondents said they worried that if the government guaranteed health coverage, they would see declines in the quality of their own care and in their ability to choose doctors and get needed treatment…. ‘It is the responsibility of the government to guarantee insurance for all,’ said Juanita Lomaz, a 65-year-old office worker from Bakersfield, Calif. ‘But my care will get worse because they’ll have to limit care in order to cover everyone.’”. To her credit, and that of most of the other respondents to the survey, this did not keep her – and them -- from supporting health care coverage for all. But it does indicate how effective the propagandists from the insurance companies and the right have been in convincing people that there is a trade-off between excellent care for themselves and coverage for everyone. The fact is that the United States spends far more than enough money to cover everyone, and to give them access to excellent health care. Countries that spend much less per capita than we do manage to do this, and have far better health outcomes. We spend a great deal of our health care dollar on unnecessary but well reimbursed tests and procedures. We ensure that elective procedures for the well-insured (a decreasing group, certainly) take precedence over the necessary care for the less-well, or un-insured. We spend huge amounts of money on interventions and almost nothing on prevention; while prevention may not always save money, as I have previous discussed (February 13) in commenting on the JAMA article by Steven Woolf[1] and addressed in the wonderful-in-many-ways article by Abraham Verghese in the Wall St. Journal June 20, 2009, it can save and improve the quality of lives.

There will certainly be more to do. Many of my postings have addressed the importance of having a health system built upon Primary care (December 11, April 5, April 29, May 21), and we don’t – that is why newly covered people in Massachusetts can’t find a doctor. And we are not on track to – think about it. If we need 50+% primary care doctors, and we now have 30% or so, we are not going to get there by having between 20% and 25% of medical students enter primary care as we are now. Or even 30%. Even at 50%, we’d have to wait 30 years till we replaced the whole physician population to get to 50%. And yet, as previously noted, we talk about it but are not really doing anything – read “pay a lot more money for” – to effectuate it. And we have to work to convince Americans that “more” is not always “better” – but I think that the poll seems to show they are getting it. We could do this!

But, the ugly bad news is that it looks like we are not only going to not get single-payer, or Medicare for all, but we are likely to not even get a strong public option. While the New York Times editorializes in favor of such a plan (also June 21, 2009,, and these polls are published, and the letters and faxes supporting single payer come fast and furious, the Congressional leadership has maintained their well-established posture:

The report from the Tri-Committee Health Reform draft is far from encouraging. It is precisely set up to disadvantage the public option, making it weak compared to the private plans. Quite the opposite of the campaign of disinformation put forward by the insurance companies and their flaks in Congress, the concern is not that the public plan will be “advantaged” but rather that the law will be written to “advantage” private insurance companies. This is because they are, at base, greedy profiteers who could not compete with a public plan on a level playing field. This is articulately addressed by Karen Tumulty in the Swampland blog,

Don McCanne, the brilliant analyst and author of “Quote of the Day”, addresses the core problems with the Tri-Committee proposal”

"Is this the model of the public option that is going to ensure that reform will bring affordable health care to everyone? Well, here are a few things that this reform will NOT accomplish:

* Not a single one of the Republicans or conservative Democrats who are opposed to the public option will sign on to this version. It is a government program not only in name, but in fact. Not only would it eliminate any hope of bipartisan legislation, it is quite likely that it could not even muster the vote of a simple majority.

* By requiring the public option to have the same market reforms as the private plans, it will prevent the government from using the great power of beneficent public social policies. A regulated insurance exchange within a fragmented, multi-payer, business-oriented insurance market would provide a very shaky infrastructure for delivering to the community the benefits of a social insurance program. Even with greater regulation, our private insurers have a business mission whereas the European private insurers have a social mission.

* A public plan that is required to comply with private insurer rules could never provide a back door entry to a single payer system. As Medicare Advantage demonstrates, the private insurers will always use devious means to provide them with an unfair advantage over our public program, even though they provide lower value per dollar spent.

* An insurance exchange, with or without a public option, perpetuates a fragmented system that prevents us from obtaining greater health care value by having the powerful purchasing strength of our own public monopsony - the secret of other systems that have slowed cost inflation.

* The administrative complexity of this model of reform makes it impossible to cover everyone. Initial estimates that this would cover 95 percent of the population are likely overly optimistic. Regardless, supporting a program that would leave even 15 million people on their own to fend for health care reflects a callous disregard for the needs of these individuals, and certainly belies the notion that we are a caring nation.

* Although this proposal shifts spending between individuals, employers and the government, creating the appearance of financing reform, it does very little to slow the continuing escalation in health care costs. Until that is seriously addressed, as it could be through an improved Medicare for everyone, the rest of this ‘stuff is written in smoke,’ as Karen Tumulty writes.”

The same folks who bailed out the banks instead of the people (why pay banks so that they don’t lose money foreclosing on people’s houses rather than give people the money to pay off the banks, so they keep their houses and the banks stay whole?) and now let them write the financial reform laws; who voted down caps on credit card interest rates 2:1, now are firmly set on letting the insurance industry write the health reform laws. Sorry, America. The only chance we have is if everyone who cares, every day, calls, faxes, and emails their representatives to say “single payer”; maybe then they’ll feel so pressured they’ll “compromise” on a strong public plan.

[1] Woolf SH, A Closer Look at the Economic Argument for Disease Prevention, JAMA. 2009;301(5):536-538.

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