Thursday, May 28, 2009

"The Nation"'s Health Care Bottom Line is Bottom of the Barrel

I was initially surprised at reading the editorial "Healthcare Bottom Lines" by J. Douglas Feder in the ostensibly progressive Nation (June 8, 2009) After rereading it I was both shocked and disappointed that the Nation would feature this as an editorial. It could truly have been placed by Max Baucus' publicist.

For starters, the piece doesn't even mention the single-payer option. Even the New York Times disagrees with Baucus and other Democratic leaders saying that this being "off the table". A single-payer plan, such as the improved and expanded Medicare for All program that is called for in Rep. John Conyers' HR 676, which has 100 co-sponsors in the House, is the only proposal that will both cover everyone and save a lot of money. Nothing else comes close. More important, it is not only supported by a lot of Congresspeople, but a lot of the public. Single payer is the ONLY proposal with a mass movement of church groups, labor unions, consumer groups and others behind it. Every other proposal has as supporters politicians, policy wonks, academics and talking heads, but no mass movement. Over 60% of the American people support such a plan in poll after poll, and even 59% of physicians support it. How can a magazine such as The Nation not even mention it in an editorial?

Feder cites three "top points" that must be considered in health reform, and all are misdirected. His first, "The public plan must rein in costs" ignores the most important way that costs can and should be reined in: by eliminating insurance company profit. Even those first-world countries without a single-payer system have only non-profit health insurance companies. While other methods of controlling the growth of costs must definitely be pursued, the elimination of profiteering generates a huge initial drop in cost. If there is only a public “option”, rather than a public single-payer, the savings will be real but will be much reduced as providers (doctors and hospitals) will need to maintain their enormously expensive billing and collecting infrastructure. Feder’s second point "The public plan must fix uncompetitive markets" follows the tortured logic necessary if one believes that we need to maintain the private, for-profit companies, which is a bad idea (see above).

Finally, Feder says "medicine must be practiced more cost-effectively", noting that "…$700 billion a year -- one in three healthcare dollars -- goes to treatments that have not been shown to improve outcomes". Well, yes, this is an issue, but both here and in his discussion of his first point, Feder seems to be calling for payments to physicians to be cut across the board. He does not address the most important issue, which is that our system (or non-system) is built on tertiary care, paying for enormously expensive (and to be sure, often unproven) treatments but not for the care coordination and prevention that characterize primary care. Overwhelming research, by Starfield and her colleagues at Johns Hopkins, by Wenner, Baicker, Chandra and colleagues at Dartmouth, as well as many others, show that systems built on primary care -- in this country and across the globe -- have lower costs and higher quality. Tom Daschle, for goodness sake, in his ill-fated confirmation hearings, rightly showed the US as an upside down pyramid: while other counties begin by spending on primary care and go up to secondary and tertiary care until the money runs out, the US does the opposite. With terrible results. The Patient-Centered Primary Care Collaborative ( was begun by international corporations that realized that their costs were lower and the quality was better in countries where the health system is primary care based, in contrast to the US. The perverse tertiary-care, subspecialty-based payment system we have means that our already low primary care component (about 30% compared to a desirable 50-60%) will get even worse, as medical students are entering primary care at rates close to 20%. Feder, the Nation editorialist, ignores this entirely. That these issues are much better addressed by the New York Times, Tom Daschle, and IBM (through PCPCC) is a complete embarrassment for The Nation.

Let me reiterate the two important points:
The US needs a system built around primary care, one that increases the incentives to enter primary care and increases payment for primary care. A plan that does not do this fails the American people. It also needs to save the extraordinary percent of our "healthcare" dollar not spent on healthcare, but on corporate profit. These are the two important points, not those of Feder. It is hard to believe that The Nation is so out of touch with its readership and the American people.

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