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Subject: qotd: Dr. Mitchiner explains single payer to his emergency
medicine colleagues, and to all of us
Date: Fri, 2 Nov 2012 09:05:34 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>
American College of Emergency Physicians
ACEP News
August 7, 2012
It's Time for Single-Payer
By James C. Mitchiner, MD, MPH
"You can always trust the Americans to do the right thing, once they've
tried everything else."
Winston Churchill's iconic remark, reportedly issued at the dawn of
America's entry into World War II, is equally applicable to the present
American health care debate and the crisis that spawned it. Regardless
of whether you are elated or disappointed with June's historic Supreme
Court decision upholding the constitutionality of the Affordable Care
Act, it is certainly no panacea for the problems facing U.S. health
care. Even with the law intact, and despite its best intentions, it will
still leave some 25 million uninsured, underinsure millions more, expand
the corporatization of health care, and do little to control the
escalating costs of care over the long term. So it's clear we need to do
the right thing: the creation of a national, universal, publicly funded
health care system, free of the corrupting power of profit-oriented
health insurance, and at the same time capable of passing constitutional
muster. In short, the right thing is an expanded and improved
Medicare-for-All program, otherwise known as single-payer.
Don't be so shocked. For the last 30 years, we have tried all the
alternatives, and none of them have worked. We have experimented with
HMOs, PPOs, high-deductible health plans, health savings accounts,
pay-for-performance, capitation, and disease management. These ideas
have been promoted in various iterations, often with great fanfare, by
public and private payers alike, yet none of them have shown long-term
success at bending the cost curve. And the promise of the latest reforms
du jour, such as Accountable Care Organizations and Patient-Centered
Medical Homes, is speculative at best. American health care is unique
among the world's democracies in that it was never planned in terms of
enabling legislation or explicit constitutional authority. As others
have stated, our employer-based insurance system, which now covers about
160 million Americans, was an accident of history. Its lineage can be
traced to FDR's wage and price control policies during World War II,
where employers were permitted to offer workers health insurance in lieu
of higher wages as a job inducement. This benefit has evolved piecemeal
into the Rube Goldberg complexity that is contemporary
employer-sponsored health insurance, with some 1,200 private plans each
doing the same things – medical underwriting, coordination of benefits,
claims adjudication and denial, marketing, public relations, lobbying,
litigating, and paying shareholder dividends and inflated CEO salaries
while forcing individuals to pay a higher share of premiums, increased
deductibles, expanded copays, or a combination of all three. Taken as a
whole, private insurers' activities are duplicative, inefficient,
wasteful of scarce health care resources, conducive of job lock, and
completely misdirected in supporting the 21st-century health care agenda
that America needs and deserves.
The objective of the ACA's individual mandate was to remedy a flaw in
the market for health insurance: the expectation by the uninsured that
the costs of their inevitable illnesses would be benignly transferred to
those fortunate to have coverage. If you believe that guaranteed issue
and community-rating requires 100% participation in the health insurance
market to sustain financial viability, clearly the most efficient
mechanism to achieve this is not through an individual mandate, in which
the heavy hand of government coerces people to do what they otherwise
would not. If the federal government has a professed welfare interest in
controlling health care costs, it can – and should – accomplish that
goal through a more economically efficient single-payer mechanism.
Given that the primary business objective of a for-profit insurer is to
make a profit, the fundamental question we should be asking is this:
What is the marginal value of private health insurance? That is, what
advantage vis-à-vis a single-payer model like Medicare does our system
of private, profit-oriented health insurance convey to patients,
providers, and employers? What exactly do private insurers do, above and
beyond what Medicare does, that is deserving of their inflated premiums?
To my knowledge, there is no evidence that commercial insurance provides
easier access or less hassle-free care, is more cost effective, produces
care of higher quality, or has better consumer satisfaction ratings than
Medicare (if anyone has evidence to the contrary, from the peer-reviewed
health policy literature, please advise). And according to a recent
poll, most Americans prefer to keep Medicare as it is, rather than
switching to a premium-support financing mechanism as advocated by Rep.
Paul Ryan (R-Wis.). Whatever bad things you can say about our
government, at least the Feds are not required to make a profit but are
required to answer to all taxpayers, rather than private shareholders
who are concerned only with the bottom line.
Under a single-payer system, every American would receive a basic
package that would include inpatient and outpatient care, primary care
and specialty physician services, emergency care, preventive and
restorative care, mental health and substance abuse services, dental
care, prescription drugs, home health care, and long-term care. Doctors
and other providers would be paid based on a fee-for-service schedule,
as negotiated with state governments, with funding coming from
progressive payroll taxes paid by both individuals and employers.
Quality would be monitored and publicly reported, with financial
incentives awarded to providers who followed clinical guidelines
endorsed by their medical specialty societies. All services provided
would be publicly accountable. Medical decision making at the bedside
would be left to the physician.
Conceptually, single-payer is imbued with many myths and misconceptions.
Myth #1: Single-Payer Is One-Size-Fits-All
The No. 1 myth – the alpha myth – is that single-payer represents a
choiceless, one-size-fits-all, government-run health care monopsony.
This is a blatant falsehood. Single-payer is simply a more efficient and
more equitable way of financing health care – and nothing more. By
consolidating the administrative functions of insurance, it eliminates
bureaucratic duplication and reduces administrative waste, saving time
and money for employers, providers, state governments, and consumers
alike. It would remove the profit motive from financing care, but not
from delivering it. Single-payer would efficiently provide for all
Americans – regardless of age, health condition, income, or employment
status – universal health care that is portable, affordable, equitable,
nonterminating, publicly accountable, and funded through progressive
taxation, which for the average family would imply a small additional
payroll tax that is much less than its current outlay for insurance
premiums. A single-payer system would not supplant the private practice
of medicine; you could go to a primary care doctor, specialist,
hospital, pharmacist, and lab of your choice.
Myth #2: Canadian Health Care Would Be Bad for America
Americans love to repeat anecdotes about the supposedly lousy medical
care our northern neighbors receive from their single-payer system, by
demoralized and overworked doctors who work at ill-equipped hospitals
with out-of-date technology. This is rubbish. Do Canadians often wait
for weeks to see a specialist? Yes. Do Americans also wait? Yes. There
is no evidence that Canadians are dropping dead in the streets while
waiting for their emergency bypasses or appendectomies, nor is there any
evidence that Canadian physicians are emigrating to the U.S. or other
countries en masse. Further, there is no evidence that the quality of
care in Canada, across the board, is inferior to that practiced in the
U.S. Despite comparable rates of smoking and alcoholism, Canadians on
average live longer than Americans by more than 2 years, and their
infant mortality rate is less than ours. Finally, consider this:
Canadians spend much less than we do for health care, both in per-capita
dollars and as a percent of GDP, so I have no doubt that if we were to
adopt a Canadian-style system and fund it to the tune of $2.6 trillion
annually, we would not have 9-month waits for MRIs, even if every one of
them was clinically indicated.
Myth #3: Market-Based Medicine Trumps Single-Payer
Some argue that our private, market-based system is fundamentally sound,
that it should be freed of government regulation and tweaked to promote
greater competition based on price, and thus choice of health insurance
plans. Really? Does anyone seriously believe that purchasing health care
services is fundamentally no different from buying a new car or a
flat-screen TV? (If so, I suggest he or she take a course in health
economics.) And would anyone seriously believe that Americans want a
choice of health insurance, when what they really desire is a choice of
doctors and hospitals? What could be more American, more
consumer-friendly, and more constitutional than the ability to choose
your health care provider based on whatever criteria you deem important?
So why not cut out the middleman and let doctors, hospitals, and other
providers compete on such things as quality, service, reputation,
convenience, and other personal preferences, rather than having private
insurers make these choices for us?
Just consider what "The Market" has done for health care in the last 30
years: a steady increase in the number of uninsured; a decrease in the
choice of providers; diversion of resources into more profitable
hospitals and services; consolidation of HMOs into health care
oligopolies; underfunding of less profitable endeavors, such as public
health, trauma centers, and mental health services; unaffordable
prescription drugs; dissatisfied patients; frustrated physicians; and of
course, an inexorably increasing trajectory of health care costs.
Myth #4: Single-Payer Would Stop Medical Innovation
To my knowledge, there is no correlation between innovation and a
country's method of health care financing. Many technologies and medical
advances we now take for granted originated in nations with national
health insurance, for example, CT scans and MRIs (Great Britain),
laparoscopic cholecystectomy (Canada), percutaneous coronary angioplasty
(Germany), and H. pylori treatment (Australia). The largest single
source of funding for medical research in the U.S. is a government
agency – the National Institutes of Health – which provided almost $31
billion in funding for medical research in fiscal year 2012. And in
terms of per-capita drug R&D costs, the U.S. lags behind Britain and Sweden.
Myth #5: Single-Payer Is Impossible to Enact Politically
Perhaps this is true – for now. But if social change depended solely on
what was politically pragmatic, women would not have achieved the right
to vote in 1920, civil rights legislation would not have been enacted in
1964, and Medicare would have failed in 1965. We should always be
careful to distinguish between what's desirable and what's doable. The
fact that tort reform is certainly desirable, but not politically doable
at the present time, has not stopped ACEP from investing significant
time and financial resources to advocate for change. Public opinion
polls have consistently shown that the level of public support for
single-payer is 60% plus. A survey of physicians published 4 years ago
showed that single-payer garnered 59% support among the 2,193 physicians
polled (support among emergency physicians was even higher, at 69%).
Despite this, there is no question that moving to a single-payer system
will face enormous obstacles. What is needed, as columnist David Lazarus
of the Los Angeles Times pointed out, is a "massive infusion of
political courage and the willingness to forsake political purity."
Myth #6: We Can't Afford Single-Payer
Given our current system, perhaps the better statement would be "we
can't afford not to have single-payer." The most recent financial
projections portend no overall decrease in the cost trajectory for
health care over the next 8 years, even if the ACA remains intact. Under
a single-payer model, a modest increase in taxes would be overshadowed
by savings from elimination of insurance premiums, offsets from
economies of scale, decreased out-of-pocket payments, and the
disappearance of cost-shifting. The annual savings from transforming to
a single-payer system are estimated to be $400 billion. If you look at
the cost curves for U.S. and Canadian health care, they were identical
until the mid-1970s, when Canada's health system was fully implemented.
From then on, the curves diverged, with America's climbing much faster
than Canada's. When Taiwan converted to single-payer in 1995, the costs
went up in the first year, as expected, and then leveled off to a
reasonable increase of about 3% per year.
What Does This Mean for Emergency Medicine?
Well, consider the ED as a de facto single-payer environment. Patients
come to us by choice without needing to first check with their health
plan (assuming they have one) to see if their ED visit is covered. We
see them without asking them to pay in advance for their ED services,
and their care is not predicated on their job, income, or insurance
coverage. As emergency physicians, we have more autonomy than our
primary care colleagues in terms of making diagnostic and therapeutic
decisions without the nonsense of "pre-authorization" or other
interference from an insurer who is interested only in the bottom line.
While it's nice to be able to make medical decisions without checking on
insurance status, it would be even nicer if we actually got paid for
every ED patient treated. Private insurance companies simply have no
incentive – in fact, it's not at all consistent with their business
model – to pay for EMTALA-mandated services provided by out-of-network
emergency physicians.
Looking again to Medicare as a single-payer model, consider how we
emergency physicians interact with Medicare vs. private insurers. In 29
years of practice, I have never had to seek permission from a CMS
official to admit a fee-for-service Medicare patient, have never had a
consultant refuse a referral for a Medicare beneficiary, and have never
had a pharmacist call me to say the prescription for my Medicare patient
was not covered by the formulary. This is not true for some of my
patients in managed care plans, including those who were sick enough to
be admitted but had to be transferred because my hospital (which the
patients self-selected) did not participate in their plan.
Single-payer is the only remaining option to simultaneously and
synergistically expand access, control costs, preserve choice, and
reduce disparities. There is simply no other efficient and
constitutionally safe way to do this. Any other proposals are nothing
more than tinkering around the edges and based on blind faith that some
kind of future financial salvation will somehow save us from the
impending health care meltdown. A single-payer, improved
Medicare-for-All program would overhaul our dysfunctional health care
financing system so that it works best for patients – and for physicians.
Dr. Mitchiner is an emergency physician in Ann Arbor, Mich., a former
president of the Washtenaw County (Mich.) Medical Society, and a member
of Physicians for a National Health Program.
http://www.acepnews.com/index.php?id=495&cHash=071010&tx_ttnews[tt_news]=1564#
<http://www.acepnews.com/index.php?id=495&cHash=071010&tx_ttnews[tt_news]=1564#>
Comment: Single payer is not on the table in next week's presidential
election. It should be. This article explains why.
Dr. Mitchiner's explanation of single payer, addressed to his emergency
medicine colleagues, is so clear, concise and compelling that it should
be widely distributed so others can understand the imperative of a
single payer system - an improved Medicare for all.
It should be downloaded from the ACEP link above, or from the PNHP link
below. Both can be converted into printer friendly formats by clicking
"Printer friendly" (ACEP) or "Print page" (PNHP). Then be sure that as
many people as possible read it and then share it with others. And on
the Internet, this needs to go viral!
http://www.pnhp.org/news/2012/november/its-time-for-single-payer
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