Right now, in the heat of August, we've decided to take the temperature of health care in America. It promises to be a big issue in the '08 election, but often we don't start learning about its intricacies until faced with serious health issues of our own. Then, the medical bills start piling up on the kitchen table, and you just don't know where to begin.
Well, to get a handle on health care in this country, we fired off 10 Questions to two experts: On the right we had Robert Moffit, who's the director of the Heritage Foundation's Center for Health Policy Studies. We posted his answers last week.
One thing we found interesting: when we asked the two men our first question — to name the one thing they'd change about the health care system — they both began with the exact same words: The financing. And then they diverged.
1. If you could change ONE thing about our health care system, what would that be?
The financing. Instead of hundreds of profit-seeking health insurers, money should be collected and bills paid by a single government payer.
At present, insurance company overhead and the paperwork that inflicts on doctors and hospitals wastes more than $350 billion a year — money that could cover the uninsured and eliminate co-payments and deductibles for those who currently have partial coverage. Progressive income taxes would be paid, just as we now do for other financially socialized benefits such as libraries, the police, schools, Social Security and, in the health area, for Medicare. Because of the huge administrative savings, a single payer system could cover everyone without expending any more dollars.
2. Most people agree that the costs are out of control. What can be done about that?
By far, the fastest growing element of cost is wasteful health administration. The number of doctors increased 2.5-fold from 1970 to 2005, largely in proportion to growth in the population. The number of registered nurses grew a bit more slowly. But the number of health administrators increased 26-fold during the same interval.
Another rapidly growing cost is the price of prescription drugs. Unlike all other developed countries where prescription drug prices are negotiated or controlled — and as we do for the Department of Defense and for the Veterans' Administration — the costs for everyone else in this country are largely out of control and, for many, unaffordable.
The single payer approach could cut paperwork costs drastically, and force drug prices down.
3. What works in our system? What doesn't?
Our system of medical education and our medical research are as good as most places in the world. But, because of the enormous expense of U.S. medical schools, much higher than most countries in the world, many students from poorer economic backgrounds are less likely to go into medicine.
The success of U.S. medical research would not be possible without the huge public subsidy through the NIH, now funded at more than $28 billion a year, another example of a progressively taxed, financially socialized benefit for everybody.
As discussed above, the current multiple payer financing is unaffordably wasteful and forces a larger and larger proportion of the $2 trillion we spend on health each year to fund people who are not, in any remote way, delivering medical care. They are not doctors, nurses, pharmacists or other health care providers but, in many cases, health care deniers whose job it is to fight with each other (insurance administrator vs. hospital administrator or doctor's office administrator) to deny payments or even coverage for needed health services.
4. People come to this country from all over the world and get great medical care. But so many Americans slip through the cracks. What can be done to close this gap?
In what has been described as medical tourism, the United States, with its large pharmaceutical and medical-device industries and high-tech hospitals, has traditionally been a destination for patients, primarily those affluent enough to pay out-of-pocket, or those who have generous insurance coverage that extends beyond their countries of origin.
But recent years have also seen a flow in the opposite direction, with large numbers of American patients traveling abroad in search of less expensive and often more luxurious health care, frequently surgery.
The problem of Americans "slipping through the cracks" because of being uninsured or underinsured can only be dealt with by providing universal health coverage for all people in this country.
5. We hear a lot about the number of uninsured Americans. Just how many are there?
At the time of a government survey in 2006, about 43.6 million people in the United States, or 14.8 percent of the population, had no health insurance. But about 54.5 million people in the country, or 18.6 percent of the population, had no insurance for at least part of 2006.
An even larger problem is the growing number of people who are underinsured. Illness and medical bills cause about half of all bankruptcies, and three-quarters of these people forced into medical bankruptcy had health insurance coverage — at least when they first became ill. In many cases people cannot afford policies with optimal coverage, or they choose a policy with a relatively low premium but a massive deductible, often thousands of dollars a year. Such inadequate coverage keeps them from seeking care because of the unaffordable out-of-pocket expenses.
Conservative estimates are that about 100 million people in this country — one third of our population — are either uninsured or underinsured.
6. What's the lowdown on managed care? HMOs? Single payer?
In its origins, managed care was dominated by excellent not-for-profit HMO models such as Group Health Cooperative of Puget Sound, located in Seattle. The market is now dominated by large, non-local, for-profit managed care companies, whose quality of care has been shown to be significantly worse than that of the non-profits.
Single payer means the government collects the money and pays the bills. By having all people in this country covered by a single payer health system, not just those on Medicare, our current expenditures for health — in excess of $2 trillion a year — could go much further and all but eliminate the serious problem of one out of three people being uninsured or underinsured.
In Canada, for instance, people can choose any doctor or hospital they wish to go to, unlike the increasingly restricted lists of doctors that managed care companies in this country allow.
7. What role should the government play in providing Americans with health care? What role should the marketplace play?
The government should guarantee that everyone in this country has health insurance by collecting the money and paying the bills, cutting out the pick-pockets in private industry.
The role of the marketplace — and this includes for-profit health service entities such as HMOs, hospitals, nursing homes and kidney dialysis centers — has been succinctly stated by my colleagues, Harvard professors and doctors Steffie Woolhandler and David Himmelstein. They co-founded Physicians for a National Health Program, which now includes more than 14,000 physicians, medical students and health professionals who support single payer health insurance.
In an article eight years ago in the New England Journal of Medicine, they wrote: "In our society, some aspects of life are off-limits to commerce. We prohibit the selling of children and the buying of wives, juries, and kidneys. Tainted blood is an inevitable consequence of paying blood donors; even sophisticated laboratory tests cannot supplant the gift-giving relationship as a safeguard of the purity of blood. Like blood, health care is too precious, intimate, and corruptible to entrust to the market."
8. Is there a model for a health care system that you think works, that we might model our reformed system after?
The model we adopt for our single payer health care system can be crafted from the best elements of existing systems in the many countries, such as Canada and France, that already provide universal health care. All of these countries spend far less per capita than we do in this country, and everyone is covered.
The best models eliminate private health insurers, require that hospitals and other health institutions be run on a non-profit basis, and exercise strict control over the pharmaceutical industry. The multiplicity of state health insurance initiatives, with the exception of California state senator Sheila Kuehl's bill, which advocates a single payer, are doomed to fail. They are thinly disguised versions of the failing system we have now, one dominated by wasteful private health insurers.
9. The baby boomers are now starting to retire, and people question whether Medicare will be able to handle them. Will it?
At present, Medicare is wasting about ten billion annually overpaying private Medicare HMOs, which have been touted by pro-market enthusiasts as the solution to Medicare's problems. Doctors and hospitals drain tens of billions more for unnecessary, but profitable, procedures, drugs etc.
For instance, thousands of kidney dialysis patients have been given dangerous overdoses of epoiten because dialysis centers and drug companies have made huge profits from this drug. Similarly, about half of all cardiac stents are unnecessary, leaving the patient no better off, but gaining the hospital about $20,000 per patient. Eliminating HMOs from Medicare, reorienting Medicare payments to minimize incentives for over-treatment (as well as under-treatment), and encouraging primary and preventive care would go far to assuring the long-term viability of the program.
Assuring coverage for people under 65 would also save Medicare money. When the uninsured turn 65, their Medicare bills are far higher because they failed to get timely care.
Financing Medicare by a much more progressive tax, and improving Medicare coverage to eliminate current co-payments and gaps in coverage for prescription drugs would also broaden support for the program. Canada's universal coverage program, which is also called Medicare, shows that national health insurance is the best solution to rising costs.
When Canada's program began, in 1971, they spent the same proportion of GDP on health care that we did. Now they spend about 40% less.
10. What role will the health care issue play in the election? And is there a political candidate in this broad field who you think has the right idea?
We can not only hope that health care plays a major role in the coming presidential election but also that the ideas put forth are more progressive than those currently being espoused by all of the so-called leading candidates. Representative Dennis Kucinich is the only candidate with the guts and honesty to tell it like it is, instead of pretending that versions of our failed system can work. His support for the current single payer House Bill (HR 676) sets him apart from all the other candidates.
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