From the surgeon-blogger:

Let me say it up front: I favor some form of a single-payer system.* It’s my view that the many problems with such a system can be overcome: it’s not single payer per se, as I see it, to which people seem to object. It’s some of the accouterments. Before getting to that, I’ll state what I think is the obvious: having countless health insurance companies — many of them for-profit — sucks gazillions of dollars out of the health care realm, in form of profits to shareholders, salaries of executives, and tens of thousands of workers in cubicles. Both in the bowels of the insurers’ buildings, and in hospitals and clinics and medical offices around the country, people input data, make calls, argue for and against payments, follow differing contractual rules within and between companies; in short, money that could be spent on care of the sick is diverted into pockets of those who provide no actual service to those in need of it.

The biggest problems with Medicare are that it treats providers like shit, has stupid rules, and responds little, if at all, to input from those who know what’s going on. It not only doesn’t recognize, but actually deincentivizes excellence. No small things; but there’s no reason a single payer has to be that way. What I’m saying, basically, is this: let’s have a single payer, and let’s make it smart and responsive. I think it’s not categorically impossible.

I know I’m basically quoting his entire post, but he gives a good, fair perspective and raises his concerns with Medicare and single-payer without saying it’s hopeless, and admitting that having such administrative duplication has to waste huge amounts of money that could be going toward patient care.

(Just one critique, Dr. Schwab–Canada is single-payer: doctors are private, clinics are privately owned, and hospitals aren’t run by the government. They’re just paid for by the government.)

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Waiting lists can be a form of rationing, but it’s far more humane than denial of treatment through systematic exclusion from most of the health system (which is what lack of coverage means). Great post.

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Panda will always provide me with plenty to blog back about . He rails about personal responsibility and health care policy, which just makes no sense to me at all. Let’s go one by one:

“Nothing wili [sic] ever change, no matter how or to whom you shift the costs because:
1.Patients are not encouraged or expected to take personal responsibility for their own health.”

I think patients are encouraged all the time to take personal responsibility for their health. Every doctor tells them this, and they know this. We all have to take personal responsibility for ourselves. I should probably eat less cereal and more vegetables. Some of my patients should probably take their antibiotics so they don’t develop worse infections.

I think the health care system also expects patients to take personal responsibility– and almost all of them do ! Panda is experiencing quite the selection bias–in fact, all hospital-based physicians experience it. We don’t see all the healthy people in the world, only the ones who are sick, or were healthy but didn’t take “personal responsibility.” But what should we do, Panda, if patients fail to meet our expectations? I would love to hear his answer: three strikes and you’re out? No more medical care? Just triage you right to hospice?

I agree that personal responsibility is important, but I feel like the “personal responsibility” crowd doesn’t acknowledge that systemic and societal issues greatly impact how much time, energy, and money a patient has to perform said personal health care maintenance.

“2. As every insurance scheme insulates the patient from the true cost of health care, there is no incentive for patients to make good economic decisions.”

This is true. But as I’ve said before , the “good economic decisions” people could make make up only a very small portion of the health care costs in the country. Rail against the molehill of incentives and economic decisions all you want, but it won’t do anything for the mountain of expenses you’re ignoring.

“3. The legal environment makes it impossible for anyone in authority to exercise common sense.”

Agree here. I think we should reform the tort system to a “loser pays” system–in Canada, for example (oh no, Canada!), if you sue someone and you lose, you pay their legal expenses.

“4. Futile care, which is in no way discouraged, sucks up a vast amount of medical care, everything from the physicians time to the cleaning lady mopping the floor of the ICU.”

Agree. People need to have more rational discussions about death, dying, and care with their loved ones. Sometimes I think Americans are so afraid of death and so obsessed with youth that we put a lot of dying people through a lot of sufffering so that the living can feel more comfortable. Grand daughter to me: “The doctors told me my grandmother may only have less than a year to live.” Me: “Well, yes, that very well could be true–she is 91.”

“5. Doctors don’t know how to say “no” or admit defeat.”

Eh. I don’t know if it’s our place to say no. But that’s a whole other post entirely.

“The true crime is that the zealots believe a single-payer system or some other scheme of “We Swear It’s Not Socialized Medicine” is going to make health care less expensive. Unfortunately, until the structural problems are addressed, health care will just keep getting more expensive. To address them is, ironically, to preclude the need for anything other than consumer driven changes which are the only kind that will work.”

Oh come on. This is another silly attack on single-payer, and Panda doesn’t even know what he’s talking about. No serious single-payer advocate has ever argued that it will make health care less expensive. We argue that it will reduce the rate of increasing health care expenditures. We argue that it will make more health care dollars go to patient care instead of advertisements, million dollar executive pay, shareholder premiums, and administrative overhead, but the single-payer plans I’ve seen all keep the US health care expenditures at the same level as they are currently–they don’t say we should or can cut costs.

I agree that our health care system is setup to continually increase expenses, but for my reasoning, read Money Driven Medicine by Maggie Mahar . She’s spot on.

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Med Innovations goes on the attack about the NYTimes’ reporting of medical stories and wishes they were more in line with his beliefs about the true America:

It all comes down to altitude and attitude. From their lofty perch, The New York Time’s editorial staff has yet to tumble to the reality America is basically a conservative nation, distrusts centralized government, wants choices of care and providers, demands access to the wonders of high tech medicine, and believes a market-based system, with all its faults, such as profits for entrepreneurial and innovative health care companies and doctors, are worth the price and value received.

He is talking about the United States of America, right? I was wondering why this poll didn’t get more coverage on the medical blogosphere showing that two thirds of Americans believe the government should provide national health insurance even at the cost of higher taxes. I don’t think our country is at all as “basically conservative” and distrustful of centralized government as Med Innovations thinks. I don’t think the country believes in a market-based system either.

I think the country knows that the health care system sucks, but many are scared of change or reform because they would have to risk their coverage to provide it for everyone. They know someone in the middle class or have read about someone with cancer–or even a kid with asthma–losing their wonderful “market-based” coverage after having paid into the system for years, and they’re worried they could be next. And they know if you’re uninsured and really sick it can devastate you not just physically and emotionally, but financially too, and that’s not something people should have to risk, especially kids. They worry about waiting times because everything everyone talks about is waiting for elective hip replacements in Canada.

I think they want their health care to work like I want my electricity does–when I flick the switch, the light should go on. That is, if Medicare or a single-payer or whoever can keep the level of quality and choice the same but provide coverage to everybody, then we should all get it–they’ve been screwed over by HMOs and for-profit HMO billing fraud and drug company lobbying enough. They know the “efficiency” of the “market place” is crap in health care, because they’ve spend 30 minutes on the phone with a claims reviewer getting something covered that should’ve been covered in the first place. And they know that “pre-existing conditions” are an America-only concept created only to maximize profits and resist providing medical coverage for actual medical problems.

Do you think the government should provide a national health insurance program for all Americans, even if this would require higher taxes?
Yes 64%
No 35%
No opinion 2%

Do you think the government should provide a national health insurance program for all children under the age of 18, even if this would require higher taxes?
Yes 73%
No 25%
No opinion 2%

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(In which we mostly correct the Panda Bear .)

Major points to Panda Bear for his passion, but his health policy leaves something to be desired, I must admit. His latest rant is good–and I agree some of it in theory, but he doesn’t seem to be well-versed in the single-payer “woo,” so here we go:

The key thing to keep in mind is that the various plans proposed to insure the entire nation will do nothing to lower the cost of medical care because they are just another scheme to shift the costs from one set of consumers to the other.

Actually, that’s not correct, Panda. Single-payer plans have consistently been evaluated and shown to cover everyone while saving money. They do this by cashing in on the massive savings associated with administrative waste (probably at least $100 BILLION), allowing drug price negotiating, and setting global budgets for health spending. (See the California Health Care Options Project , The Vermont Single-Payer Study , The Maryland Single-Payer Study , Massachusetts Health Care Studies , and Maine’s Single-Payer Microsimulation .) Just to be clear, these analyses were done by The Lewin Group and Mathematica Consulting , not single-payer supporters.

The only difference will be that instead of half, every single health care dollar will take a trip through the federal sausage mill.

60% of health care dollars already take a trip thru the federal sausage mill–yes, 60%–and when they go to the Medicare mill, you actually get more sausage (health care) for your buck. There’s lower overhead costs compared with most private insurers–no advertising, no huge executive salaries, no profit demanded by investors.

The money is going to come out of somebody’s pocket and it’s not going to be the government which has no pockets, just hands to grab from one to give to another

This is how insurance works–not just health insurance, but car insurance, home owner’s insurance–all of it. It’s risk pooling. And the bigger your risk pool, the better to keep the system going. Money for our health care system comes from the citizens, whether it’s from Medicare taxes or loss of income from businesses providing health insurance (the businesses get to write off the health insurance bucks).

This is why the concept of Health Savings Accounts (not to mention privatizing Social Security) invokes such howls of rage from our ruling elites. Not only do they hold the people in contempt thinking them incapable of planning for their own future but the money tied up in these accounts and owned by citizens is just another chunk of money that cannot be stuffed into the voracious maw of the political influence machine.

I’m against HSAs because they won’t do squat for our problems. 80% of health costs are from 20% of patients –those are obviously our sickest patients–and they’re going to spend thru their HSAs within the first 2 days. HSAs are a great tax-free way for the rich to protect their money from taxes, but like I said before, they’re focusing on a leaking faucet when there’s a Niagara Falls right next door. Also, sure, an HSA might make someone think, “Should I really go to the doctor for this cold? Maybe it’s a virus.” Okay, so you’ve saved the system 50 bucks. But what consumer patient, when truly sick, is in any state of mind to decide if he needs the CT scan the doctor is recommending? Or if she should be admitted? Come on. (It’s a myth that more consumer information improves health care decisions , anyway.)

It would be demoralizing to our nation to have the disparities of medical access so wide that the poor and ignorant suffer or die from conditions that those who can think and plan ahead easily eacape. We will, unfortunately, always need to give medical care as charity.

Awkward! 18,000 people die each year from lack of access to proper health care. You’ve never seen an uninsured diabetic come into your ER with a nasty foot ulcer or infection that eventually leads to amputation, Panda? Come on. And survival rates after amputation suck.

I don’t think we will, fortunately, always need to give medical care as charity. There are tons of other nations able to provide for health care for their citizens, because it’s a priority for their countries. We can make it one too, if we want to.

There are many conflicting forces in medical care, each one trying to stiff the other with the bill. The insurance companies want to pay as little in claims as possible which is understandable given the nature of their business. The medical industry, from physicians to the lady mopping the hospital floors, would like to get paid fairly for their services. The government wrings its hands at the cost but at the same time would like as many people dependent on government as possible. The people want all the medical care they can eat but they want somebody else to pay for it.

You’ve really gotta read Money-Driven Medicine, Panda. You’ll love it.

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This Des Moines Register editorial spells out our problems so cleanly that I’d link to it anyway, but they also mention this bute:

Just a few weeks ago, this editorial page told the story of Jan and Gary Clausen, who didn’t have the option of buying health insurance through an employer. They went out on their own and bought AARP-endorsed plans for about $700 a month. They were left with more than $200,000 in medical bills after Gary was diagnosed with cancer.

Some insurance.

If you support the current system, you support a system that does this to people.

Or this , Shadowfax’s incredibly sad CT scan and story about a 54 year-old uninsured woman with metastatic cancer who will soon be leaving her 4 children behind.

Bravo, bravo, encore, encore!

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It’s really kind of sad/scary/amusing that a guy that runs a blog called “Health Care BS” and claims to have spent 20 years in health care finance doesn’t know the difference between a single-payer system and a national health service .

Boy David Catron, that’s pretty embarrassing:

For years, advocates of socialized medicine have been extolling the virtues of the VA hospital system. Ignoring the collective cri du coeur (No! Don’t do it!) from veterans who have actually been subjected to its tender mercies, the single-payer evangelists have doggedly insisted that the Veterans Administration constitutes a good model for a “universal” civilian system.

(Nice one-two with the “socialized medicine” buzzword there.) If Mr. Catron knew what single-payer is (and honestly, I think he does, but couldn’t pass up an opportunity), he would realize that single-payer advocates advocate for a private health care system, publicly funded. No single-payer advocate I know of is advocating for a “universal civilian system,” like the VA, where government owned facilities and government-employed docs and nurses provide the health care.

I’ll say it until I’m blue in the face: NHS isn’t NHI .

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It’s not particularly news that the lack of health insurance is affecting the middle class, but this NYT piece provides a good reminder : a women with a history of cancer, making $60,000 a year, was unable to afford health insurance. Here were her options:

1. One plan offered to insure her for $27,000 a year. After taxes, that’s easily more than half of her income.
2. Another HMO told her to go back to her old job and get insurance through them.

So there’s your options if you have a history of a serious illness and you’re trying to buy insurance (note: the “make everyone purchase insurance” option is sadly one of the leading plans to get everyone covered in the US): pay half of your salary, or go back to an old job, quit your small business, so you can afford your own medical care.

What a joke.

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One of the great myths of Canada says that doctors are leaving in record numbers because of their terrible health system. It simply isn’t true, according to the Canadian Institute for Health Information : (I’m essentially quoting Don McCanne’s Quote of the Day here, a great listserv that if you’re not on, you’re missing):

Over the past five years, the proportion of Canadian physicians moving in and out of the country has decreased by 30.6%. While both the number leaving and the number returning to the country are on the decline, Canada has seen a larger decrease in the number of physicians leaving the country. As a result, the proportion of physicians returning to the country is now greater than the
proportion leaving.

When comparing the number of physicians moving abroad to the number of physicians returning from abroad, Canada registered net physician losses from 2001 to 2003. Starting in 2004, Canada began registering net gains of 85 physicians in 2004 and 61 physicians in 2005 due to
international migration.

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(The Part Two in the Series)

People seem to be taking sides in our little medblogger health care debates; I hear a lot of people that would be unhappy with a single-payer solution, but not a whole lot of other ideas to fix our health care system (ie: more negative ads than positive ones). The fundamental thing I don’t understand from libertarians is this: what’s a better option? Libertarians would have you believe that if we all just were responsible for our own health care costs, we would decrease our spending and la la la everything would be okay. But that’s not going to happen.

We have a law on the books saying that any ER has to screen patients who walk through the door. Now, you can take this law and do one of two things with it:

1) Keep it, and deal with the consequences that it creates.
2) Repeal it. (But let’s be honest, people, no one but wealthy crazies actually believes that this is reasonable policy.) So we repeal it, and ERs are allowed to turn away emergency patients (or patients who think they might be emergencies). We’re going to let people die on the streets? This would never, ever happen, and if it did–talk about health care revolution.

So here we are. We as a society have agreed that we will take care of the acutely ill, no matter the cost.

From where I’m standing, then, if we’re going to take care of the acutely ill, we might as well keep societal costs lower by preventing people from becoming acutely ill (or from developing the consequences of chronic illness). Am I crazy? Am I missing something here? You can’t tell me that our system makes sense in this way. We will allow an uninsured diabetic to go years without any preventive care, because lack of ability to pay, but once his foot becomes necrotic and he needs an amputation, and gets an ICU stay for becoming septic–oh well, let’s definitely pay for that!?

So here are the facts: single-payer would not cost us any more in ABSOLUTE dollars than we are paying today (as evaluated in the California Health Care Options Project , The Vermont Single-Payer Study , The Maryland Single-Payer Study , Massachusetts Health Care Studies , and Maine’s Single-Payer Microsimulation . Just to be clear, these analyses were done by The Lewin Group and Mathematica Consulting , two economic analyst groups. Not single-payer supporters.

(A note: single-payer critics will say that single-payer causes tax increases; while this is technically true, as money would be directed to the government, it would not be new money, it would essentially be the same money that employers are already paying for health insurance to HMOs right now.)

Single-payer would cover everyone.

Single-payer would slow costs.

Single-payer would allow people true choice–to see any doctor they wanted, provided that the doctor was available to see them.

Single-payer would allow for lower prescription drug costs.

Single-payer would not “cherry pick” healthy people; single-payer would eliminate the American concept of “pre-existing conditions.”

Look, if you have a problem with the “political feasibility” of single-payer, that’s fine, we can debate that. If you’re weary of allowing a government entity to set all health care reimbursement, that’s fine, we can debate that. But to stick your thumbs in your ears and ignore that we’re already ready to pay for emergency care, because of the consequences of the alternative is just stupid, plain and simple.

So, what’s your better solution?

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