Based on comments at a July 1st Federalist Society debate on health reform

Single payer:  freedom, choice and quality

Healthcare is a human right.  It is fundamental and instrumental to life, liberty and the pursuit of happiness.

We are paying for a first rate system but getting a mediocre one, getting phenomenally low value on the dollar.  We spend twice as much as other developed nations but are not healthier as a result.  In many indices of major health outcomes we trail other developed nations.  We have scarcity in the midst of excess.  This is a scandal and a shame and we can do better.

I reject the notion that many propose, that healthcare is a zero-sum game in which universal access threatens quality.  Universal access combined with public accountability will enhance quality.  The whole system is stronger and better if we all go in together to one big risk pool.  By publically insuring everybody, we could, with the money we are spending now, provide what we need/when we need it healthcare for everyone.  This is single payer, Medicare 2.0.  It is public insurance with private delivery.

Single payer is controversial in some circles.  However, it’s beneficial effects regarding cost containment are generally conceded on all sides.  I will not dwell on these.  I will focus instead on how single payer can enhance freedom, choice, and quality in American medicine.

The “Other in our midst”

Before going on I want to first address a pernicious idea promoted by many who oppose health reform head on.  It is rarely spoken of directly.  There are many who would like you to believe that there is some “other” in our midst whose ills and lifestyles account for the poor health status and high costs of Americans.  These are, variously, overweight, substance abusing, drunken driving, gun-fighting, illegal immigrant, unwed mothers, smokers and others.

“Others” aren’t the cause of high costs

The idea that the bad aspects of our system are limited to various “others” is a folly, and a dangerous one.   The “expensive” people in healthcare are the sick and, alas, we will all be there someday, somehow.  The single biggest risk factor predicting high utilization of healthcare services is not obesity, smoking, drinking or other putatively “voluntary” lifestyle factors.  It is age.  The bulk of healthcare spending in any given year is on a very sick minority.  The majority has an interest in protecting this minority because, literally, we could join them anytime.

“Others” aren’t the cause of bad US healthcare outcomes.

There are more unwed mothers and many, many more smokers in Europe.  Conventional wisdom about alcohol use aside, there is no evidence that Europeans suffer fewer medical complications of alcohol overuse than we do.  They are also rapidly gaining on us in girth and also have large populations of documented and undocumented immigrants.

Quality and Quantity of US Care

As I have said we have scarcity in the midst of excess with healthcare distribution according to ability to pay/get reimbursed.  Up to a third of overall medical expenses are judged to be due to unnecessary interventions.  At the same a third of Americans say they are cutting back on medications and routine medical care due to cost.

Make no mistake, unnecessary procedures are not just expensive, they cause net harm including permanent injury and deaths.   High costs are not just lamentable for bean counters, they mean large numbers of Americans don’t seek timely care and don’t take meds.

High Tech Care, Research and Innovation

Our supposed reward for accepting the harsh reality of un- and under-insurance is high tech medicine and a system on the cutting edge of research and innovation.  This is a false choice.  Systems without for profit insurance are clearly able to support high quality and high tech medical care as well as cutting edge research.

There are more frequent hip replacements in Sweden and more bone marrow transplants in France and Italy.   Japan and several European countries have many more CT and MRI machines per capita than we do.

Biomedical researchers benchmark advances in knowledge by numbers of journal articles and how often other researchers cite those articles.  The US trails several European nations in this regard. Half the top ten pharmaceutical companies are European and pharmaceutical industry R&D per capita is greater in Sweden, Denmark and the UK than in the US.

We do a lot of clinical trials, but, frankly, these are rarely designed to answer questions clinicians want answered (like is this medicine any better than what we’ve got already) instead they are focused on marketing needs.

The case of “proton pump inhibitors”

I want to discuss one particular type of drug because I think the case illustrates how profit incentives can distort quality and value in healthcare and why it’s so important to Big Pharma to negotiate with many different payers rather than a single powerful one.  Multiple payers keep Americans paying the highest drug prices in the world and make it profitable to recycle old inventions rather than come up with new ones.

Take, for example proton pump inhibitors (PPIs ).  This category of medication was discovered in the late 80s and was a significant advance.  It’s used for stomach problems. The bedrock science research used to discover the drug was supported by US taxpayers via the National Institute of Health.  Nexium, the purple pill you may have heard of or actually take, is manufactured by an Anglo Swedish company which is the market leader in the PPI field. It is used mostly to treat heartburn, re-christened by industry marketers more ominously as GERD or gastroesophageal reflux disease.

New developments in this area since the late 80s looks like this:  6 new branded PPIs in 15 different forms made by 5 different pharmaceutical companies only 2 of which are American.  There is no scientific basis for believing any of the new formulations are better than the original one.

The original idea and basic research was done by an Austrian born and Scottish educated American.  He was working for a Swedish company at the time and is now at the US Dept of Veteran’s Affairs.

The basis for the most recent new PPI patent, issued over 20 years after the innovative compound was discovered, was for compounding the drug with baking soda so it would be “immediate release”.   Ultimately $44M was spent on product research and $48M was spent on marketing including a full time sales force of 400.   This is poor health value for dollars spent.

The PPI market is now driven largely by inappropriate prescriptions which are now estimated to accounting for up to 70% of all usage.  The problem is bigger than the money wasted.  Stomach acid fights infection as well as causing stomach irritation.  Use of these drugs causes increased rates of pneumonia and has contributed to the emergence of a treatment resistant superbug known in shorthand as “c diff”.

Now I’d like to address choice.

We need to get real on choice.  If there’s a single payer, everyone takes it.   I looked up my choice with my current plan (Aetna FEHB) versus traditional non-privatized Medicare.  I looked up my choices in two places: Wilkes-Barre PA and zip 10025 on UWS Manhattan where I live and work.  In both places I had more choices of doctors in a range of specialties with Medicare.  Sometimes Medicare recipients had over four times as many doctors to choose from as I did.  No, I didn’t get “just the best”, most everyone on Aetna also took Medicare.

I also know about choice available with private versus public Medicare from the range of referral options I discovered I had for my patients at Bellevue.  Want cancer care at Sloan Kettering or deep brain stimulation neurosurgery for Parkinson’s at Columbia?  You better have “real” public Medicare, not one of the privatized “Advantage” plans, because they don’t take them.

Private insurance offers the false “choice” of picking which for-profit shareholder accountable entity will get to limit your choices.   Let me say it again. Private insurance means limited choices.   Single payer means you choose to see anyone you want.

Let’s talk Wait Times

When I was pregnant many years ago I had private insurance but had to pull strings to get an appointment with an OB/GYN anytime in the first trimester of my pregnancy.

Last week I called up my gynecologist’s office to check on appointment availability and found there is a two 2 month wait.

Wait times for various services are related to the profitability of delivering those services rather than to medical urgency.

These are the wait times I found for Columbia Presbyterian Eastside Practice on East 60th Street in Manhattan:

To see dermatologist to evaluate a “suspicious mole”: 3 months

To see a dermatologist for a cosmetic evaluation: 2 weeks

For medical evaluation for insomnia which may include a lucrative “sleep study”: 3 weeks.

To get a mammogram: 3 months

I could get my hip replaced electively in Toronto sooner than I can get a mammogram or see my GYN in Manhattan.  I know that because wait times and procedure availability for all sites is web published in Ontario to help patients choose where to go for care.  No equivalent information is available to me in NY.

Let me address the feared army of bureaucrats:

I have seen this army.  It is not coming, it has already arrived!  US physicians report MORE external reviews of their clinical decisions to control costs than doctors in other countries.  Here’s a recent example from my practice to show you why we feel that way:

This was at a model private rural care delivery system in Pennsylvania with sophisticated electronic health records.   I ordered an ultrasound of the carotid arteries in a patient who had just had a stroke.  This is deeply within standard non-controversial medical practice since carotid artery disease can cause strokes.  A screen popped up informing me that the patients insurance would not cover the test.  I don’t know how much the test costs, our medical culture involves ordering from a menu with no prices.  It seemed safe to assume it was at least several hundred dollars an amount my clinical judgment told me might be challenging for this particular person.

In the great tradition of modern medicine, using all the bureaucratic skills as I have learned in dealing with multiple payers and random requirements over many years, I jiggered his ICD-9 diagnosis codes until the procedure was flagged as approved.  This was a waste of my time.  My time, by the way, was paid for by the greater “system”.

That same week I was also called on to consult on a patient who found herself in the “donut hole” of the entirely private Medicare part D drug plan, unable to afford critical medicines for multiple sclerosis.  I confess, I had nothing to add.  She needed the drug, it’s massively expensive (>1K/mo), there is no cheap alternative, and she could not afford it.  Industry patient assistance programs had multiple barriers to access and, when Part D was initiated, categorically declined to assist most of these patients.  I suggested a social worker get involved although I knew a social worker had already been involved. End of depressing consult.  She was in the hospital for timely performed elective knee replacement, paid for by her insurance.

All of the drugs which can change the course of multiple scleroris are “biologics”.  There is no current pathway for these to become generic and deal making in the production of current democratic legislation includes protections to further protect these agents from generic competition.

I want to adress freedom.

Single Payer separates insurance from employment, thus liberating business from a major drag on international competitiveness.  Single payer also ends the “job lock” phenomenon where people stay in dead jobs because of insurance availability.  The end of job lock supports a flexible labor market and the healthy entrepreneurship, which is the backbone of American innovation.

Private Health Insurance: not enough security

There is no freedom without security.  Private insurance does not provide even the relatively healthy population they cover with health security.  Most US bankruptcy involves medical debt.  Medical bankruptcy is unknown in other developed nations.

This past june the LA Times reported that congressional investigators found that three private health insurers canceled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over a five-year period.

It also found that policyholders with breast cancer, lymphoma and more than 1,000 other conditions were targeted for rescission and that employees were praised in performance reviews for terminating the policies of customers with expensive illnesses.

A Texas nurse said she lost her coverage, after she was diagnosed with aggressive breast cancer, for failing to disclose a visit to a dermatologist for acne.

The sister of an Illinois man who died of lymphoma said his policy was rescinded for the failure to report a possible aneurysm and gallstones that his physician noted in his chart but did not discuss with him.

One employee, for instance, received a perfect 5 for “exceptional performance” on an evaluation that noted the employee’s role in dropping thousands of policyholders and avoiding nearly $10 million worth of medical care.

American Values

Now I do not always feel that Uncle Sam is my best friend.  Nonetheless, I do feel better about Uncle Sam than I do about these private insurance companies.  It’s not very complicated, the government is publically accountable, privately held companies are accountable to their shareholders.

Most Americans including most physicians support single payer health insurance.  Special interest health industry lobbies are spending $1.4M DAILY to help spread a message of fear about health reform and continue on with a “business as usual”.  But American values and American health are best supported by a single payer system.

I am not afraid of the postal system.   I am not afraid of the highways.  I am not afraid of Medicare and I am proud to serve in our Department of Veteran’s Affairs.  I have seen the rough edges and devastating human consequences of our failed system over and over again.  Government provision of health insurance is the best way to guarantee healthcare quality and assert individual freedom and choice in obtaining this basic human right.