Q & A by Dr. John Geyman President (2005)
http://www.pnhp.org/publications/falling_through_the_safety_net.php
SOME COMMON QUESTIONS AND CONCERNS
1. Wouldn’t NHI bring on socialized medicine?
This is a widely held concern, fueled by opponents of NHI, but a misperception on any account. NHI would be a system of publicly funded and administered social insurance, but providers would not work for the government. Physicians would be in private or salaried group practice, and bill the government for services provided, as they now do for their Medicare patients.
2. Why must investor-owned for-profit industries be phased out under a program of NHI?
As has been well documented in earlier sections of this book (e.g., Chapter 11), investor-owned for-profit health care corporations pursue a mission of profits for themselves and their shareholders as their primary mission. Compared to non-profit providers and facilities, investor ownership has been shown to lower quality of care in hospitals,21-23 nursing homes,24 HMOs25 and dialysis centers.26 The market ethic holds that health care is merely a commodity, to be bought and sold at a profit. This ethic has put necessary health care beyond the reach of tens of millions of American families while corrupting the healing mission of medicine. With its traditional emphasis on civil liberties, it is ironic that the U.S. is still alone in not considering health care a basic right, as is the case in all other industrialized Western nations.
3. Under NHI, why must duplicative private insurance coverage be proscribed?
This important question has been well answered by the Physicians’ Working Group for NHI in this way:27 “Private insurance that duplicates the NHI coverage would undermine the public system in several ways. (1) The market for private coverage would disappear if the public coverage were fully adequate. Hence, private insurers would continually lobby for underfunding of the public system. (2) If the wealthy could turn to private coverage, their support for adequate funding of NHI would also wane. Why pay taxes for coverage they don’t use? (3) Private coverage would encourage doctors and hospitals to provide two classes of care. (4) A fractured payment system, preserving the chaos of multiple claims databases, would subvert quality improvement efforts, e.g., the monitoring of surgical death rates and other patterns of care. (5) Eliminating multiple payers is essential to cost containment. Only a true single payer system would realize large administrative savings. Perpetuating multiple payers—even two—would force hospitals to maintain expensive cost accounting systems to attribute costs and charges to individual patients and payers.”
4. Won’t NHI involve unacceptable rationing?
This question implies that we don’t already ration care, which we do extensively by income and class, as is well documented in this book. As Robert Kuttner points out:28
…one form or another of rationing exists everywhere in the world. The real issue is whether it is rationing based on private purse or on medical need. A system that coddles wealthy patients with minor ailments but cannot find money for universal vaccinations is, of course, rationing. A system that spends millions keeping alive twenty-week premature babies, and subsidizing in vitro fertilizations, but has forty million people without basic health coverage, is also rationing.
The other side of the rationing question is whether the affluent will still be able to purchase additional services not covered by NHI. The answer to that, of course, is yes, by purchasing supplemental insurance or paying out-of-pocket for uncovered services such as cosmetic surgery. At the same time, universal coverage for all medically necessary services, as defined by evidence-based clinical science, will be achievable through a single-risk pool based on need, not ability to pay.
5. How can NHI provide universal access to comprehensive health care and still save money?
Single-payer coverage would provide enormous cost savings, estimated to be at least $280 billion a year, by eliminating excess administrative costs, profits, unnecessary duplication, and cost-shifting within our present system. An additional annual savings of $50 billion is projected as a result of bulk purchasing of prescription drugs.29 Administrative simplicity under NHI is the major reason for cost savings. As we saw in Chapter 12 (page 135), large cost savings have already been demonstrated by the Lewin group in some states through micro-simulation models.30-31 Universal coverage systems spend more on primary prevention and less on wasteful overhead (e.g., the overhead of health insurance in the U.S. is 10 times higher than in Canada).32 Under NHI, public funds now directed to private insurers would be used to fund public coverage. Since very few Americans have coverage for the high costs of long-term care, the inclusion of long-term care benefits by NHI would require a modest increase in taxes, preferably on an equitable, progressive basis. In the end, however, most people would spend no more, and perhaps less than they are already spending on health care ($6,167 per capita in 2004)33 while trading our wasteful and inefficient health care system for a more cost effective and efficient one with universal coverage in a single-risk pool.
6. Why would American business want to support NHI?
Although many U.S. employers have been expected to provide health benefits to their employees since the advent of the voluntary employer-based system in the 1940s, many are now seeking refuge from the increasing cost burden of such coverage. Health insurance which is financed by tax mechanisms and which helps to assure a healthy workforce, is clearly in the self-interest of business. In today’s global economy, foreign companies such as Nokia and Volkswagen get full medical benefits at much less cost, an advantage worth billions over their U.S. competitors, Motorola and Ford. Dr. Donald Light, a Fellow at the University of Pennsylvania’s Center for Bioethics, observes that conservatives in every other industrialized country support universal access to needed health care. Noting that this has not yet been the case in the U.S., he argues that universal coverage is essential to achieve these four traditional conservative moral principles: anti-free-riding, personal integrity, equal opportunity, and just sharing. He offers these guidelines for conservatives to remain true to these principles:34
1. Everyone is covered, and everyone contributes in proportion to his or her income.
2. Decisions about all matters are open and publicly debated. Accountability for costs, quality, and value of providers, suppliers, and administrators is public.
3. Contributions do not discriminate by type of illness or ability to pay.
4. Coverage does not discriminate by type of illness or ability to pay.
5. Coverage responds first to medical need and suffering.
6. Nonfinancial barriers by class, language, education, and geography are to be minimized.
7. Providers are paid fairly and equitably, taking into account their local circumstances.
8. Clinical waste is minimized through public health, self-care, prevention, strong primary care, and identification of unnecessary procedures.
9. Financial waste is minimized through simplified administrative arrangements and strong bargaining for good value.
10. Choice is maximized in a common playing field where 90-95 percent of payments go toward necessary and efficient health services and only 5-10 percent to administration.
7. Who wins, who loses with NHI?
As with any major policy change, there will be winners and losers, just as there are with the status quo. Most parties win with NHI. Patients would have a right to comprehensive health care, gaining access to a better system with an NHI card without deductibles or copayments. They would have free choice of provider and could expect more continuity with their physicians with less administrative complexity. Taxes would increase, preferably based on ability to pay, but would be more than offset by elimination of insurance premiums and out-of-pocket health care costs. Physicians would be freed from many of today’s bureaucratic hassles and could spend more of their time on direct patient care, with more continuity and with less overhead. Billing would be greatly simplified. The patient’s NHI card would be reprinted, the complexity of the encounter would be checked, and a bill would be sent by mail or electronically to the physician payment board.
The administrative workload of other health care workers would be lightened. Some jobs, especially related to billing, would disappear, so that job retraining and placement would be necessary. Nurses could spend more time on nursing, thus relieving the current acute nursing shortage.
Hospitals would join the winners’ circle as well with simplification of billing and administration. Their revenues would become more stable and predictable. For-profit hospitals would be required to convert to not-for-profit status, and benchmarks for future planning would be based on community need, quality of care, efficiency and innovation.
Business would win by becoming more competitive. Many employers would see cost savings, as their new taxes are more than offset by no longer needing to cover the high costs of private insurance coverage.
The main losers under NHI would be for-profit health care corporations which can no longer divide and conquer in a segmented, largely unregulated health care marketplace. Many administrative and marketing jobs in today’s private health sector would disappear. Within a single risk pool, insurers could perform contracted services under NHI or offer supplemental coverage for services not covered.
8. In view of the current problems in the Medicare and Medicaid programs, how can we expect that a larger government program will be successful?
Despite its critics, Medicare is by far the most efficient and popular part of our entire health care system. It operates with an administrative overhead of less than 3%, a small fraction of that in the private sector.35 It has been shown in an October 2002 report to outperform private sector plans in terms of satisfaction with insurance, access to care, and overall insurance ratings, despite widespread anger over its limited prescription drug coverage.36 Its main weaknesses have been its lack of a reasonable prescription drug benefit (which would be resolved under NHI) and underfunding which has reduced access to patients due to unacceptably low reimbursement to providers. As a program, it has nevertheless been a great success since 1965, and no politician could face the consequences of any attempt to curtail it. The Medicaid program is even more seriously underfunded, while being hobbled by wide variations from state to state in eligibility and administrative procedures. The fundamental problem with both Medicare and Medicaid, of course, is that they end up with the highest and most expensive risk pools in the country—Medicare, with its elderly population at high risk for chronic disease and long-term disability, and Medicaid, with its population of low-income people at high risk for disease and disability. Both of these programs would be folded in under NHI, simplifying administration and efficiency with improved and more predictable funding.
9. Since we are now hearing so much about Canada’s problems, how can we expect NHI to succeed in the U.S.?
The Canadian health care system, involving NHI in all provinces since 1984, has been structurally successful, remains politically popular, but has been seriously underfunded since the early 1990s. Successive governments have been pressed by more healthy and affluent voters into funding cutbacks with the intent to avoid cross-subsidizing care for the sick and poor. Increasing pressure has been brought by for-profit interests wanting to divide the system into privatized and public sectors. Canada directs only about one-half the annual per capita spending on health care than does the U.S. While it is presently plagued (due to underfunding) by prolonged and increasing waits for some elective surgical procedures as well as some screening tests (e.g., mammography), the health outcomes for its population remain much better than in the U.S. by almost any measure.37-38 Most health policy experts agree that these problems would evaporate if Canada spent anywhere near as much on health care per person as we do south of the border. The problem is not the structure of the Canadian system, but its grossly under-funded status with its opponents exaggerating its problems in their own self-interests. There is no question but that the Canadian system requires a more adequate and stable funding base, yet its strengths are frequently underestimated and its problems overstated. On the plus side, Canadians have free choice of physician, have full access to emergency and urgent care (not true in many U.S. emergency rooms), maintain high standards in medical education, and operate their health care system with an overhead of only 1%.39 Myths abound on the negative side, such as an alleged high number of Canadians seeking care south of the border. Most of these myths are groundless. A recent example is a study reported in Health Affairs showing only a very small number of Canadians seeking care in the U.S., and most of that number for urgent or emergency care while already traveling in this country.40
10. What if states move ahead with single-payer universal coverage before NHI?
As Thomas Bodenheimer observed 10 years ago, some states may develop single-payer systems of universal coverage as demonstration projects before NHI is initiated.41 That may well occur, since considerable momentum in that direction has been developing in California, Oregon, Vermont, Massachusetts, Maine, and some other states. A state enacting single-payer universal coverage would likely establish a new non-profit foundation, funded by the state, to pay for all medically necessary services, including emergency care, dental, vision, mental health, long-term care, and alternative medicine. Such a plan would be financed with federal funds already allocated to the state’s public programs (Medicare, Medicaid, S-CHIP, current government expenditures for employee health benefits), as well as by additional income and payroll taxes. Universal coverage would be provided to the state’s population without any exclusions for pre-existing conditions. In the longer term, all payments would be through an NHI trust fund, with a shift to funding by a progressive, income tax and employer payroll taxes.42
CONCLUSION
As we have seen from the family stories and personal vignettes earlier in this book, as well as from the fully documented trends in our failing health care system, the “safety net” is a cruel illusion for a large and growing part of the U.S. population. How can this affluent, otherwise advanced country tolerate the disparities and inequities of the market-based system? Where is our sense of outrage? The social injustice embedded in our present system, where health care is bought and sold as a commodity, is not fitting for a society which avows its commitment to civil rights and equal opportunity for all.
Would NHI give the U.S. a perfect health care system? By no means; any country’s system is less than perfect and a work in progress. Would NHI be our best alternative to effectively reform our collapsing system? Emphatically yes, for all the reasons and evidence advanced in this book. Given the political will to confront the powerful defensive maneuvers of opposing special interest groups, the U.S. has the potential to develop the best health care system in the world. It already has these assets to build on—well-trained health professionals, excellent hospitals and facilities, strong biomedical research, more than 15% of its GDP already committed to health care, and a popular (though underfunded) existing Medicare program. NHI won’t solve all of our health care problems, but will provide a framework to resolve other problems once the system is restructured and stabilized.
There are many, including some who believe that NHI is a good idea, who believe that it is still politically unrealistic. The events of September 11 certainly shifted priorities away from domestic social needs. The nation is grappling with economic problems and deficits as it mounts a military response to global terrorism. Yet history tells us that war and its aftermath have often coincided with major social advances. Examples include desegregation of the U.S. military and Saskatchewan’s hospital insurance program soon after World War II, and the Great Society programs (including Medicare and Medicaid) during the Vietnam War in the 1960s.43
Health care reform in the U.S. has become urgent, and gets more so every day. An intense national debate is again underway as to reform alternatives. As public opinion is shaped during this debate, a critical public needs to value facts over ideology and transparency over obfuscation. It is fitting to close with this observation by Avedis Donabedian, international expert in quality assessment of health care, during an interview a month before his death in November 2000:44
One positive aspect of the current chaos is that it is generating dissatisfaction on all sides. Sooner rather than later we are going to have to develop a national health plan. The design and implementation of such a plan will be an exciting task of the fairly near future, I believe. This country has tremendous wisdom and tremendous goodness. Eventually they will triumph in health care.