Single-payer healthcare advocate Johnathon Ross M.D., M.P.H. takes a local look at the national HMO crisis
by Johnathon S. Ross, M.D.
Toledo City Paper
Published August 8th 2007
Johnathon Ross doesn’t see Michael Moore’s op-ed documentary “Sicko” as a film — it’s his life.
Ross has practiced and taught internal medicine at St. Vincent Mercy Medical Center for 27 years and every day witnesses the results of America’s crippled state of healthcare. Whether it’s trying to find ways to help uninsured patients get treatment or helping insured patients find care when their HMOs refuse to cover their medical expenses, Ross has his hands full.
And he’s mad as hell it got to this point.
Ross is one of many advocates of a nationally based single-payer health insurance system and is a member of the state council of the Single Payer Network of Ohio (spanohio.org). He is currently campaigning in support of House Bill 676 (co-sponsored by Dennis Kucinich, Marcy Kaptur and other Ohio House members) ensuring that all Americans have access to tax-paid national healthcare.
In a City Paper exclusive, Ross recounts some of the horrific experiences that Toledoans are forced to endure due to the current state of healthcare. In simple, direct language, Ross explains what national healthcare is, can be, and — more importantly — that it’s not akin to socialism.
Perhaps you have seen the billboards and the full-page ads. Perhaps you have asked yourself, as I have, why the health insurance companies, drug companies and health-care systems are allowed to waste so much money on advertising when ordinary people struggle to get the care that they need? Perhaps you have seen the movie “Sicko” and wonder if you could be the next insured person that the system will fail. I have come to believe that in healthcare, market forces are the disease for which they are supposed to be the cure. These “healthcare marketing wars” in Northwest Ohio and elsewhere in the country soak up billions and are symptoms of that disease.
Every day in the St. V’s clinic, I see a near miss. Every week I see a wounding. Every month or so I see a death due to a sickness care non-system that leaves 50,000 Lucas County citizens, more than a million Ohioans, more than 45 million Americans uninsured, and all of us unsure if healthcare will be there for us if we need it. The Institute of Medicine, our most prestigious health experts, estimates that more than 18,000 of our fellow citizens, our friends, neighbors and family, die every year from lack of health insurance alone, and nearly another 100,000 will die from medical errors. The system is broken and it needs to be fixed.
By the time you’ve read this article and have thought about it for just a few minutes, another fellow American will die from lack of health insurance. One person dies every half hour or so, day after day, year after year. While our elected representatives quibble, we sacrifice these people up to our stubborn market ideology.
A day in the life of a Toledo clinic
A recent Friday morning was a typical clinic session where I work. Here are a few stories from just that single morning. Imagine similar stories day after day for the past 27 years and you will understand why I am writing this article. I have changed the names for privacy but I did ask each patient if it was OK to tell their story and each agreed.
Tommy’s heart
Tommy is 41. He was making his first visit following bypass surgery after suffering a massive myocardial infarction (heart attack). Tommy can’t read or write very well. He was working a low-wage job that did not have insurance so he never saw a doctor. That doesn’t matter much now since he lost his job due to his illness. He became very depressed in the hospital and started on medication for his depression and for his heart. Fortunately, he was at the clinic with a family member who had paid more than $100 for medication to keep him alive until his appointment with us. Thanks to CareNet, a free-care program I helped to devise which helps some of the uninsured in Lucas County, he was able to see us in the clinic without charge. But there was little likelihood he would be able to pay for follow up with the heart specialists, let alone the bills they would soon be sending for his hospital care. One of our nurses spends hours every day trying to help people get “free” drugs from the pharmaceutical companies. She looked deflated when we gave her the long list of expensive medication he needed. The drugs may be “free,” but her salary is not.
Shelly’s stomach
Shelly works as a temp at another hospital. She doesn’t have any benefits or health insurance, even though she works full-time as a nurse’s aide. The irony of a healthcare worker who is not covered for healthcare is not lost on me, as I see lots of nurse’s aides who work in extended care facilities with no benefits. She was seen in the emergency room for severe stomach pain. She hasn’t seen the bill yet, but I suspect her stomach pain will get worse when she does. Her stomach still hurts and she had no money for the ulcer medicine they wrote. I search the free samples and manage to find about two weeks of medicine. I give her a follow-up appointment and hope for the best. Even if she was covered, it can take a month or more to get a gastroenterologist to see my patients at the hospital sponsored GI clinic, although with a personal call sometimes our generous gastroenterologists will let me jump the line for an urgent case.
Where’s Nolan’s Medicare?
A clerk tells me that Nolan is at the window and he is upset. He is out of pills and needs samples of medication for his blood pressure. He should be covered by Medicare as he is 68. He has a card, but the pharmacy says it is no good — he is not sure if it is no good for all or some of his medication. He just knows he is not supposed to miss his medicine. We have referred him several times to the Social Security office and they tell him he is covered by his card. There are 50 different plans, all with different formularies, and there is no time today to sort out (again) why his card is no good. I tell the nurse to give him samples and we will try to sort out what is wrong with his card later. The Medicare D program will continue to send money to the middlemen who will continue to not pay for Nolan’s medicine. Somewhere, the stockholders are smiling. Thank you, President Bush, for such a totally complex and confusing program.
Chris: Out of breath
Chris has asthma, low back pain and high blood pressure. She is doing OK with her current medication but isn’t sure if her re-application for Medicaid will go through in time to allow her to get the refills that she needs. She says that she might have to “spin down”. She’s not sure what this means, but I know. She works a little and may have made too much money this past month to qualify for help and might need to “spend down” not “spin down” to poverty or perhaps she will do both. In any case, she will be out of medicine in about 10 days. The last time she missed her asthma medicine she ended up in the ER with an asthma attack. I give her one of my last samples of an inhaler just in case, and hope I don’t need it for someone else with more immediate needs.
Arthur’s hunt
Arthur, on the other hand, has insurance. He has Medicaid, our state-funded insurance for the poor. This is his third visit for a rash that won’t go away. I would make a referral but it seems there are no dermatologists in town who will take his Medicaid HMO. I try to make light of a bad situation and remark that his new private insurance card (they contract with Medicaid) is actually a hunting license — we get to go hunting for specialists who will accept his plan. We decide to continue our game of musical medicines to see if one will help. At least, he has coverage for his medicines. Welcome to the best healthcare system in the world.
Sharpen the focus
For patients, soaring health insurance premiums are the norm and uninsured Americans now exceed 45 million. Eighty percent of the uninsured are working people and their kids. They are not covered by their jobs or cannot afford to buy health insurance when faced with skyrocketing premiums or are refused coverage for pre-existing conditions. Managed care, with its restrictions and market competition, failed to cure rising costs or expand access, but it surely created hassles for doctors and patients. Those same self-interested insurers who brought us HMOs insist that financially squeezing patients using high deductibles will cure the cost crisis. In reality, high deductible health plans and health savings accounts are just another way that insurers and employers shift the cost burden onto employees, whose co-payments and deductibles soar while their coverage sinks. If doctors and patients have problems now with billing, collections, insurance hassles, and continuity of care, just wait until HSAs with Swiss cheese coverage become the norm. Unfortunately, market forces will not work. There will never be an effective market for healthcare services. Why?
Healthcare is not an ordinary product that people want. Rather, it is a necessity that they must have. The consumer’s not sovereign. The doctor, not the patient, orders the care. There’s no easy exit from the market for patients. Price does not matter. When critically (and expensively) ill, you buy or die. The most expensive healthcare is necessary not desired. Even the best physicians are unsure at times what tests or treatments will benefit a patient. Thus, the costs of patient care are often unpredictable. It is this uncertainty and unpredictability that creates the need for insurance in the first place. Asking patients to assume more responsibility for out-of-pocket costs will not work. Americans already pay the highest out-of-pocket healthcare costs in the Western world, and this has done little to control costs. Research shows that higher out-of-pocket payments will reduce the number of outpatient visits, but these payments fail to increase the appropriateness of the visits. Paying more does not create wiser consumers of healthcare. To understand the absurdity of using individual market forces to control healthcare costs, imagine open-heart surgery is on sale. Would you have two? The most expensive surgery or medical care is the least optional, predictable or negotiable. The sickest 10 percent of patients generate 73 percent of the healthcare bills at an average of about $39,000 per person yearly. They will save nothing in their HSAs. The market for medical services fails these tests of an effective market and will fail in the guise of HSAs. The insurance industry says that consumers need to have “more skin in the game”. They think it’s a game. We know who will get skinned.
Massachusetts is forcing uninsured working families to buy bare-bones coverage from private insurers who will keep a big chunk of the premiums for administrative costs and profits. This is hailed as reform but hardly seems wise, fair or efficient. It will leave these families vulnerable to large healthcare bills that are potentially financially fatal to working families, and there seems to be little effort to improve the quality of care under this so-called reform. It is a Marie Antoinette solution: “Let them buy high deductible health plans”! Many of these families cannot afford to keep food on the table and the lights on. A riddle: What is the difference between a mandatory premium payment and a tax? Answer: A mandatory premium allows insurers to keep a larger percentage of the money collected before healthcare is delivered (20 percent for private for profit insurers vs. 3 percent for Medicare).
If market forces cannot work, the proven alternative is a tax-financed universal health insurance system. It may seem counter-intuitive that a tax-financed universal health insurance program that covers everyone could be less expensive than a health system based on cutthroat competition between private insurance companies that leaves 45 million Americans uncovered. Yet, this has proven to be the case for every other industrial democracy. Recently, Taiwan made just such a switch and again proved it could be done. They covered everyone with little increase in cost. On the other hand, national health insurance, as proposed in HB 676 (co-sponsored by Congressmen John Conyers [D., Mich.] and Dennis Kucinich [D., Ohio]), would replace private premiums with fair payroll taxes. These funds, added to current public spending, would create a single insurance pool adequate to cover all Americans with no added spending. Here in Ohio, The Health Care for All Ohioans act could do the same thing for all Ohioans. Ohio could lead the way. How can this be true?
How it could work
In multipayer systems, complexity yields high administrative costs. Each insurer, hospital and doctor must keep track of a myriad of contracts, discount arrangements, benefit packages, formularies, limited referral networks, and insurance regulations designed to reduce utilization. Market solutions leave this insurance and billing bureaucracy in place and add the complexity of tracking 300 million individual insurance policies. The result can be predicted from Economics 101: One person’s income is another person’s cost. The growth of administrative personnel in healthcare has jumped more than 2500 percent in the past 30 years while the growth of doctors and nurses has grown about 150 percent. Healthcare has become a jobs program for an army of paper-pushers. Most of them are chasing the money to pay for care and, in our multipayer system, chasing money is complicated work.
The current system is failing most if not all of us. Americans and Ohioans need affordable, guaranteed, high-quality healthcare coverage that they cannot lose if they change or lose a job, whether they are rich or poor, whether they are healthy and want to stay that way or whether they are sick and want to get well. Single payer national health insurance or a similar state-based plan could accomplish the goals of guaranteed coverage, quality and cost control.
Doctors would get paid for every patient and malpractice and administrative costs would drop. They could maintain continuity of patient care. Patients would get needed care as ordered without a wallet biopsy. Outcomes and quality would improve. Emergency room overuse and abuse would diminish. Chronic disease management would improve. Multiple studies confirm that the administrative simplicity of a single universal insurance pool — like Medicare — yields hundreds of billions in savings that allow comprehensive coverage for all at current levels of spending. A tax-based public system is simple and efficient. There is simply less work to do. The data from a universal system can also be used to track and evaluate the appropriateness and the quality of care and offers the best opportunity to improve the quality of care.
Healthcare costs are hurting the competitiveness of our products in the world markets. American business and governmental employers are struggling with the burden of healthcare costs and, despite almost twenty years of experimentation with these different approaches to cost control, healthcare costs are growing at double the rate of the Gross Domestic Product. At the same time, the number of uninsured full-time workers has soared by tens of millions, as premiums have become more and more unaffordable. Several large industries are giving up responsibility for insuring their workers, creating insurance trusts that will be maintained by unions who — not surprisingly — support national health insurance. The largest U.S. employer, Wal-Mart, has come under severe criticism for its failure to cover its workers. They are targeted with state laws aimed at forcing them to insure their employees or pay special taxes to the state to help cover the uninsured. More business leaders are calling for a national solution. One can only speculate that it must be ideology alone that keeps many business leaders from supporting a national solution.
Business owners should realize that the healthcare system provides the maintenance on their work force just as other experts provide maintenance on their expensive and complex industrial and business machinery. It makes good sense to get the most comprehensive maintenance system for the best price. More for the same money, value, is what a tax-financed universal health insurance system can provide. Those businesses avoiding the cost of insuring their employees are still the recipients of cost shifting. This occurs through higher taxes to fund indigent care and higher prices paid when doing business with companies who continue to insure their employees and pass along the healthcare costs shifted to them in the price of their products. Counter-intuitive or not, even conservative businessmen should support a single-payer universal health insurance solution. Financially, they already are.
Join the movement
The necessary economic conditions for an efficient competitive market for health services do not exist. Evidence from the current competition between insurers shows it is likely that market forces will aggravate the dual problems of high cost and poor access. A tax-financed universal health insurance offers the best alternative and is consistent with both progressive and conservative principles for reform.
The enactment of tax-financed universal health insurance at the national level will most likely require successful enactment at the state level. A significant mass movement for sweeping health reform will be needed and will require substantial leadership from the provider community to overcome the concentrated insurance and business interests likely to oppose reform. The opponents of reform will try to scare us off again.
“I am Oz the great and terrible — Pay no attention to that man behind the curtain! Taxes bad! Government bad! Socialized medicine bad!”
I, for one, will not listen to that humbug any more. Taxes are an efficient way to collect the money. The government is our own. It is not socialized medicine, this is social insurance just like Social Security, and Medicare. These programs work, and what would our seniors do without it?
A single-payer tax-financed universal health insurance, an improved and expanded Medicare program as that proposed in HR 676 or the HCFAO act will cover all of us comprehensively at no added cost. It’s good for business and our health. Single-payer national health insurance is conservative of the basic structure of the American healthcare system and in that it changes mainly the financing, easing our efforts to improve quality. It is conservative of individual freedom and responsibility in that it allows free choice of provider and eliminates financial barriers to preventive and chronic disease care. Single-payer national health insurance would cover everyone, save lives, save money, and it is the right thing to do. Join the movement and let’s roll.
Johnathon S. Ross M.D., M.P.H. Past President, Physicians for a National Health Program (pnhp.org). Member of the State Council, Single Payer Action Network of Ohio (spanohio.org).