Single payer: mainstream and 'shovel ready'
The following letter was sent to the editor of The New Yorker on Jan. 22.
In “Getting there from here” (Jan. 26), Atul Gawande suggests that the Massachusetts 2006 mandate plan is a model for national health care reform. He sees his stance as pragmatic, politically feasible, rooted in the particular history of American health care and gifted with the commonsense wisdom that we must start from where we are. Advocates of national health insurance (single payer) are characterized as ideologically driven extremists with “contempt” for pragmatists. I respectfully disagree.
Most Americans, including most physicians, supported national health insurance even before the recent economic collapse, polls show. Endorsers of the single payer bill H.R. 676 (Expanded and Improved Medicare for All) include 93 co-sponsors in the House of Representatives, 450 union organizations in 45 states, and countless others representing a wide range of constituencies. This is not a fringe movement.
High costs are the root cause of Americans’ health insecurity. Gawande’s analysis is flawed by use of a framework centered on insurance coverage rather than the more fundamental issue of health care value. Gawande sees employer-based coverage as the “path-defining” element of our current system because most people are covered by it. Well, it’s all in how you look at it. We need to keep our eyes on the prize, the health care dollar, and follow the money. Government already dominates: tax dollars fund most health care expenditures in the U.S. This is because government covers the sickest and poorest people, tax-favors employer-based private insurance, and covers its own employees. To use Gawande’s metaphor, the lifeboat is already bigger than the “main boat” of American health care. This is where we start.
Gawande asserts that Massachusetts “recently became the first state to adopt a system of universal health coverage for its residents.” As Yogi Berra said, this is like déjà vu all over again. A nearly identical assertion was made twenty years ago by then Gov. Dukakis about Massachusetts’ 1988 reforms. More breathless proclamations heralded reforms in Oregon (1988), Minnesota (1992), Tennessee (1992), Vermont (1992), Washington (1993) and Maine (2003). These plans all had common themes: public spending initiatives, new regulations and mandates, and continued dominance of private insurance in covering low risk populations. None achieved universal coverage. The common denominator of the ultimate failure of all these plans was the absence of effective cost control. Two weeks ago Gov. Deval Patrick of Massachusetts warned that rising costs, “threaten to crush families and businesses and doom Massachusetts groundbreaking experiment with universal insurance.”
In the face of economic collapse and soaring unemployment, with a third of Americans forgoing medical care due to cost, “Job No. 1” is getting value for our health care dollar, not preserving employer-based health insurance. The repetition of failed experiments is not pragmatic, it is part tragedy and part farce. Electronic medical records, chronic disease management and more emphasis on prevention are all important for many reasons but we must admit that short- and long-term cost implications are unknown. Some of these measures may actually increase costs. Medicare is not perfect, but it is demonstrably more cost effective than private insurance and beloved by most Americans. It is “shovel ready.” Single-payer supporters say: everybody in, nobody out. Burned in the fires of the failed Clinton reforms, I believe Gawande misreads the plate tectonics of political possibility at this moment in history, asserting, “No, we can’t” when the opposite is true.
Laura S. Boylan, MD
Clinical Associate Professor of Neurology, New York University School of Medicine
Attending Neurologist, Department of Veteran’s Affairs
Board Member, Physicians for a National Health Program Metro NY