[The following letter to Washington Post columnist David Broder from Dr. Ray Bellamy of Florida discusses not only Broder’s recent arguments, but also those of Dr. Atul Gawande at The New Yorker.]
December 11, 2009
Mr. David Broder
Washington Post Writers Group
1150 15th Street NW
Washington, DC 20071
Dear Mr. Broder,
I read with interest your column titled “Health Care Brings Freshman Senators to the Forefront” in today’s edition of the Tallahassee Democrat. I agree cost control is the key issue in health reform and has not been addressed in current congressional efforts. The output from Congress seems focused mostly on what is politically possible and increasingly on what can be supported by 60 votes, not true reform.
The mainstream media seems to have bought into the notion that, since the Republicans are trying to block reform and perhaps make health reform “Obama’s Waterloo,” the House and Senate output should be supported. Although allowing for deep flaws in the legislation, there is the feeling that incremental steps toward a better system are good. You and the excellent writer you reference, Dr. Atul Gawande, have apparently bought into this mindset. Allow me to disagree.
Gawande, in his latest article in The New Yorker titled “Testing, testing,” speaks of small-scale pilot projects in the proposed legislation with hope they will show the way toward cost savings.
Yet we already have pilot projects all over the world that have met with dramatic success: nearly every other developed country has universal coverage with higher citizen satisfaction and far higher medical outcomes at roughly half the per-capita cost as U.S. health care. Half the cost.
Why do we need new pilot projects? We have the knowledge that the only two successful health care models in these countries are either (1) highly regulated nonprofit insurers who sell health policies as an inducement to the purchase of profitable property, fire and auto insurance, or (2) some version of single payer.
We know no country utilizes a system like the model Congress is proposing and that none like it has ever been successful. Eight prior state efforts using this model all failed, usually within a few years. Massachusetts, currently starting its third year with a similar model, is not able to control costs, and has the most expensive health insurance in the world. This is the model for what Congress has proposed.
Medicare for All is criticized for being a “government takeover.” Really, we have entrusted health care to private insurance long enough to know that their business model of avoiding the sick, then dumping those who do need care rather than spreading the risk as insurance is supposed to do, does not work. Medicare has a 92 percent enrollee satisfaction rate. Private insurance cannot approach that.
Critics also charge that Medicare is bankrupt. What do you expect when the funding is provided by a dwindling collection of payroll taxes from fewer and fewer workers to support current Medicare enrollees who are swelling in numbers? Funding Medicare with a 2 percent or 3 percent progressive income tax would be the answer – an amount that would certainly be less than what most people pay today for premiums, co-pays, deductibles, uncovered services and other out-of-pocket health care costs.
The individual mandate to have insurance, as proposed by the House, is an effort to avoid adverse risk selection, which occurs when those who are currently young and healthy wait to purchase insurance until they get sick. Insurance obviously works best with the largest possible risk pool and that is why health savings accounts and skimpy coverage for different groups are bad ideas. What would work best is every American covered in the same risk pool. We could have comprehensive coverage, all with the same policy as every member of Congress – truly egalitarian – for what we currently pay in health care in this country now: $2.4 trillion annually.
Gawande mentions the benefits of improved information about what works, comparative effectiveness, and the problem of overutilization (which he headlined in his previous New Yorker article). Yet look what instant information would be available if we had single payer: instant data on comparative effectiveness, overutilization, and disease outbreaks anywhere in the country.
Gawande has also written about a Texas border town, McAllen, with high utilization and cost. His information was obtained through Medicare data, which is the best nationwide health care data we have available. Single payer would give us such high-quality information instantly for the entire nation, not just the Medicare population.
Gawande also speaks of the need for tort reform, of which there is essentially none in current congressional proposals. If we had truly universal comprehensive, egalitarian Medicare for All, we would eliminate the cost of future medical expenses from all personal injury lawsuits, not just Med-Mal. This is a major component of economic damages in personal injury lawsuits.
Current congressional proposals retain the main low-hanging fruit for cost cutting and reward it: the wasteful administrative expense, marketing cost, profits of the for-profit insurance industry. To the current 31 percent administrative waste in the system, Congress proposes to add additional bureaucracy and a czar so we are likely to reach 35 percent overhead and waste. That figure, the highest in the world almost by a factor of two, could be lowered for a saving of $400 billion a year within our current budget, with the savings used to cover every one of us without raising costs.
The additional opportunity to sensibly manage our nation’s health budget with the inevitable rationing decisions necessary in the future, with global budgeting and so on, would also stem from a single-payer system.
Now one last word on true reform: if we moved away from fee-for-service reimbursement for physicians and instead provided incentives for them take salaried positions, like those in the Veterans Administration and the U.S. military (along with those at the Mayo Clinic), there would likely be huge additional savings. Socialized medicine? No. By and large, you’d still private physicians working in private hospitals.
Under a single-payer arrangement, patients would have more free choice of physician and hospital than we have now. Every American would have the choice to go to the Mayo Clinic, so the competition would surely result in improvements for all facilities and caregivers.
I read what you write and what Dr. Gawande writes with interest, but in this case I strongly disagree. Congress needs to start over on health reform, and this time it needs to compare single-payer Medicare for All with other options. I guarantee you that single payer will win hands down.
Sincerely,
Ray Bellamy, M.D.
Dr. Ray Bellamy is an orthopedic surgeon in Tallahassee, Fla.