By Joel A. Harrison, Ph.D., M.P.H.
East County Magazine (San Diego), March 30, 2019
Unfortunately, our media is dominated by misinformation designed to protect our private for-profit health insurance industry. One of the latest, by syndicated columnist David Brooks, was published in the San Diego Union-Tribune on March 6th. Since that newspaper reaches over 1 million San Diegans, I hope those reading this article will agree and share it with others. At the bottom I list several articles/papers that give a more comprehensive detailed discussion of why a single-payer system designed to benefit people trumps a for-profit health insurance industry designed first and foremost to enrich corporations.
According to Brooks, “Patients would have to transition. Right now, roughly 181 million Americans receive health insurance through employers. About 70 percent of these people say they are happy with their coverage.”
Since most of the 70 percent have NOT experienced a major illness or injury, only when they, their loved ones or close friends do, will they discover too late the high cost of pharmaceuticals, non-covered care, fighting with insurance companies to get the care they need, inundated with paperwork, and facing bankruptcy (75% of bankruptcies in US involve medical care).
The enrollment will be almost automatic. It will NOT cost people more and in most cases less. Instead of premiums, copays, deductibles, out-of-pocket additional costs, all will be covered, mainly through the equivalent of an increased Medicare payroll tax. In addition, one’s kids will be covered, even when in college, and whether between jobs, early retirement, etc. one and ones loved ones will ALWAYS be covered and ALWAYS be able to keep the doctors they choose. With single-payer, when facing some illness or injury, dealing with it, not fighting with insurance companies and an inundation of paperwork.
Brooks states: “The insurance companies would have to transition. Lots of people work for and serve this industry. All-inclusive public health care would destroy this industry beyond recognition, and those people would have to find other work.”
Insurance company employees include doctors and nurses who would much better serve us working in actual health care. Proposals for a single-payer health-care system all contain provisions for training and helping insurance company employees find other jobs, jobs not designed to increase health insurance profits by minimalizing expenses, that is, the care we get. As discussed below, the for-profit insurance companies actually decrease our choices, often delay care, and the quality of care we receive, so, bottom line, keeping them in business makes no sense for the vast majority of Americans, unless the vast majority prefer the current nightmare that is our fragmented, dysfunctional for-profit health care system for the benefit of a few corporations at our expense, economically and health-wise.
Brooks says: “Hospitals would have to transition. In many small cities the local health care system is the biggest employer…If you live in a place where the health system is a big employer, think what happens when that sector takes a sudden, huge pay cut.”
More than 10% of hospital costs are for the excess administration necessary to deal with the private for-profit health insurance industry. Hospitals will either continue to be paid fee-for-service or given global budgets. Again, any employees losing jobs will receive retraining. Not one doctor, one nurse, one medical staff employee will lose their jobs nor see substantial pay cuts.
Brooks claims: “Doctors would have to transition. Salary losses would differ by specialty, but imagine you came out of med school saddled with debt and learn that your payments are going to be down by, say 30 percent. Similar shocks would ripple to other health care workers.”
American doctor’s bills include approximately 10% administrative overhead just to deal with the insurance companies. American doctors devote approximately 15 hours or more to filling out excess paperwork and on the phone fighting to get a patient a referral or other care compared with doctors in Canada and other nations. Since everyone will be covered, lawsuits will not include health care cost, the major portion of doctor’s liability insurance, so their insurance costs will be much less (and because we will be covered, we will get the care we need, not delayed in hopes of winning a lawsuit). In the U.S. approximately 30% of doctor bills are denied by insurance companies, while, for instance, in Canada approximately 2%. With an average of 15 minutes per doctor visit in U.S., the additional 15 hours would allow doctors to see and bill for up to 60 more patients per week.
Neither will surgeons face substantial reductions in income. So, the vast majority of doctors will see little to no reduction in income and have the satisfaction of taking care of people, not functioning as bureaucrats. And studies have found that the excess administrative efforts doctors are forced to endure actually affects them, their stress level, some often considering leaving the profession. They devoted many years and effort into learning to help people, not the time and stress of excessive paperwork and fighting with insurance companies.
Brooks states: “The American people would have to transition. Americans are more decentralized, diverse and individualistic than people in the nations with single-payer systems. They are more suspicious of centralized government and tend to dislike higher taxes.”
Under single payer each American will be able to choose his/her doctor and hospital. Much more individualistic than allowing a for-profit insurance company with their often-limited network of doctors and hospitals to decide. And without copays and deductibles, Americans will be able to do so. Currently, under our current system, with some plans having high deductibles and copays, people delay seeking care, ending up using emergency departments, and with their condition more serious, more costly, often less successful, care. And those getting care often face restricted networks, sometimes not with the specialist they need or want.
Brooks claims: “The Sanders plan would increase federal spending by about $32.6 trillion over its first 10 years.”
Yep; it will increase federal spending, but not the total amount going into health care. As discussed above, mainly one simple tax, rather than premiums, copays, deductibles, out-of-pocket will result in the monies we pay into health care actually going to health care and NOT costing us more. Brooks ignores that given current projections using our present system, the total amount will be considerably higher. Brooks omits compared to what! Quite simply, the reduction in administrative costs alone will be substantial, together with bargaining with drug companies. Despite what they claim, there is ample data showing the costs of developing drugs is exponentially less than claimed and, in fact, much of it funded by the taxpayers.
Brooks further claims: “The government would also have to transition. Medicare for all works only if politicians ruthlessly enforce those spending cuts. But in our system of government, members of Congress are terrible at fiscal discipline.”
Given that everyone will be in the same system, including our politicians and their families, and that it will be transparent, this is unlikely. However, for those afraid of government insuring health care, NOT running it, do they really trust private for-profit companies more?
Single-payer is NOT socialized medicine. Doctors will not be employed by the government and hospitals will not be owned nor run by the government, simply an expanded version of Medicare, our most successful and popular healthcare program, with no need for supplemental insurance, no deductibles, no copays, and including dental, vision, long-term care, and home health care.
Sooner or later most families will need either home health care or nursing home care—finding out too late how expensive both are and that to be eligible for various Medicaid programs having to spend down, basically reach the level of impoverishment. And poor dentition leads to poor nutrition which leads to poorer health, so covering dental care saves money.
Brooks opines: “Patient expectations would have to transition. Today, getting a doctor’s appointment is annoying but not onerous. In Canada, the median wait time between seeing a general practitioner and a specialist is 8.7 weeks.”
Wait times in Canada for life-threatening and disability threatening conditions is as short as here and international studies show Canada has longer life-expectancy, lower infant mortality, and equal to better outcomes for many chronic diseases and illnesses, despite having a higher percentage of immigrants and refugees than the U.S. And, of course, Brooks ignores the wait time for the un- and underinsured in the U.S., eventually costing our system more with worse outcomes. More importantly, Canada spends only about 2/3 of what we do for health care and over the past couple of decades they have been working to shorten wait times for non-emergency care.
Currently, in the U.S., over 30 cents on the dollar goes to the excess administration, profits, and bloated salaries of health insurance executives. And what most people don’t understand, our taxes, including from those uninsured and underinsured, fund approximately 65% of health care, as much as the next most expensive system in the world which covers everyone with high quality care. So, we fund health care and the 30 cents on the dollar goes to for-profit insurance companies benefit, which results in deductibles, copays, limited doctor networks, fighting with insurance companies, and often bankruptcy.
In other words, the 30 cents on the dollar actually impedes choice and care, certainly nothing that fits any free market model I know of. Thus, the amount we have available for health care, including the 30 cents on the dollar wasted by our for-profit health insurance industry will be more than enough to ensure ALL Americans get timely care. A simple question is: does anyone believe that this 30 cents on the dollar, this money ensures as good or better care than putting it directly into health care?
Every technologically advanced, industrialized democracy in the world has some form of universal health care coverage which international studies have found to rank far better on a multitude of measures than the U.S. And they do it for less, allowing more monies to be used in the economy for consumer spending, investment, infrastructure, and research and development. And our current system puts American industry at a disadvantage in international competition because of the high cost of health care and the wasted administrative costs of either dealing with for-profit insurance companies or running their own “in house” insurance.
Don’t be fooled by opinion pieces such as David Brooks. And don’t be fooled by anecdotal evidence how one or a few cases in another country didn’t receive the care they should. Anecdotal evidence is used to arouse emotion and short-circuit thought; but no system is perfect and one should always ask the question: Compared to what? The answer is that for every anecdotal case in another country, we have hundreds if not thousands here.
After finishing the above, I came across a San Diego Union-Tribune Letter-to-the-Editor, “Single-payer not the panacea it seems to be” (San Diego Union-Tribune, March 29, 2019 which states: “Eliminating the private insurance industry takes monies out of research for medical innovation . . . European health care is barely adequate, and there are few specialists to treat specialties. We have personal experience with this where in a London hospital, for two weeks, a diagnosis couldn’t be made, putting my wife’s life in serious jeopardy. With an emergency flight back to the U.S., in 10 minutes a specialist diagnosed and put her on a course to resolve the issue . . . The government cannot efficiently run any program (see U.S. Postal Service).”
First, almost all medical research in the U.S. is grant funded, carried out in medical schools and universities, in-house by our National Institutes of Health, FDA, and Centers for Disease Control. For the most part, the research conducted by for-profit health care companies is marketing research and devising plans to save money/increase profits. A few non-profits like Kaiser Permanente do conduct quality “legitimate” research. I repeat “non-profits”; but even Kaiser has much higher administrative costs than Medicare. Second, the UK has contributed a heck of a lot to medical research, also, mainly paid for by government. And, despite having comparable stats on infant mortality, life-expectancy and other measures, the UK spends less than many other universal health care systems, partly still trying to undo the extreme cuts by the right-wing anti-government Margaret Thatcher.
Second, yep, an anecdote about a bad experience. I am currently watching for the second time a series on Animal Planet, streamed online for free, called “Monsters Inside Me.” What is fascinating is that every case presented starts with the patient getting one, two, or even more misdiagnoses. Of course, in some cases, the signs and symptoms are quite similar so the doctor didn’t do anything wrong; but in other cases, the doctor simply decided without hearing the patient out or running the extra labs, just jumped to a conclusion, which in some cases caused serious hardship. In the U.S. the number of autopsies performed on hospital deaths has declined precipitously, partly because of our for-profit health care system not wanting to pay for them and partly because families refuse to allow them. The problem is that when autopsies have been performed, up to 25% of the diagnoses were wrong. This doesn’t automatically mean if the diagnoses had been correct the patient would have survived; but certainly they didn’t get the correct treatment. Without autopsies, doctors can’t learn about their mistakes and, thus, may repeat them (Baumgartner, 2016; Combes, 2004; Groopman, 2007; Pastores, 2007; Reichert, 1985; Wittekind, 2018). And I have personally been misdiagnosed on several occasions; but before going on meds with significant side-effects, did my own research and then got a second opinion.
I’m glad the Letter-to-the-Editor writer’s wife finally received a correct diagnosis and was successfully treated; but one anecdote doesn’t prove anything. Not every UK hospital is equally good, so had they used another hospital the result may have been quite different, just as in the U.S. we have excellent hospitals; but not all are and even two equally competent doctors may each misdiagnose a case where the other would have gotten it correct. Medicine involves a very complex set of variables. And it is obvious the writer knows nothing of the funding of research nor international comparative statistics.
As for the remark about the U.S. Post Office, an oft used trope that is both wrong and insulting to those who work for the Post Office. And Medicare, with administrative costs much lower than that of the for-profit health insurance industry is a very popular program. Yep, they sometimes makes mistakes; but compared to what?
Combes A, Mokhtari M, Couveland A et al. (2004 Feb 23). Clinical and Autopsy Diagnoses in the Intensive Care Unit: A Prospective Study. Archives of Internal Medicine; 164: 389-392.
Groopman J (2007). How Doctors Think. Houghton Mufflin Company.
Dr. Joel A. Harrison is a retired epidemiologist who has studied and worked in several countries, including Sweden (where he earned his doctorate) and Canada (where he earned a Master’s degree). Dr. Harrison is a long-time member of Physicians for a National Health Program.