Alex Blaze

More on single-payer

Filed By Alex Blaze | July 29, 2008 5:00 PM | comments

Filed in: Living
Tags: bioethics, France, health care reform, single-payer, Stephanie Woolhandler, US

nyceve pointed out testimony before The President's Council on Bioethics about single payer in the US from Dr. Stephanie Woolhandler, and I wanted to highlight it here. That's just the right forum for the issue, in the context of medical ethics, since the ability of people to even access the health care system is the biggest medical ethics question of our time. Discovering a new treatment for a rare disease with stem cells doesn't do anything for anyone if people can't afford it.

Dr. Woolhandler comes to the conclusion that the best system that the US can implement would be a version of single-payer, in that the government covers all necessary, routine, and preventative medical expenses, and knocks down all arguments that stand in her way. Some highlights from the testimony, after the jump.

(I have a little space before the jump here, so I'm just going to point out that, yes, yes I do think that this is an LGBT issue, one of the most important LGBT issues that there is right now. We're put at a disadvantage when it comes to accessing health care in so many ways that if a single payer system were implemented, we'd benefit disproportionately. And I think that's great, since the problem rests with us disproportionately.)

It's a great way to open up, telling people that even what Barack or Hillary are offering aren't real solutions:

I'm not a medical ethicist. I'm a primary care doctor, and the way I think about health policy in this context is in terms of the issue of placebos. That is, for us as doctors it's unethical to prescribe a placebo when there's an effective therapy.

And I'm going to argue today that many of the current proposals are, in fact, placebo reforms and that they're unethical to endorse because, actually, effective reform exists.

The problem: We've got 47,000,000 uninsured Americans generating about 18,000 excess deaths among adults each year. So that's a problem. As we sit here over the next two days, 100 people will die in the United States for lack of health insurance. That's the core ethical problem we're trying to face here.

But there's also the issue about Americans being impoverished by paying for illness. That is, they do get the care, but they're impoverished.

Indeed, what they're offering, while better than what we have, won't solve anything. But at least they are willing to listen to what experts in the field like Dr. Woolhandler are saying.

Here she sums up the number one reason why we need to implement single-payer:

I think this is due, at least in part, to the very high overhead in the for-profit HMOs. I've sort of listed the market leaders here. Twenty-three, 21, 20 percent overhead. What that means is that for every dollar that is paid in as premium, either by the individual or in the case of Medicare by Medicare -- every dollar that's paid in, only about 77 cents actually comes out to pay a nurse, a doctor, a drug company.

Twenty-three cents stays right there with Aetna to pay for their overhead and profit. So a very simple-minded view of why HMO care does cause problems in terms of care of the chronically ill is that too much of the money is diverted away from care and toward overhead and profit, including the CEO pay and stockholdings, 2005, most recent date I could fine.

And I just love to pick on Jack Rowe , number three. He's a former colleague of mine at Harvard . He worked for Aetna for just under five years and earned about half a billion dollars. And to give you some sense of how much that is, Jack was earning $220,000. That is $220,000 per day for every day he worked at Aetna , including weekends and holidays. So that's money that's diverted away from patient care toward his exorbitant salary, also overhead and profit.[...]

And the US is already spending -- these are figures from a couple of years ago -- by far the most of any nation on earth on healthcare. The US is on the bottom. On the top I've listed total health expenditures in other developed nations. For the US at the bottom I've listed total per capita health expenditures divided into the publicly funded and the privately funded share.

And in publicly funded I've included not just Medicare, Medicaid, VA, but also the benefit cost of public employees like schoolteachers and FBI agents, also, so-called tax subsidy to private health insurance. And when defined in that way, I want you to just look and see where that yellow bar ends. Look where the yellow bar ends.

That is, we are already through our taxes paying the full price of national health insurance in this country, and then we take an additional $2,500 out of our pockets and pay privately, and we still have the circumstance of 47,000,000 uninsured people, millions more forced into medical bankruptcy.

Now, what do we get for the extra money? And in this set of slides I've got the US in yellow, the other countries in green. What do we get? We do not get longer life expectancy compared to other nations. We do not get lower infant mortality than other nations. In fact, our infant mortality is twice that of the world leaders.

We don't get more days in the hospital. We send patients out of the hospital quicker and sicker. We don't even get more innovation, more science. And I know one of the speakers brought that up earlier.

When you look at medical journal articles on a per-capita basis (and you get the same results if you look at total scientific output on a per-capita basis, the United States is not a world leader. So our extra spending is not generating more in the way of science when we look at it on a per-capita basis. That is a myth.

Even for certain high-technology treatments such as bone-marrow transplants, the United States is just in the middle of the pack. Where we do lead the world is in our insurance overhead and our administrative costs. And this is expressed on a per-capita basis for every man, woman, and child in the United States .

We lead the world in insurance overhead. We lead the world in difficulties getting care. This is people are asked, percent, finding it extremely, very, or somewhat difficult to get needed care. We lead the world. This is just the English-speaking world.

Single payer has the backing of both the American public and doctors in particular:

And in the latest poll I could find on this, an ABC News poll/ USA Today /Kaiser survey, people were asked, "Would you prefer the current health insurance system or a universal coverage program like Medicare that is government-run and financed by taxpayers?"

It's a pretty fair description, only I want to say that a single payer is not exactly universal Medicare. It's universal Medicare without co-payments and deductibles. So for those of you who work in health finance, we have a term for people, dual eligibles, who get Medicare and Medicaid, who get Medicare coverage, only everything is free.

So single payer is kind of like Medicare for all or Medicare dual eligibility for all. All effective treatments are, in fact, free, as they are in much of northwestern Europe and Canada .

Well, it turns out even with this question, a clear majority of Americans endorse the idea of a tax-funded system. In fact, when people are asked, "Which do you think is more important, providing healthcare for all or holding down taxes," a majority of Americans feel that it's more important to get healthcare for all.

Again, a bit of a loaded question because other countries have single-payer systems that are, in fact, cheaper than what we have. You might have to raise taxes, but then you would lower people's out-of-pocket payments and the amount of money deducted from their income for their employee benefits.

Finally, we did survey a random sample of Massachusetts physicians. We got the random sample from the AMA master file to ask, "Which of the following three structures would offer the best healthcare to the greatest number of people for a fixed amount of money?"

And, again, asking doctors, "What do you recommend? Not necessarily what you support, but what do you recommend as best for your patients?" By more than two to one, single payer beat out all the other alternatives, existing fee-for-service or managed care systems.

But the health care industry is going to continue to block it. I know that 23% of health care costs go to managed care overhead, but I wonder what percentage of that money goes to lobbying to prevent single-payer.

I just had access to the best health care system in the world up until just about a month ago. It was great - if I had anything wrong or was feeling sick I could just pop in to the doctor's office and see what was up. If it was a sign of something more severe, I would have known that at least I caught it early.

Nothing was wrong while I was on the French health care system, but then again I'm the exact sort of person who needs to be put on to a health care plan with people who need more health care. I'm young and pretty healthy, and others aren't. We all balanced each other out, so that no one has to pay hundreds of thousands of dollars for necessary treatment. And if something happened to me, I'd know that I could still go to the doctor and get it taken care of.

The US is so far behind on this, and it's up there as one of the biggest reasons I'm looking for work here in France instead of the US. I just don't know if Americans will ever just accept that this is a necessary part of living in a civilized world and whether American politicians could ever just let go of the money they get from lobbyists and implement something like this.

I know it's probably not going to happen any time soon. But at least I'll be healthy until we switch over... I hope.


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Alex, I agree single-payer solves the access to medical care for the uninsured which I agree is the number one problem for the citizens of this fair country. But there are ramifications. Right now a number of the existing insurance plans are starting to cover transgender medicine, which is mind-boggling expensive for most trans persons. Considering the governments position on trans, vis-a-vis the IRS position on deductability and the insistence on GRS for identification change, isn't this going to mean that a significant number of transgender persons are going to LOSE the health care benefits we have worked so long to get into place? I think from an LGBT perspective we need to be working towards solving those problems simultaneously otherwise we end up compounding the injustice on some of the most medically vulnerable in our community.

When the Federal government can demonstrate successfully taking care those it has already promised"free" healthcare, i.e. the 3 million current and former veterans of this nation, then come talk to me about all the wonderful niceties of government provided care.

Until the stories stop about veterans dying while in VA waiting rooms, there is no way whatsoever our family will participate in a singlepayer government system.

Down with the politician's Plutocratic Aristocracy and their empty promises.


Robert Ganshorn Robert Ganshorn | July 29, 2008 11:36 PM

Alex, your concerns mirror mine about the state of American health care. I had to sue an insurance company to pay for an emergency surgery I had fifteen years ago. Unbeknownst to me the insurance agent changed my application to insure coverage and his commission. I paid into the policy for a year and had an ulcer flareup requiring a hospital stay.

With all the margins you mention it was only then that the insurance company reviewed my doctor's medical files to find anything they could to deny me coverage. They work to deny coverage much harder than they are willing to work to validate coverage. And then they blame you for the malfeasance of their agent.

While paying an attorney to sue Blue Cross I also had to make a monthly payment to the Catholic hospital against the bill and the hospital acted as though I were a criminal while I was paying an attorney to get them paid.

The wrangling took a year, we won, the agent lost his job, my house was not legally attached and I endured this stress without further health problems. Fortunately I could afford to defend myself and when deposed was a powerful witness that brought the insurance company's attorney to my side with an apology. he was afraid of court damages for the action of his agent. How many people can't afford to do this, or are intimidated and lose their home, savings and credit history?

Health Care in America is an abomination in another way. It cuts in to the competitiveness of all American manufacturers who employ people. With this yoke removed our domestic manufacturers could get on with the business of production and job creation sorely needed now more than ever. I am sure single payer coverage can include trans persons equally Shannon. The next plague of bird flu or whatever will not discriminate between sexual orientation or gender identity and I hope we come to our senses to understand how vulnerable we are.

ShannonB~ That is a big problem. The only thing I can think of is that trans leaders need to be at the table when this is being worked out, if it's ever worked out.

Alli~ It's more than a little disingenuous that conservatives have done all that they can to destroy the government's effectiveness at solving problems by cutting funding to emergency and social programs (like FEMA or army hospitals, I really haven't heard anything bad from the past 15 years concerning veteran's hospitals), and then turn around and say that the government is ineffective at solving those problems, just look what happened during the Bush administration!

I really think that was the whole point of this disastrous presidency - destroy our confidence in our ability to solve problems together by just fucking everything up.

Robert~ There's the 47M people uncovered, there's the 30 or so million more with inadequate coverage, and then there's the unknown number of people who think they have adequate coverage... until they find out otherwise.

You're right, though. If there is a plague, a lot of people aren't going to go to the doctor to get treated immediately. That doesn't bode well for our country, and we keep on wasting time that we could be using to take care of that.

Insurance CEO ranks right up there with Big Oil CEO. Bah.

Wolfgang E. B. | July 30, 2008 11:28 AM

ShannonB, that's the big issue for me. My current insurance provider covers some of my expenses, but they have the "trans-exclusion" in their policy, so either they don't know I'm trans yet or they think my endo visits and blood tests are not transition related.

At any rate, it doesn't mean much to me when candidates talk about health care because I know they aren't thinking about the trans community. They're thinking about the average Joe and Jane and their 2.5 kids "traditional" family. Those people need help too, of course, but not at our expense.

Social Security and other institutions also need to change their identity change policies. Only 10% of transmen choose genital surgery, so guys who've had mastectomy and hormone treatments and appear 100% male still have to deal with having "female" on their ID documents, which interferes with some basic rights at best and puts us at risk of violence at worst.

The whole system is so frustrating.

Bill Perdue Bill Perdue | July 31, 2008 12:11 PM

Why do right wingers have hissy fits about socialized medicine.

Alli cites stories about the VA that are at least as believable as the Enquirers headlines about two-headed human-alien hybrids born out of wedlock. Alli, do you have any really scary stories about socialized medicine or state organized medicine in Canada, Cuba, France and England? Please, share. We all need a good laugh from time to time.

Obama, the Clintons and McCain are members of the worlds second oldest profession and they oppose it because their clients in the HMOs, insurance companies and big Pharma corporations would be destroyed by it. But that, I think, is why we need it.

Ganshorn opposes it because it means taxing the rich and corporations. He says “Socialized medicine" in order to work correctly is paid for by all taxpayers in substantial dollars. The axiom of "soaking the rich" and "those greedy corporations" overlooks the fact that if you want employment at all you need corporations.”

Robert, did you ever consider the idea that the rich need a bit of soaking. Rightwinger Bill O’Reilly says “Yes, I am part of the 1 percent of Americans that paid an astounding 40 percent of all federal income tax in 2006. According to recently released Internal Revenue Service figures, about 50 percent of my fellow Americans paid no federal income tax at all that year. My fellow 1-percenters and I covered for them. But for some it is still not enough.” Why not soak O'Reilly and the obscenely bloated rich who are solely responsible for the health swindle that kills and kills and kills?

They can use a soaking. The the WSJ released a new IRS report headlined “ Income Inequality Grows’ "In a new sign of increasing inequality in the U.S., the richest 1% of Americans in 2006 garnered the highest share of the nation's adjusted gross income for two decades, and possibly the highest since 1929... Meanwhile, the average tax rate of the wealthiest 1% fell to its lowest level in at least 18 years. The group's share of the tax burden has risen, though not as quickly as its share of income."

http://online.wsj.com/article/SB121677287690575589.html?mod=special_page_campaign2008_leftbox

Socialized medicine and strong unions for medical workers are the basics for ending our medical failure. Corporate insurance, HMO’s and big Pharma and more tax breaks for the rich should be eliminated.

Where does your candidate stand?