Sunday Dialogue: Curing the Health System

This piece appeared August 27, 2011 in the New York Times' on-line edition here

Author: Samuel Metz

Date: 08/25/2011

To the Editor:

In “Will Health Care Reform Survive the Courts?” (State of Play, Sunday Review, Aug. 21), Philip M. Boffey states that “reforms would work far less well without an individual mandate” that requires citizens to buy health insurance or pay a penalty.

I disagree. Health care reform could provide better care at less cost by replacing individual mandates with a single-payer national health care plan financed by taxes. Congress’s power to mandate purchase of private products sold at a profit is disputable, but Congress’s power to tax is not.

Other industrialized countries have national health plans providing care to more citizens at less cost with better outcomes than our system. And they don’t use mandates that allow insurers to charge different prices for different people.

These health care systems have three common properties: public subsidies ensure that everyone has access to care regardless of health, wealth or employment; primary care is encouraged; and publicly accountable, transparent, not-for-profit agencies transfer funds from patient to provider.

There is no need to experiment with mandates. Convert our current health care system into a national health plan.

SAMUEL METZ Portland, Ore., Aug. 21, 2011

The writer, an anesthesiologist, is a founding member of Mad as Hell Doctors, which advocates a single-payer system.

Readers React

Dr. Metz is spot on with his advocacy of a single-payer plan instead of the individual mandate.

Sadly, despite the success of Medicare — a single-payer system that politicians tamper with at their peril — the “just say no” climate in Washington, fostered by Republicans who place ideology over country, took that option off the table and left us with an alternative that not only raises legal questions but also fails to address the real threat: the escalating costs of health care.

That said, the health care plan that the politicians have given us, which extends protection to millions of uninsured, is better than no plan at all.

After decades of talking about reform, we finally have a plan in place. With luck, a day will come when the political will for a single-payer system exists.

Until then, let’s do our best to make the plan we have work.

JAY N. FELDMAN Port Washington, N.Y., Aug. 24, 2011

Dr. Metz is right that a single-payer system would be better than an individual mandate. But he does not mention that Medicare, although it is a single-payer, tax-supported system, still cannot control costs and will soon be bankrupt. A national health plan that controls costs needs to reform the way doctors are paid and are organized in practice.

This is how doctors, if they are really “mad as hell,” could help. They should join salaried multispecialty, not-for-profit group practices that can accept capitated prepayment for comprehensive care instead of fee for service, and can provide good, cost-effective care that supports primary-care doctors working in close collaboration with specialists.

ARNOLD S. RELMAN Cambridge, Mass., Aug. 24, 2011

The writer, a physician, is professor emeritus of medicine and of social medicine at Harvard Medical School and a former editor in chief of The New England Journal of Medicine.

Dr. Metz’s call for single-payer national health care imposes costs on taxpayers rather than directly on those being served. Patients are not charged more for services they value the most or are more costly to provide. Tax bills simply rise in sync with something else like income, property or sales.

It takes no leap of faith to understand how this will affect demand for health care. Anyone who has dined at a fixed-cost food buffet knows the outcome of not directing price with food portions.

It is tempting to believe that government will fairly and efficiently make these choices for us, but experience suggests otherwise. Dr. Metz appears to anticipate this problem given his suggestion that Congress’s power to tax is indisputable and so government will predictably raise taxes to pay for growing demand for health care.

MICHAEL L. MARLOW San Luis Obispo, Calif., Aug. 25, 2011

The writer is a professor of economics at California Polytechnic State University, San Luis Obispo.

Here are my suggestions:

First, impose a three-year moratorium on increases in health care costs.

Second, dissolve Medicare and Medicaid and use that money to provide for universal coverage for the less fortunate.

Third, require every person to participate.

Fourth, every participant would be required to have a yearly physical, major medical catastrophic insurance and a health care savings account to provide for a large deductible.

The yearly physical would start the process of creating a universal electronic patient record. Furthermore, the physical would be an attractive revenue stream for doctors in primary-care practices. The yearly physical and universal coverage would make medicine more prevention-oriented.

EDWARD L. BYRD Atlanta, Aug. 24, 2011

We need Dr. Metz to keep the flame of national health insurance alive until this country is ready to embrace it as the most cost-effective way to provide coverage. But as Winston Churchill said, “You can always count on Americans to do the right thing — after they’ve tried everything else.”

The battle to pass the Affordable Care Act and the challenge to sustain it should make clear that national health insurance will not be given serious consideration by politicians for some time.

Our approach to health reform has desirable features, like elimination of pre-existing condition exclusions. An individual mandate is required to make health reform work.

Dr. Metz simply prefers another way to require all Americans to have coverage. More power to him. In the meantime, let’s try the next best thing.

BRUCE KELLEY Minneapolis, Aug. 24, 2011

I am a young professional who is just starting out on my career path.

I have already been juggled among health care systems because of different schools and different jobs, and the experience was not fun. Recently, I was lucky enough to find employment that offers health insurance, but if I should lose my job, I would lose my health insurance. This doesn’t make me feel secure. The individual mandate doesn’t make me feel secure either. Health insurance does not equal health care.

I don’t want to start paying into health insurance that I may lose because of powers beyond my control. With a single-payer system, you simply get enrolled into a public health insurance system. Through my taxes, I would be making an investment in my health future that would be there whether I lost my job or not. Now that would make me feel secure.

MOLLY TAVELLA Rancho Cucamonga, Calif., Aug. 24, 2011

The writer is the education and outreach coordinator for Physicians for a National Health Program California.

Of course Dr. Metz is correct that a single-payer system — comparable to that used in a number of other countries — would be both beneficial and less expensive than the privately skewed, hodgepodge system we have now. Unfortunately, the lack of political maturity in this country means that arguing that other societies have better ideas than we do is counterproductive, since the myth of American exceptionalism is more important than actually providing better health care while saving money in the process.

ALAN POSNER East Lansing, Mich., Aug. 24, 2011

Dr. Metz presents a compelling argument in support of a single-payer plan. He cites the experience of other countries to show that such a system provides better health outcomes at lower cost. Our own experience shows that Medicare requires only about 3 percent for administrative costs, as opposed to 29 percent for private health insurance.

Alas, these arguments are fated to fall on deaf ears. Between 2006 and 2009, the health sector spent $1.7 billion lobbying Congress and federal agencies. No wonder our government can’t hear the rest of us!

SHERMAN C. STEIN Philadelphia, Aug. 24, 2011

The writer is a clinical professor of neurosurgery at the Hospital of the University of Pennsylvania.

Let me add some data to support Dr. Metz’s proposal. The evidence is overwhelming. The cost of health care per person in other industrialized countries is on average less than half of that in the United States. If we spent as much per person as the other countries do, we would save $1.3 trillion every year.

One characteristic of those countries’ health care is that there is a single entity that runs the system. This ensures uniform and minimal overhead and compliance costs, and provides guidance and regulation for the medical effectiveness of the various procedures.

We can learn much from other countries. The question is whether we are mature enough to do so.

LEONARD S. CHARLAP Princeton, N.J., Aug. 24, 2011

The Writer Responds

I thank these readers for their thoughtful comments.

Dr. Stein notes that private insurance overhead is many times higher than Medicare’s. Most economists agree. Including the cost to providers to collect from insurance companies nearly doubles the difference.

This administrative excess is more than sufficient to finance comprehensive health care for every American. Nearly 25 state and national studies of single-payer plans corroborate this.

Although single payer enables universal care without additional cost, Dr. Relman notes that it will not slow cost increases. He proposes a salaried physician model to replace fee for service. There is much evidence in support.

The salaried physicians in the Department of Veterans Affairs medical system care for America’s sickest patients at the lowest cost with the best outcomes and highest patient satisfaction of any system in the country. Clearly, when financial pressures are removed, physicians provide superb care.

Mr. Marlow is only partly correct. In countries with national health plans, patients see their physicians more frequently than we do and spend more days per year in the hospital. Despite this increased access to care, these nations spend half as much as we do, and their populations are healthier. Presumably, unlimited access to inexpensive primary care reduces consumption of more expensive, more complex intensive care.

Ms. Tavella makes two important points. First, an insurance policy is no guarantee of health care. Most personal bankruptcies in America are precipitated by medical crises in families with health insurance when the crisis began.

Second, when the young, healthy and employed make health care payments in excess of what they consume, this is not a loss. It is an investment in future care when they are old, sick and retired.

Messrs. Feldman, Kelley, Posner and Charlap mourn our inability to achieve single-payer health care despite its obvious financial advantages. But our obstacle is not political, but moral. Many Americans believe that it is immoral to pay for other people’s care, even if doing so reduces their own costs. Others believe that it is immoral to pay taxes for health care, even if doing so protects their family from illness and financial catastrophe. We cannot argue morality, but we can present the health and financial consequences of allowing these morals to drive health care policy.

American single-payer systems include the Department of Veterans Affairs system; the Indian Health Service; Tri-Care, the military health plan; Taft-Hartley multiemployer plans; and Medicaid and Medicare. Any of these systems could be improved and expanded to cover all Americans.

Single-payer health care is America’s health care solution to America’s health problem.

SAMUEL METZ Portland, Ore., Aug. 25, 2011



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