TheMillerCircle.org

Tommy Douglas (1904-1986), the fiery Canadian progressive, is the father of the Canadian system of Medicare; he has been honored by the CBC as the greatest Canadian politician in history (for a little Americana reference, he is also the grandfather of actor Kiefer Sutherland, son of the marriage between  his daughter, actress Shirley Douglas and actor Donald Sutherland). Tommy Douglas headed the first socialist government in North America, when his party won the election of 1944 and he became the Premier of Saskatchewan. He later went on to become the national leader of the New Democratic Party of Canada. Although he was responsible for many progressive legislative initiatives, he is most fondly remembered as the father of Canada’s modern universal health care system, passed in 1967 when Lester B. Pearson was Canada’s Premier. So, the message is this: if Canada views the father of its Medicare system as its greatest politician, why doesn’t our current President begin the casting of his own bronze likeness on the Washington monument scene by supporting universal health coverage or “Medicare for all?”

So far,  Obama has proven to be something of a wimp on health care reform, although some have argued that he is clearing the way for such a plan by first further reducing the influence of the Republican Party in national politics (I thought that already happened). Even if true however, Obama has managed to shut out the single payer sponsors from participation in the debate and Senator Max Baucus, who is holding the Senate hearings on health care reform, has said on many occasions that a single payer plan has no chance of passing. Baucus incidentally, has received more political campaign donations from health insurance companies and the pharmaceutical  industry than any other Democrat. Obama also received campaign donations from the health insurance industry and drug companies and this may be a factor in persuading him to support a very conservative and unworkable fix to our health care system. The problem front and center is that profits of private insurers and the inferior health care system they have imposed to insure those profits, is not really a health care system at all–it’s an exclusionary practice in which more and more people are saddled with increasing debt and reduction of care. More than half the bankruptcies in America are from medical bills that cannot be paid. If we stopped the profiteering from taking place in our health care system, we would, according to students of our health care system, such as David Himmelstein and Steffie Woolhandler, have enough money to pay for our entire health system and cover the 48 million who presently have no insurance. Think of it: we would eliminate the huge bureaucracy that has grown up under the current system, dramatically reduce the paper work to justify billing and allow physicians far more time to spend with their patients. In other words, we would allow doctors to practice medicine like they used to, where patient care becomes their top priority. Right now our patient care system is simply imploding. Obama’s promise to fix it is the best thing that has happened since Clinton tried to do the same early in his first term. Let’s hope that we can get something done this time. Perhaps way down the road, it may be necessary to begin rationing health care, but if so, with a single payer health care plan, it could be done fairly and uniformly for all. In the meantime, we pay enough into the system to cover all current costs for now and well into the future.

Obama’s proposal is to leave the insurance industry more or less intact, with perhaps some modifications to their “behavior,” like the elimination of “preconditions” and allowing transportability of health insurance. As an alternative to private insurers, Obama wants to start up a Federal program for those that do not have access to a private health care plan.  He would also allow for the importation of pharmaceuticals from other countries, like Canada, where drugs are typically less expensive. The insurance companies have carried out their own polling, the results of  which suggest that as many as 130 million would opt for the Federal plan and their intention, without publicly admitting it, is to eliminate the optional Federal insurance plan, to effectively gut any chance at serious health care reform. Like it or not, Obama will have a fight on his hands no matter what, so why not unite the nation and go for the whole enchilada. National polls have consistently demonstrated that the majority of Americans favor a single payer plan, including the majority of physicians.

While the for-profit health insurance companies are mounting an advertising campaign against the formation of a government-sponsored form of health insurance, we must recognize that these companies have historically spent $ millions on weeding out subscribers with high health care costs, so that they can derive obscene profits from a much healthier patient base. Yet many of these insurance companies are beginning to see a silver lining in the government insurance plan. What they would like to see is the Federal plan assume responsibility for insuring  the most costly patients that drain their profits, so that they can keep the healthy people on their roles, from whom they already make big bucks. The model for doing this is already in place with for-profit Medicare HMOs (see below). The current trends in medical care are largely driven by investor-owned corporations, so their sole objective is profiteering at all cost.   But, if all goes well for them, they might further increase the noise coming from their busy cash registers. The question for them is the following: if they can’t defeat the Federal program, can they modify it to actually enhance their profiteering? Here is how they have done it with Medicare–a little note from history:

1. When Medicare was formed in 1965, it had a dramatic impact on the security and health of senior citizens. At the time is was implemented, most seniors were uninsured and forced to rely on haphazard government institutions,  charity or their own fee-for-service resources. At that time non-seniors were covered through private plans that were largely controlled by doctors and hospitals (Blue Cross/Blue Shield), typically provided by the companies where they worked.  Medicare brought new revenue into hospitals and began to attract attention of the business community. In those days medical care reimbursements were done as a fee-for service system.
2. Originally, Medicare reimbursed hospitals for their patient costs with a fee-for-service strategy.  Soaring medical costs beginning the in the 1970s forced employers and the government to begin asserting more control over medical costs.  This pressure to reduce health care costs gave birth to the  health maintenance organizations (HMOs), most of which were controlled by investors rather than health providers, and this was the beginning of the high profit motive for medical care. As you know, HMOs are based on a monthly fee charged to everyone in the system, not the fee-for-service of the old days.
3. Beginning in 1983 Medicare began to support the market-based medical care system of HMOs, when it shifted its reimbursement from hospitals, based on their actual care costs, to a fixed, per-admission hospital payment.  It is important to recognize that the older fee-for-service system before 1983 did not generate excessive profits or losses for hospitals. The system seemed to work.
4. The system that began in 1983 changed the name of the health care reimbursement game: under the new system, with a predetermined payment for patient admission, the duration of a hospital stay meant that a profit or loss was possible based on the outcome of each patient. Short stays were profitable and longer stays could mean a significant loss. Hospitals were also now rewarded for “upgrading” the diagnosis from one disease to another, often adding the words  “with complications.” The system also now rewarded the bottom line if sick patients were released as early as possible. This was the beginning of the overnight stay for things that sometimes involved major surgery. As you might imagine, this new system led to a doubling of hospital managers between 1983 and 1988. The gaming of our health care system had begun.
5. In the mid-1990s yet another layer was added. Medicare began encouraging the elderly to enroll in private HMOs. Under this arrangement, the government paid each HMO a monthly fixed rate for each person who switched from traditional fee-for-service (non-profit) Medicare, with the HMO taking over responsibility for purchasing or providing health care (which, in many cases they did not do). This change was touted as the means of converting Medicare to the higher efficiency of a market-based system, but everywhere it has been put in place it has added about a 15% increase in medical care cost.  You can guess what happened. Stimulated by the Medicare-HMO option, many new HMOs were formed to specifically focus on this new source of revenue;  it was to their advantage to make sure that their Medicare population was healthy.  About 22% of the elderly population consists of very healthy individuals who require little or no medical care. So now the HMO’s responsibility for profiteering from the elderly was to take on the healthy Medicare seniors and weed out those that would detract from the bottom line. Unfortunately, the first examples of this new crop of Medicare HMOs included many scam organizations that signed thousands of Medicare patients up without ever arranging for their health insurance, taking $ millions in payments from the Federal government. Following the initial series of scandals, astute HMOs recognized that they could make huge profits by “cherry picking” elderly patients. If patients were sick or got sick under the support of the HMO, they would be encouraged to switch back to the government’s regular Medicare program. The result was huge profits for the HMOs, with the government assuming the costs of the most expensive and needy patients. What we have to realize is that we already pay for more than 60% of our entire health care bill, so it is not as though we have a huge private enterprise out there that greatly exceeds what we are already paying for in terms of our health care system. This is one of the under-appreciated facts about health care in America–we already cover most of the costs! What’s the big deal? Why not take the simple step of converting Medicare into our national health insurance plan and gutting for-profit organizations? Well, there is a little issue called politics and the money used for politicians to get re-elected.

The pharmaceutical industry of course is in on this plan too, as they continue to try and invent diseases out of normal behavior that can be treated with their new drugs, or, better yet, treated with drugs that are already on the shelf that have run out of patent protection. When a drug company finds a new use for an old drug, they can get a new patent on it, and thereby greatly extend the profiteering from drugs that they would otherwise have to give up on. In many ways it merely comes down to marketing. I have a friend whose mother was in an assisted living home. She watched lots of television and each time an ad for a new drug would appear, she wrote down the name of the drug and asked her doctor if she shouldn’t be on it. Somehow the culture of few drugs is better than many has bypassed our society because of the ability of drug companies to advertise, something they cannot do in many other countries. So, we can identify two deep pocket, for-profit forces that want to see minimum changes in the our health care system. Who then are the people and what are the arguments that support a single payer health care plan, also known as “Medicare for All?”  Well, for one thing, poll after poll shows that the majority of citizens favor a single payer health care plan, even when it’s referred to as “socialized medicine.” Taxpayers are beginning to resonate with the idea that there is something terribly unfair and un-American about a health care system that forces people into bankruptcy and early death.

One of the major debates that still goes on in America today, is whether health care is a right or a privilege. For many years, the AMA framed the issue as if health care was a privilege and many within that conservative organization still hold onto that view. It was the AMA that played a big role in defeating Truman’s goal for a single payer health plan by referring to it as “socialized medicine”–the death knell at the time of the early beating of the drums of McCarthyism. But polls of physicians reveal that the majority of practicing doctors favor a single payer health care plan and do so for simple reasons. Such a plan would eliminate the gigantic level of paper work that doctors must go through, including the back and forth arguing and faxing necessary to get the treatment that they recommend for their patients. A single player plan would virtually eliminate the costly and wasteful administrative expenses involved whose objective is to simply reduce treatment for patients and eliminate the patients that are truly in need of health care. The present health care system is, to me, nothing less than criminal. By the way, another motivation for physicians and their support of a single payer plan is the fact that for the past twenty years, they have watched their public esteem dwindle, as patients blame them directly for the poor quality of care that many of them receive. The MD of today is no longer the master of patient care, but subservient to the profit motive of the for-profit organization that pays his/her salary. This is a lower calling than the one they had in mind when they first decided on a medical career.

Among the most knowledgeable individuals on the benefits derived from a single payer plan are Steffie Woolhandler and David U. Himmelstein who have written extensively on the subject. In addition, the California Nurses Association is equally passionate about single payer health insurance and, together with members of the Physicians for a National Health Plan and members of other groups, they demonstrated recently in the Senate hearing on health care held last week with Senator Max Baucus from Montanna as the Chair of the Committee. As these doctors and nurses spoke out against the health insurance companies, they were led out of the hearing and arrested. Bill Moyers had David Himmelstein and Sidney Wolfe (from citizens.org) on his Journal program on PBS on May 22 and you can watch that interview, along with many others on the single payer health care plan and why it is given so little play in Washington.

Today, the health care system of the United States is about as dysfunctional as any health care system in the world, save the third world countries that lack a health care system altogether. We pay more per capita for health care compared to any other major country in the world. Yet today, we have 48 million people without any health care insurance and each year, according to the National Academy of Sciences, 18,000 people die because they do not have a health care option that gives them treatment in a timely manner. People like GW Bush, who supported the present system of a privatized, profiteering health care system, have claimed that those without insurance do get treatment because they can go to the emergency room. While some do pursue that option and place unfair health cost burdens on the cities and counties that have to take them in, many others do not and among them are the 18,000 who die each year because of our failed system of health care and the intimidation factor that prevents many from seeking diagnostic and treatment attention. Only a system of capitalistic profiteering would continue to pursue the kind of health care system we have today, a true abomination from mindless wondering in the forests while supporting a non-sensical mantra of a market-based system of profit for a few and tragedy for the many. Simply put, we currently have a system of health care that destroys the lives of its own citizens, puts millions of lives at needless risk, while providing excessive profits to those that run the organizations, who know very little about health care issues. Only in America!  How can anyone rationalize against the simple conclusion that a for-profit system would be good at only one thing–making a profit and that for our health care needs, such a system would fail at every other attribute we would like to see as part of a national health care system? It is obscene to have health care and for-profit in the same sentence. We need to impose a new literary standard. Today we find both the Republican and corporatist Democrats so brainwashed by the dialog of a free market economy that they believe our present system can be fixed by the process of “tweakitization.” If we succumb to this form of Washington fever, we will replace one broken health care system with another and very likely, it will be far more costly.

The French have a much better health care system than we do; they are ranked #1 by the WHO. They live longer and lead healthier lives. Within our own health care system, we can directly compare the results with our non-profit Medicare system and the for-profit HMO Medicare system that was has grown up around the traditional system. First, the costs of the for-profit Medicare system have grown faster than that of the non-profit Medicare program, with worse results for patients. Meta analysis of data has shown the private Medicare treatment programs for end-stage renal disease have a 9% higher mortality rate than the same patients in the non-profit Medicare program. Investor owned hospitals, which receive more than half of their revenue from public coffers lead the non-profits in death rates (2% higher) and costs (19% higher). The for-profit units spend less on nurses and other clinical personnel, while splurging on managers. It’s the managers that help move the patient selection process to “cherry pick” the more profitable patients. If you are well, you are a welcome addition to their roles, but if you are sick, they will steer you back to the non-profit Medicare program. On your way to the new place, you just might die. If the for-profit expenses get too high and profits decline, they will close their operations entirely, leaving all their patients on the streets so to speak. These facts about the difference between non-profit and for-profit organizations are never reported in the mainstream press. It takes an act of public scholarship to find the data. By emphasizing the selection of patients, the proportion of health funds devoted to administrative costs have gone up 50% in the past 30 years and now stands at 31% of our total health care bill. This is about twice what Canada spends on its health care administrative costs.

People like to talk about market-driven success, without ever talking about market-driven failures. The absence of the conversation is almost surrealistic in the present climate, as we are now living in the worst economic failure of the free-market approach and the failure can be attributed to excessive greed and social indifference of those who practiced their greed on us, the daily consumer and ultimate bailout provider. So if the economic model of free-market behavior turned out to be a disaster when it was supposed to be confined to the financial sector, just imagine what disaster awaits us with our free-market health care system, where we are headed for another train wreck that could hit us in the next few years. The privatization of health care was supposed to drive down the cost of medical care. But, there is a difference between driving down the cost of medical care by avoiding unnecessary costs, and driving down the cost of medical care by endangering the life of the patient. Furthermore, the profiteering of the for-profit health care systems is created by off-loading the patients who consume the highest percentage of health care costs onto other programs or creating additions to the already huge component of our population who lack medical coverage entirely.  Investor-owned health care systems do not drive costs down, they drive costs up, but these increased costs are not because of increased patient care, but rather increased administrative costs and share-holder profits. These groups are now so powerful that they can control the health care agenda of Congress and the White House. Worse than that, many of these organizations, such as Columbia/HCA are fraudulent organizations that create profits from falsifying patient records. Worse, some of these organizations such as Tenet, have performed hundreds of cardiac procedures on healthy patients and collected hundreds of millions in unearned payments from Medicare. In addition to the fraudulent behavior of many of these organizations, they have shockingly high compensation plans for their executives, often in the hundreds of millions of dollars or more, depending on the stock options and the value of the stock. There is no such thing as a free-market health care system and certainly our own system of for-profit care has more similarities to a Ponzi scheme than a system that provides needed health care for patients. There are many reasons why the for-profit model of health care needs to disappear, not the least of which is the fact that we will go broke as a nation if we continue to fund the system we have today. It is loaded with fraud and does not meet our criteria of a national standard for  health care. The light at the end of the tunnel, that of a single payer health plan, can take the money we spend now and cover all our current bills for many years into the future, including coverage of the 48 million citizens that do not have coverage today. That number incidentally, is about the same as the number of U.S. citizens that did not have health insurance when Medicare went into effect in 1965.

Down the road we may have to ration some aspects of health care and weed out unproven treatments. If we have everyone on a single payer plan, the day rationing becomes necessary, everyone will be on the same playing field, so that any reductions in care will be projected across the board and happen to all, with transparency in our system as a way of validating the concept of fairness. That seems to me like the most American-like of all the options and because we already have an effective system called Medicare, we have a robust skeleton of the system we need to get everyone under the same tent. A single payer health care system is at the top of the polls that have appeared from the Millennial generation–those born between 1978 and 2000. They will increasingly occupy a larger fraction of the voter block in this country and they are proving to be far more progressive than any other generation. So, I believe that we will have something like a single payer plan, if not now, at some point in the not too distant future. Just as we have recognized that our economic system was a free-market bust, so too we have to recognize that our health care system is, if anything worse, as it is a system that does not meet our needs as a nation, not even close. If we make the transition while sensible options and debate can take place, we can tune our health care system to meet all of our needs. If not, we are headed for the mother of all train wrecks and further dismemberment of our culture.

The World Health Organization currently ranks the United States health care system at #37, with France at #1. Most European countries and many South American countries rank above the United States. Although we like to tell ourselves that we have the best health care in the world, it is not possible to prove it by objective criteria. We are ranked 24th in life expectancy, with Japan, Australia and Frances listed, respectively at 1,2 and 3. But when it comes to the % of our GDP that we spend on health care, the Marshall Islands is listed as #1 (15.4%; 2005), with the United States as # 2 with 15.2% of our GDP (2005) consumed by health care costs; in contrast the best rated health care system in the world, that of France, achieves its ranking by spending 11.2% of its GDP–and everyone is covered. If you as a non-French citizen get sick in France, you will receive excellent care and, when you are well, you will be discharged without getting a bill. We should be ashamed of the benefits we get when our health care system is as expensive as it is: something is terribly wrong. We badly need to repair our health care system and in the process rejuvenate America!

Do not be fooled by the recent promise offered by the health insurance industry to dramatically trim costs. This promise is non-binding and it has been offered before when Carter threatened to do something about health care costs. But, nothing came of it then and nothing will come of this promise now. It is merely a means of heading off the new Federal insurance program, which is what the health insurance companies fear could begin their derailment. We need reform that we can count on, that has substance to it, with better health outcomes for out citizens. What we don’t need is another layer of empty promises coming from a Trojan Horse. I don’t know if the WHO will ever rank the U.S. as # 1 in health care, but we need to climb out of the cellar we are in with a ranking of # 37. That ranking will change quite dramatically with a single payer health care system, whose objective is good health care without a profit motive as the more important objective. As long as one speck of our health care system puts profits in front of health care, we will have a broken health care system. Currently we spend 16% of our GDP on health care and that number is projected to double that amount within 25 years. Current estimates suggest that we spend about $ 700 billion on excessive costs that do not get translated into patient care–waste through excessive profits and inefficiencies. The good news is that the waste we have each year in our health care system is enough to cover everyone in the country with “Medicare for All.” So, save our nation and our economy and vote for single payer!

RFM