User Steve posts on MAHD home page:
“As a practicing physician for 20 years, I can’t believe that other physicians want a “medicare for all”. Medicare is a bloated government program that is barely functioning. Now I’m not saying that our system is perfect- far from it. However, throwing out WHO statistics that rank us just above Cuba is misleading. Statistics only tell a certain amount of truth. For example, it is a well known fact that african-american women have a higher infant mortality rate than caucasions- irregardless of socioeconomic levels.
As someone who has worked in other countries (albeit in 3rd world countries), I feel that our level of care in this country is extremely high. Also, I had a personal situation which made me realize how high our general medical care is. My friend (a physician) was skiing in Canada when his son had an accident and struck his head and had a loss of consciousness. They were in Kelowna (the 3rd largest city in BC) and were told that the only CT scanner in the city was broken and the closest CT scanner was in Kamloops, a 3 hr drive away. If the kid had an epidural hematoma, he likely would have suffered the same fate as Natasha Richardson (wether she would have died if she was in Vail is another topic).
Yes there are problems with our system, but to paraphrase our President, instead of taking out a hatchet to the medical system, doesn’t it make sense to take out a scalpel? Address the issues that make our system work and address the issues that don’t work. Tort reform, insurance companies (Blue Cross with 180 million in profits and the CEO making 4 million), and the general costs of running an office all need to be addressed.
I’m not willing to trust the government to run our medical care. Have you guys forgotten what it’s like to work at the VA or at a county hospital? Also, how do you expect to pay for this one payer program? I don’t know about you guys, but if I relied on medicare/medicaid payments, I would have to close shop.”
Dr. Samuel Metz responds:
I thank Steve for his heartfelt comments about health care reform. He raises critical points, each deserving of a thoughtful response. I’ll try to provide them.
Steve correctly observes the inefficiencies of Medicare. Its high overhead (relative to other single payer systems) and Congressionally-determined (i.e., lobbyist-determined) physician reimbursement rates produce nationwide inequities in cost and quality. Physician anesthesia, my specialty, would be eliminated at Medicare rates. “Medicare for All,” I contend, is a misleading slogan to sell single payer health care to reluctant Americans.
But for all its flaws, Medicare’s overhead is one tenth that of private insurance [1]. And it provides medical care to elderly citizens uninsurable in a free market economy. And being uninsurable in our country is a death sentence.
Steve is correct that American health care looks pretty good compared to third world countries. But the US is not a third world country. When we compare ourselves to other industrialized nations, the results are shocking.
It is not only WHO statistics that make us look bad. The Organization for Economic Cooperation and Development, the Commonwealth Fund, the Kaiser Family Foundation, and even the CIA confirm the sad fact that by almost any measure of public health, we rank last among civilized nations [2-6]. Ironically, one of our few high ranking areas is patient satisfaction with their physician, but not, notably, with their insurance, coverage, costs, results, or access.
Steve points out that our incredible density of MRI scanners enables some American trauma victims to survive what might have been a fatal accident elsewhere. In contrast, however, 44,000 Americans lose their lives every year even living across the street from a first class hospital because they lack money [7]. No other country can make that claim.
Steve remembers the same Veterans Administration hospitals that I witnessed 25 years ago. It was not pretty. But that was then. Today’s VA provides, hands down, the highest quality health care at the lowest cost to the sickest patients with the highest patient satisfaction [8-14]. If VA care were available to all citizens, costs would plummet and public health skyrocket overnight.
Steve worries about government inefficiency. As mentioned, Medicare administration costs are the highest of any single payer health care system in the world, running about 3.8% (that is, 96.2% pays for actual medical care while the rest goes to overhead)[15]. Other single payer systems, both in the US and abroad, enjoy lower administrative costs. In Taiwan and the VA, overhead is less than 2% [16-17].
However, compare this with the 18% administrative overhead of American private health insurance companies. Even this number is deceptively low. If we include costs to employers, physicians, and hospitals to deal with private insurance, administrative cost rises to 35%. That’s about $350 billion annually paid by Americans to have private insurance move their money, not to provide health care [16]. Redirecting that $350 billion through a single payer system would finance universal, no-deductible, low co-pay health care for every American without new taxes or altering physician remibursement [18]. While such a system would leave many insurance executives unemployed, at least they would have health care.
Steve suggests a scalpel to preserve what works in our current health care system. It will take a sledge hammer to excise private insurance from our health care system. And as long as we preserve private insurance, nothing else will change.
Health care reform is not synonymous with socialized medicine, or physician poverty, or eroded physician-patient relationships. Union medical trusts, the VA, Kaiser Permanente, the Mayo Clinic, and other private medical clinics are American single payer systems providing cost-effective health care with far better efficiency, patient (and physician) satisfaction, and public health outcomes than our private insurance industry. Once we let go of private insurance, the future of health care looks very bright indeed.
1. Woolhandler S, Himmelstein DU. Costs of health care administration in the United States and Canada, NEJM 2003;349:768-772. http://content.nejm.org/cgi/content/full/349/8/801
2. Organization for Economic Cooperation and Development (OECD) policy brief. Private health insurance in OECD countries. September 2004. www.oecd.org/health/healthdata. www.oecd.org/health/healthataglance
3. Schoen C, Davis K, How SKH, Schoenbaum SC. US health system performance: A national scorecard. Health Affairs Web exclusive, November/December 2006; 25(6): w457-w475,
4. Kaiser Family Foundation, http://www.globalhealthfacts.org/bytopic.jsp
5. CIA. The World Factbook. www.cia.gov/library/publications/the-world-factbook
6. World Health Organization. The World Health Report, 2000, Annex tables. www.who.int/whr/000en/report.htm
7. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. Health insurance and mortality in US adults. American Journal of Public Health, December 2009; Vol. 99, No, 12.
8. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the veterans affairs health care system on the quality of care. New England Journal of Medicine 2003;348:2218-27 http://content.nejm.org/cgi/content/abstract/348/22/2218
9. Kerr E, Gerzoff R, Krein S, Selby J, Piette J, et al. A comparison of diabetes care quality in the veterans health care system and commercial managed care. Annals of Internal Medicine 2004;141(4):272-81 http://www.ncbi.nlm.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15313743
10. Asch SM, McGlynn EA, Hogan MM, Hayward RA, Shekelle P, Rubenstein L, Keesey J, Adams J, Kerr EA. Comparison of quality of care for patients Veterans Health Administration and patients in a national sample. Annals of Internal Medicine 2004;141(12):938-45
11. Selim AJ, Kazis LE, Rogers W, Qian S, Rothendler JA, Lee A, Ren XS, Haffer SC, Mardon R, Miller D, Spiro A, Selim BJ, Fincke BG. Risk-adjusted mortality as an indicator of outcomes: comparison of the Medicare Advantage Program with the Veterans Health Administration. Medical Care 2006;44(4);359-65
12. The State of Health Care Quality 2004. Washington DC: National Committee for Quality Assurance. www.ncqa.org/communications/somc/SONC2004.pdf
13. Perlin JB. The Veterans Health Administration: quality, value, accountability, and information as transforming strategies for patient-centered care. American Journal of Managed Care, November 2004, Table 2. http://www.ajmc.com/Article.cfm?ID=2767
14. ACSI Scores for the U. S. Federal Government, American Customer Satisfaction Index I, December 15, 2005 http://www.theasci.org/government/govt-05.html
15. Himmelstein D. The National Health Program Slide Show Guide. Center for National Health Program Studies. Cambridge MA, 2000. http://www.pnhp.org/news/2007/july/_health_insurance_fo.php
16. Health insurance for the 21st Century – Upgrading To National Health Insurance (Medicare 2.0). The Case For Eliminating Private Health Insurance, PNHP website, July 17, 2009m by Leonard Rodberg & Don McCanne
17. Reid TR. Five myths about health care around the world. Portland Oregonian, August 25, 2009. http://www.oregonlive.com/opinion/index.ssf/2009/08/five_myths_about_health_care_a.html
18. Documenting this contention requires more references than is appropriate here. I would be happy to provide them on request.
and CT helps, but does it completely replace clinical judgment?
Natasha Richardson unfortunately refused transportation to hospital and air ambulance to Montreal’s Neurological Institute at McGill University was available – a fact that was often omitted in news reports.
There are gross distortions of Canada and UK health systems conveyed in the US media. Take it from someone who has practiced in Canada and experienced the UK system AND today has satisfied relatives in both countries.
Agree that there are distortions. A paper written in HEALTH AFFAIRS by Katz et al called PHANTOMS IN THE SNOW tabulated the percent of Canadians that were treated in border US health facilities in Washington State, Michigan and NY compared to Canadian facilities. This was a very small percent. And included the magnet hospitals in those areas.
We are inundated with the “government can’t do anything right” meme. Why does this persist so deeply? Is it because the moneyed factions work so hard to prevent the government from doing its job correctly? Most of the problems I’ve dealt with in the military and civilian life come from people spending their time changing systems around and not … See Morehaving proper training on simple things. If you don’t believe in government, don’t use the services: park your car, homeschool your kids, and don’t buy any regulated products. On the farm, everything I want to do is illegal, and the farmers blame the liberals, but the real culprits are the corporations that process foods and have captive markets created by regulations that THEY write for the government. Health care seems the same to me. Most things people need (better nutrition, access to diagnosis, access to medicine) are controlled not for safety reasons, but to prevent living without the companies that produce those things as some kind of guild of thieves.
and CT helps, but does it completely replace clinical judgment?
Natasha Richardson unfortunately refused transportation to hospital and air ambulance to Montreal’s Neurological Institute at McGill University was available – a fact that was often omitted in news reports.
There are gross distortions of Canada and UK health systems conveyed in the US media. Take it from someone who has practiced in Canada and experienced the UK system AND today has satisfied relatives in both countries.
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Steve bemoans the incredibly limited resources of single payer health care in British Columbia…. Kelowna has a population of 106,000. It *has* a CT scanner in its hospital. Granted, it was broken (“not working”) when his friend’s son needed it (things break down, it happens. I heard of the CT scanner being down in the hospital I was volunteering in for the latter half of last year). But I live in a community of 90,000–in the USA–and there’s not a CT scanner in my community at all. Not even our own hospital. We share one with two other cities–an area with a population of close to half a million, counting the unincorporated areas. I’d be willing to bet that it has a CT scanner. I doubt it has two. And I’d be willing to bet that it sometimes breaks down, too.
Someone needs to tell him that anecdote is not the same as data.
Our system is “good”–but only if you PRETEND that all those who have no coverage, at all, don’t even exist. Taking them into account, it sucks, on top of being hideously expensive.