Friday, June 30, 2017

Chapter Two  of  Proposed Book:  Universal Care, Multiple Payer In, Single Pay Out , But Who Shall Pay? For What? And  Who Shall Deliver Care?

Shall it be a centralized single-payer government system?   

Shall it be through increased income and payroll taxes, or perhaps,  a value-added tax,  applied to all consumer goods except food, purchased by the poor, the rich, and everybody in between?

Shall it be by open-ended entitlement programs - expansion of Medicare, Medicaid,  ObamaCare subsidies, and those in other government programs?

Shall it be Medicare or Medicaid for all, fulfilling the dream Bernie Saunders and other socialist dreamers?

Shall it be paid disproportionally by redistribution- mandates on  the rich, the young, and the healthy?

Shall it be paid by taxing the profits of organizations in the so-called medical industrial complex  and other for-profit entities?

Finally. Shall it even be necessary if the universal basic income for all Americans, as is now being proposed, becomes a reality?


These are some of the questions that haunt the body politic and the American people.
These are questions I’ve been writing about since I graduated from Duke Medical School in 1960 and completed my pathology residency in 1965.  

That  was  the year  Medicare and shortly thereafter Medicaid passed.  Together these two programs cost taxpayers over $1 trillion and consume huge chunks of the $3.2 trillion government spent on health care in 2016 with no end in sight.

Over the last 50 years, I have practiced medicine,  served at editor of the Minnesota State Medical Journal, and several national newsletters (The PHO Report, the Reece, Report, and Physician Practice Options), formed an integrated physician-hospital organization,  composed over 4000 Medinnovation and Health Reform blogs,  and written ten books on health reform.  

In addition, on the innovation front,  I have initiated and developed an Internet-based differential diagnosis program and a health measurement program .  The differential diagnosis program correctly identified over 80% of diagnoses and was issued in hundreds of thousands of reports over a six year period.  The health measurement report, which identified patients as below normal, normal, or above average , depending on whether they fell inside or outside a normal range of 80 to 120.  In  study of over 4000 Oklahoma state employees,  the average HQ was 77, largely due to obesity ,  hypertension, diabetes, pre-diabetes,  and dyslipidemias.  From these studies, I concluded it was theoretically possible to establish the diagnoses of over 90% of patients before seeing the doctor, and one could measure the health of large populations of patients and how they could improve their health.

My books have dealt with the corporate transformation of medicine,  physician shortages,   the successes and failures of ObamaCare, and the tangled politics of health reform.

As I write the future of health reform is as uncertain, and the ideological clashes  surrounding this reform  are  as deep and divisive as ever, as shown in these two editorials in the Wall Street Journal and the New York Times, which are, of course, on opposite ends of the ideological spectrum.

·        “The liberal solution to every government failure is always more government.   The California single-payer-bill reflects the left’s Platonic ideal, with the promise of free care for everyone for everything.  Patients would be entitled to an essentially unlimited list of benefits including acupuncture and chiropractor care as well as all medical care determined to be appropriate by the member’s  health care provider.  They could see any specialist without referral.  There would be no restraints on health care utilization or costs.  Patients could get treated for all maladies by any physicians at no cost.”(Wall Street Journal editorial,  “California Single Payer Dreaming,” May 27-28, 2017).

Not to be outdone,  the New York Times editorial board had its say.
“Any doubts about the senseless cruelty underlying the health care agenda put forward by  President Trump was put to rest last week two government documents. One document was the Congressional Budget Office’s detailed analysis of the Trumpcare  bill passed by the House this month.  The budget proposed billions of dollars of cuts to programs that funded research into new cures,  protects the country against infectious disease and provides care for the poor, elderly, and people with disabilities.  The CBP analysis said Trumpcare would rob 23 million people with health insurance while leaving millions of others with policies that offer little protection from major medical condition.   All of which would be done in service of huge tax cuts for the richest Americans.”(New York Times editorial,  “Trumpcare’s Cruelty, Reaffirmed, May 28, 2017).

There you have it – the gulf, chasm, and abyss between two conflicting ideological opponents  talking past on another while blaming each other. 

There is a third school of thought about  how  to bridge  the gulf – machines  bearing artificial intelligent and elegant algorithms  to measure outcomes to show who is right and who is wrong by using data to supplement and even replace faulty  human nature.  Machines, in other words, can become human, and humans can become machines.   Machines have their own set of problems.  They are designed by humans, big data is not knowledge or wisdom, brains are often more reliable than machines, and data alone often infringes upon privacy, security, and confidentially between patients and physicians.

But no matter what ideology you subscribe to and no matter what technology you use to enhance efficiency, the question remains: who shall pay?   Three states have had a stab at introducing single payer to achieve universal coverage -  Vermont,  Colorado, and California.   All have failed  because political leaders of each state have come to grips with the realities that single payer costs would be prohibitive, requiring state government to raise taxes and employers to raise payroll taxes to levels their citizens would not accept.  In California,  the single-pay cost would be at least $400 billion annually . 

Besides, superimposing single payer on the present structure would be unbelievingly disruptive to hospitals, medical supply chains,  and the 16 people needed to support each individual physician.   Still  40% of Democrats favor single-payer but just 28% of all Americans favor such a move. In California, about half the money to support single-payer would come from existing public money spent on health care.  The rest would come from taxes, in a state which already has the highest state income tax at 13% in the4 nation.  A handful of aspiring politicians in other states –New York, New Jersey, Rhode Island, and Massachusetts have proposed single payer bills , but the appetite is not yet there for the country outside of California and the upper East Coast.
This is First Chapter of my new book:   Multiple Payer Care In, Single Payer Out
Who Shall Pay?  For What?  Who Shall Deliver Care?

Chapter One

Notes on Donald Trump’s Rise to the Presidency

Before I get into the role of money in Trump’s election,   let me set the stage by talking about what events in the days   immediately before and after his  election.  I believe the election outcome rested heavily on health care events. 
On November 1, I began jotting down notes on Trump’s improbable rise to the presidency.   On that day, health plans announced  average premium rises of 25% and unaffordable deductibles, and insurers  began  to abandon ObamaCare markets . 

Here are my notes at the time.

November 1 - The Presidential election is one week away.  Polls project Hillary Clinton as a sure winner.  Newspapers universally endorse her, as do Wall Street bigwigs and hedge phone managers. The mainstream media has kowtowed to Clinton.  Foreign governments, anticipating her ascension, have given $140 million to the Clinton Foundation, and hundreds of thousands of dollars to speeches by her husband. 
The mainstream media, in particular the New York Times and the Washington Post , portray  Trump as a demagogue,  a bigot, a fascist, a homophobe, a misogynist, a white supremacist, and as intellectually and psychologically unfit to be the nation’s leader.

“On the positive side, Hilary Clinton vows to continue Obama policies.  In health care, his policies have   million from the uninsured into the exchanges and 14 million into Medicare. “

“But the economy is sluggish with a 2% growth rate over 8 years, and middle American workers in fly-over country feel forgotten and neglected with frozen wages.  Many consider themselves victims of broken health care promises that you can keep your doctor and health plans and your premiums will decline.”
“Like many physicians. I have come to believe ObamaCare is unworkable and unaffordable.  It unfairly blames fee-for-service doctors as one of the a principle cause of health care inflation.  

The truth is we have a health system that reflexes the desires  our pluralistic society.  It is a society  that wants a mix of government and private care with access to high technology.”

November 2 – Today  I would like to make these points – universal care is a noble, desirable goal but a one-size- fits-all system is a pipe dream;   government cannot effectively manage care retrospectively from Washington, data along cannot replace physicians’ experiences or intuitive diagnostic and treatment skills,  universal access is difficult because physicians have the options of not accepting Medicare, Medicaid and ObamaCare patients,  and President Obama et all made the critical mistake of ACA passage without a single GOP vote.   Instead he chose to seek standardization om s pluralistic diverse nation,   mismanaging ACA implementation with over 300 software glitches in, misunderstanding the nature of insurance risk      and how to compensate for risk shortfalls,  and failing to comprehend that America is a center-right capitalistic society favoring choice and entrepreneurialism over self-righteous moralistic government control.  America has embraced the computer revolution but wants high touch combined with high tech. and minimal intrusion into the privacy and confidentiality of the patient-physician relationship.  Government intervention, in short, has its limits.”

November 3 - This week Bill Clinton observed ObamaCare is a “crazy system” with 25 million more insured but accompanied by a doubling of premiums for the rest of Americans.  Mark Dayton, governor of Minnesota, noted, after projected premiums increases of 50% to 67% in his state, stated “The Affordable Care Act is no longer affordable.”   As Samuel Johnson (1707-1784) ruefully concluded, “The Road to Hell is paved with good intentions.”

November 4 -   Candidate Trump keeps saying the election is “rigged” in favor of the media, academic, and bicoastal elite.  I disagree.  The election is not rigged.  The media-academic- political- establishment elite have simply reached a unanimous conclusion -  HillaryCare and the safest harbor for the status quo, and Donald Trump is too much of dangerous gamble.

November 5 -  How dangerous is Trump?   Well, according to the New York Times editorial board, very dangerous.   He has a ‘history of coded race-baiting in lockstep with the alt-right, the Ku-Klux Klan, racists and misogynists. It is simply Clinton-hatred that supports a candidate who also stands for torture, hatred of women, immigrants, refugees, people of color, people with disabilities.  A sexual predator, a business fraud, and a liar who runs on the promise to destroy millions of immigrants and jail his opponents.”
The millions who support Trump and attend his rallies don’t recognize the Devil described by the Times.   They are more concerned by the lack of good-paying jobs, the slowest economic recovery since World War II, the doubling of health care premiums,  the highest business income taxes in the World.  Double taxation, by U.S. government and government where U.S. companies have headquartered their companies,   leaves $3 trillion parked abroad, and a Democratic candidate and a bicoastal elite  that dismisses them as “deplorables.”

November 7 – One day to go and Hillary Clinton still heavily favored.  She is resting,  preserving her energy, before her anticipated election.   Measnwhile,  Trump is holding multiple rallies amidst signs that blacks, Hispanics, and millennials  might not turn out in requisite numbers, and that people who have never voted before may turn up at the polls to volt for Trump.
November 9 – It’s all over, and Trump won the electoral college by 305-220, mainly by capturing key Midwest states, Pennsylvania, North Carolina, Florida, and other Southern,  Southwestern, and Midwestrern states in middle America.
It’s too early for an autopsy,  but in my opinion, these factors were important.

·        Americans in these states and rural America were sick and tired  of  being told how good things were, and of being labelled as white supremacists, bigots,  homophobes,  misogynists, and of being forced to buy insurance they felt they did not need, of being relegated to part-time work.

·        Americans are a proud patriotic people.  They were weary of being told they no longer lived in an exceptional nation,  that they should apologize for being advocates of right of center capitalism and personal responsibility, that the future resided in becoming  a European-like social welfare state, and that globalism would inevitably supplant their national culture.

·        Hillary Clinton had no message other than “It’s my turn,” or
“It’s time for a woman president,”  or “I will extend President Obama’s policies.”  These messages had no resonance among voters looking for change and economic growth that improved their circumstances.

Wednesday, June 28, 2017

Book Proposal
I am working on a book about universal care.  Here is the introduction.     The book’s chapter may follow in future blogs. At present, the book has not undergone final editing.
The book:

Title Page
Multiple Payer Care In, Single Payer Out
You Can’t Please All of the People All of the People All of the Time
 Who Shall Pay?  For What?  Who Shall Deliver Care?
Quotation Page
To the American people, who believe government should serve the people   not just the elite.
Opening Quotes Page
You can please some of the people all of the time,   you can please all of the people some of the time, but you can’t please all of the people all of  the time..
Abraham Lincoln
Compassion should not be measured by the size of the safety net, but by the number no longer on the safety net.
Jack Kemp,  Congressman
Republicans have accepted that the electorate sees health care not just as a commodity, like purchasing a steak or a car. It’s something now people have the sense that government ought to guarantee.
Charles Krauthammer, MD,  Fox News and Washington Post contributor
There is no such thing, as a free lunch.
Milton Friedman

American universal coverage, single payer or otherwise,  is not on the immediate horizon. 

Why not?

First,   the GOP-Democrat split over ObamaCare versus TrumpCare.    The two sides, for ideological and other reasons, can’t agree what constitutes the greater good.  The split boils down to the divide  between the medical-industrial-complex , with its pragmatic  emphasis on margins to stay in business, and the media-establishment-complex, with its moral mission to  show its compassion to stay in power.

Second,  the embedded structure of our current system, dating back to World War II.   Today this structure has  five functioning systems covering these populations  1)  Employer  coverage (150 million); 2) Medicare (55 million); 3) Medicaid (75 million); the Veteran’s Administration (7 million); 4) ObamaCare health exchanges (10 million); and  Independent markets (50 million), where the uninsured and underinsured reside.      Overlap  and interaction exists between the five.   Government has a hand in all sectors, and insurers are engaged in most.  Inflation and premium spikes in the crucial  health exchanges spill over into the other sectors.

Third,   American cultural obstacles .  Americans in middle America tend to bec onservative in their  politics.  They stress jobs, economic prosperity,  individual responsibility and choice.  Those on the left tilt towards a social welfare state.  What complicates this relationship is the sheer magnitude of health care spending, now about one-sixth of our economy.  Health care is a major employer.  Medicare and Medicaid are the life-blood of hospitals, other health care employers and members of the medical-industrial complex. Its members depend on profit to exist  cannot be deprived of that profit without economic consequences.


Every book needs a theme to give it coherence and purpose. 
The theme of this book? To foretell that guarantees of universal coverage, in one form or another,  sooner or later,  probably later,  will inevitably take place in America. 
But it will not be “socialized medicine,” strictly government led and controlled, the anathema of many middle Americans. Socialism is not in our DNA.

 Universal coverage will not be free. Estimates of the cost of a single payer system for the U.S. vary from $18 trillion to $32 trillion over the next decade. Estimates in California over its proposed single payer system are $400 billion over current costs for the first year.

Health care in America is twice that of any other country.  Health care now consumes 1/6 of the Gross National Product.  It employs one of eight of us. It is the largest single  employer of Americans of any business sector, and has accounted for 37% of jobs since the 2008 recession.
In no country in the world, even those with universal coverage, does government pay for all care.   The percent of care paid by government in these countries varies from 70% to 90% compared to roughly 40% to 50% in the United States. Private insurance picks up the slack for those seeking care or refuge outside of government care.

Why is U.S. care so expensive ?   The reasons are technological, financial, cultural, and structural.    As a society we assume newer, more invasive, higher-tech, and more specialized care are always better.  We have set up a system  prioritizing  and rewarding  specialty care and punishing  or minimizes primary care.   And over the last 10 years, since  Apple’s IPhone ushered in the information age in 2007, we have come to believe Artificial Intelligence (AI), apps, and algorithms,  fueled by Big Data, much of it generated by electronic health records,  will lower costs, increase efficiency, and serve as a panacea for better,  more universal care.  

We shall see if digitization will transform care for the better.    It will be disruptive, potentially replacing medical specialists like radiologists and pathologists, and it may generate massive unemployment, even among skilled workers.

 Ours is a system providing  incentives for procedural and hospital-based care  and specialists.    It is a system that results in an average compensation of $194,000 for internists and a $525,000 for orthopedists( Medical Group Management Association 2013 survey). It is a system that increases support staffs of specialists,  fosters specialty technological innovations,  functions best  in large institutional settings,  and increases appeal to medical students.   Understandably, these students, who graduate with an average debt of $150,000, chose specialties offering higher pay and shorter hours over primary care.

Two of every three American doctors are specialists.   In other countries,  the ratio is one of three or even less.   Evidence from these countries indicates primary care produces lower costs, mortality, and greater patient satisfaction.   Primary care physicians have become  U.S. medicine’s  second class citizens. (Louise Aronson, MD, “ A Tale of Two Doctors – Structural Inequalities and the Culture of Medicine,” New England Journal  of Medicine,    June 15, 2007).
As I ponder these developments, I’m reminded of a 1959 book by an English  surgeon,  Doctor Heneage Olgivie, entitled “No Miracles Among Friends.”  Doctor Olgivie formed a travelling surgical society whose members told of their latest innovations.  One member, an  American, said he had developed a new  approach  to remove tonsils.  The other members asked what was so astonishing about that.   The American replied,  “Because I removed them from behind.”

In America, said to be land of the free, we believe in small government and individual’s ability to conduct ability to conduct one’s  affairs and to make one’s choices. Universal care,  American style, will not be single paper.  Instead it   will be joined at the hip with freedom of choice.  We will  have a system covering all, but will be coupled with a private system, as is this case with most  other countries, which have private insurance to serve as choices outside of government.

Some choices will exist outside the realm of government and its insurers. In the end, if projections of what universal coverage would cost under California are correct, a single-payer system would cost 50% more than what health care currently costs, and the extra expense would have to be covered with increased taxes.

This is a book about who shall pay for care,  a subject I explore in Chapter One.    It sounds cynical  to say universal care is all about money or to base a book on following health care money as the pay to coverage for all.  But money, or perhaps I should say profit is at the root of the deep structural problems ingrained in our system.   No health care institution or those that provide care cannot do so at a loss and stay in business.  As a catholic nun CEO of a major hospital system said, “No margin, no mission”.    Besides as Milton Berle remarked. “When it comes to my health.  money is no object.” Or, as a cynical doctor friend of mine quipped, “In health care,  money isn’t everything, health is 2%.”

No Villains

This book seeks no villains, profit-making or otherwise. We are all a little bit liberal and a little bit conservative  No one is singularly  to blame for the current state of American imperfect health care system.  There are no easy answers or perfect solutions to our health care woes. Compassion alone will not be enough.  Whatever evolves, it will not be simple, and it will not be free.

What we should seek is a balance between government and free markets.  As H.L. Mencken remarked,” For every complex problem, there is a clear and simple answer, and it is wrong.”  The ACA, the Accountable Care Act or ObamaCare, or the ACA,  had its faults.    So too does the AHCA , the  American Health Care Act, or TrumpCare.


I am optimistic about the end game, balanced Universal Coverage.  In Winston Churchill’s words, “You can always count on the Americans to do the right thing, after they have tried everything else,”  and …,“The inherent vice of capitalism is the unequal sharing of blessings; the inherent virtue of socialism is the equal sharing of miseries.”  
Bleeding Hearts, Death Predictions, and GOP Health Law

Give Democrats credit.  

Democrats  know how to speak with one voice.    The chorus of voices have received their main talking point against the GOP's  America Health Care Act,  

That point is:  22 million people will lose their health plans,  and hundreds of thousands  of these people will surely die from lack of care at the hands of the cruel Republicans.

Democrats who have made these  predictions of wholesale deaths include: Barack Obama, Hillary Clinton,  Bernie Sanders,  and Al Franken (author of "Al Franken - Giant of the Senate"),  and countless others.  

The Republican alternative is portrayed as a "Slaughter of the Innocents"at the hands of ruthless and heartless  politicians without a heart but with plenty of money.  It's the needy suffering from the greedy.  It's the rich exploiting the poor.   It's tax cuts of the rich versus care cuts for the poor.

The message is, of course, that only those  currently received care from compassionate subsidized ObamaCare plans will survive if the debacle known as the American Health Care Act  is not enacted.

Not mentioned in this chorus of bleeding heart voices are these facts.   Millions of people have already lost their doctors and health plans and access to their hospitals because of ObamaCare policies, and there are no reports of mass deaths from the ACA.   A report from a large controlled study of Oregon Medicaid patients indicates that patients on Medicaid have no better results than those not on Medicaid.  Medicaid patients have a hard time finding access to doctors,  only 45% of whom accept new Medicaid patients because of low reimbursements and punitive regulations that negatively effective the doctors' bottom lines.

Republicans have a hard time countering the Democrats'  compelling emotional arguments which are highlighted by plaintive anecdotes of potential loss of coverage of those by those now subsidized by a "compassionate" government.  

Never mind the unsubsidized middle class no longer able to afford higher premiums and sky-high deductibles. Emotional arguments are more effective than rational arguments about the unsustainable costs of open-ended federal programs.