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.”  


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