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
Introduction
\
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.
Theme
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.
Costs
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.
Optimism
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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