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.


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H.E.Butler III M.D, F.A.C.S. said...

1. T. R. Reid' wrote "The Healing of America." Has anything surpassed it?

2. Given the rancor associated with this issue, should we settle for separate plans for our several states and
various federal entities (VA, DOD, IHS, etc)?

3. The British doctor in charge of the N.H.S. in 1997 said over cocktails in Philadelphia that he estimated their
administrative cost to be 7% - 9%. Canada's costs have been quoted at 12% - 14%, and ours at still higher
rates, over 30%. What is a fair estimate today; why do our costs exceed costs in other countries?

4. "Donations of Professional Services" is a Virginia tax-credit for charity-care by doctors, dentists, and lawyers.
Is such a law relevant to finding a solution to this problem? Why not adopt it for federal taxation?

H.E.Butler III M.D., F.A.C.S.
Commander, U.S.N.R., Fleet Reserve
Instructor, Psychiatry, E.V.M.S.

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