Medicare and single-payer

in Uncategorized | 17 responses

I am consistently baffled at why single-payer pundits want to put our health care in the hands of the government. People like Ezra Klein and Paul Krugman simply don’t know what they are asking for, and have zero insight into how restrictive Medicare really is for a practicing physician.

Their ridiculous reimbursement decisions, rules and restrictions are far, far worse than any private insurer. Roy Poses agrees:

This is also a reminder that those who put their faith in establishing a single payer health care system to cover all US citizens may be sorely disappointed. If a single payer system continues the irrationality, opacity, and susceptibility to political influence of our current single payer system, having such a system cover everyone might just make things worse.

My question to single-payer advocates, for which I have yet to receive an answer. How do you explain the miserable failure of the single-payer funded Indian Health Service? And before you explain that it’s underfunded, why do you have such blind faith that the government will appropriately fund a national single-payer system? I would honestly like to know.

Update:
So, the liberal dragons have awakened. Thanks for your responses Graham and Ezra.

Graham is particularly inspiring:

Why do I think we need to do it? Because of the mess. The mess of billions of dollars wasted on duplicated tests and administrative overhead. The mess that millions of people in the richest nation in the world decide between eating and buying their medications (which would often prevent doctor and ED visits in the first place), or that many honestly consider waiting out an appendicitis because they lack insurance and know their financial lives will be ruined by a $50,000 hospital bill. The mess that fragmented care complicates care so greatly. The mess that other countries can apparently do it”“and for cheaper”“and we apparently can’t. I could go on.
Why do I think we can do it? Because we’re America, god damn it. We’re the land of opportunity. Innovation. Creativity.

There are countless horror stories on both sides, so let’s get past the hospital bill anecdotes.

In theory, a single-payer system may result in less administrative waste, reimburse and focus on primary care, and provide universal coverage. It may look good on paper. And in a utopia where a government was knowledgeable about health care and had limitless dollars, it may work.

I’m sad to say we don’t live in that world. Medicare given countless examples why the government is inept in managing health, ranging from their inane coding rules, misguided emphasis on documentation, to their short-sighted and damaging cuts in physician reimbursement.

Yes, this is indeed America. A country where its government has turned a blind eye to Native Americans and Veterans, by critically underfunding their health care systems to the point of uselessness. I would not have tremendous confidence in that track record.

And yet, people are still willing to give them the keys. Call me a cynic, but be careful what you wish for. Forgive me if I don’t think these are the right guys for the job.

Comments

Evan
Kevin I really have to disagree with you. Obviously experiences in various regions are different, but out here in the West, Medicare is FAR simpler than most private insurances. Even more, in Nevada it is the BEST payer when you combine promptness and claim processing requirements.
Are you really saying that Medicare A and B are worse coverage where you practice than Medicare part C HMO plans?
Kevin
Evan,
You have a point regarding regional variation. I work in southern New Hampshire where the private plans I deal with are consistently top-10 in the country and pay 140% of Medicare rates.
Medicare is by far the more restrictive option for physicians, and cover significantly less services than most private plans I deal with.
On another note – as a single-payer supporter Evan, I am curious to hear your take on the single-payer supported Indian Health Service.
Thanks,
Kevin
Anonymous
Kevin–both Klein and Krugman have been advocating individual mandate style plans that, at most, give people the option to buy into Medicare. I’m not sure about the substance of your argument, but get better strawmen.
Kevin
Anon – that’s true.
However, if they had their pick in a utopia, single-payer would be it.
I don’t have time to find the links to where I read that, but they are supporting the plan that is most politically feasible and palatable to them.
Kevin
Evan
Kevin, IHS is poorly run because the policy of the US has been to give a fixed pot of money to the IHS and the department it is run out of is the BIA. The BIA was for long stretches of its history charged with genocide. That it is not the ideal department to run a health care service out of seems self-evident.
If I agree that the IHS is a poorly run example of single-payer, will you agree that the military medical care system, or failing that, the congressional health benefit plan is a well-run single-payer system?
Kevin
Evan,
I am not familiar with the Congressional plan, so I can’t comment on that.
I am familiar with the VA – and it’s benefits are its EMR and quasi-”universal” coverage for vets. That’s about it.
Again, it’s underfunded – which you can say for every government program. There are long waiting lists for appointments because of physician shortages. Their drug formulary is quite restrictive – much more so than a private payer plan.
It’s supposed outcome improvements are coming under scrutiny, and there are claims that they are exaggerated:
http://www.kevinmd.com/blog/2007/05/va-exaggerates-its-achievements.html
A single-payer system would be acceptable if it were funded and managed appropriately. I have zero confidence that the government can do either – as the IHS and VA single-payer systems has proven.
It is difficult for me to comprehend why single-payer advocates feel that the government would break this trend with some kind of national system. Why the blind faith Evan?
Kevin
serial catowner
Kevin, the short answer to your question is that the government will adequately fund and oversee the program because we’re white.
Strange to say, about 20 years ago I took your side of this argument in a long, and eventually bitter, argument with an old friend. Fortunately, this argument took place on a long drive to an Indian reservation on the Olympic Peninsula, where we drowned our differences in good scotch and better scenery.
Suffice it to say, you don’t appear to know anything about Indians or how they’ve been treated. This is not meant in an unkind way, nobody has to know everything about everything. But when you post, you should know something about something.
Incidentally, your link about Medicare reimbursement regs being more arduous than private insurers not only doesn’t actually prove that, but ignores the fact that Medicare and Medicaid pick up the tab for uninsured medically indigent people. Getting some care eventually is certainly a lot less arduous for the patient than getting no care at all.
Pei Loo
“because we’re white”
Looks like someone isn’t uptodate about US demographics. Minorities now make up about 30% of the population and in a few more years, this percent will be at or over 50%.
Evan
“It is difficult for me to comprehend why single-payer advocates feel that the government would break this trend with some kind of national system. Why the blind faith Evan?”
Of course it’s not blind faith. We have a system for distributing political power that vests ultimate power over EVERYTHING in the United States in the hands of the Federal government or its courts. You trust them with that if you live here. They can shoot you and if they justify it to themselves, they get off scot free. They can take all your property. You trust them with that power.
You also trust them with a monopoly on legally exercised force, police, fire protection, the protection of our borders, tax collection, management of disease epidemics, medical licensing, hospital licensing, regulation of tobacco and alcohol, food safety, drug safety, maritime safety, environmental protection and the oversight of all nuclear power.
Those are all pretty important things — not to mention the inconvenient fact that over 50% of all health dollars in the US already come from the government. So it’s not in any way a blind faith. It’s a statement that political power is easier to manage than corporate power.
Corporate boards never get elected by even their shareholders most of the time. CEO’s don’t have to be responsive to public outcries as long as the profits roll in.
Far be it from me to lionize congress, but every 2 years every congressperson does have the ability to lose his/her job and occasionally (as in 2006) they do.
Thus, ultimate power in the government in theory should come from the consent of the governed, whereas ultimate power in the corporation comes from the collection of money.
There’s no system that doesn’t require you to believe that one system is better than the other, but I can guarantee you which one is ultimately more responsive to the desires of the population at large — and it isn’t corporations.
Why do you put such blind faith in them when you chronicle their misdeeds in excruciating detail?
serial catowner
Pei Loo of course has a good point. I was simply speaking to the underlying dynamics of why Indian health care has been bad, and what about the situation would be different with universal single-payer.
Los Anjalis
So your question was this — How do you explain the miserable failure of the single-payer funded Indian Health Service?
VERY simple answer ANY MD should be able to deduce before yelling at single-payer advocates:
1. The IHS is underfunded.
2. The Fire Department is not.
That really SHOULD be the end of the argument.
I’d like to see what a privately funded IHS would look like, if given the same amount of money per capita. Actually, I fear for the health of the people were that to happen, so no I don’t want to see that.
With the caveat that I support a few different solutions to our mess, strictly speaking a Single-payer system would include ALL of us. ALL of us together have a damn lot more political power and say than some indians on a reservation who were screwed from the day we invaded their land and destroyed their culture.
And in regards to the Medicare issue (since we’re bringing up anecdotes too) — as an MD, I can count on being paid by Medicare in a timely fashion without having to call them up and argue with them about whether or not the care I provided was needed. And my patients who have Medicare are VERY satisfied.
The private market is superb at adding middlemen left and right — at every opportunity to suck some more money away from “cosumers” — hence the creation of things like the VISA Highmark Gift Card. There’s innovation for ya. Only in the US…
Anonymous
Actually, the “because we’re white” poster has a point.
Government healthcare does not iron out the healthcare access differences between socioeconomic groups. They may, in fact, make them worse, by taking away your money in taxes while forcing you to non-responsive providers.
The British call their unequal outcome “the postal code lottery”. Where you live determines the quality of medical service you will receive, even in the supposedly “equal” National Health Service.
When healthcare is a political entity, it responds to political pressure. The better-off know how to apply the pressure. They get better healthcare.
This may not necessarily translate to “white”….see the NHS….but it does translate to the “better-off”.
Speaking of unequal, Medicare does pay differently in different parts of the country, and even within the same state, from one county to another. To some degree, this may reflect what some observe, that Medicare is a good payer in one area, when a doc elsewhere says it’s terrible.
Part of the “postal code lottery” you will see in the USA if we get single-payer.
Anonymous
In my community….
1. The Indian health center is heavily funded.
2. The fire department is volunteer.
So, sorry. The Indian facilities are badly run because they can be like Central African Republics. Fiefdoms within the tribe, family feuds, factions, and not accountable in anything like a standard government facility, let alone a private charity.
The Fire Department, on the other hand, has two full-time professional firefighters, and everyone else is volunteer. They hold raffles and bake sales and sell T-shirts to raise money, and they do.
Moo-jae
Since no one seems to have actually answered your question as to why the Indian Health Service is in such shameful conditions allow me, Kevin, to venture some of your vitriolic sarcasm and try.
First of all– don’t even try to take things out of context. The current neglectful relationship between the Federal Government and the Tribal Nations isn’t a new development. The United States government has consistently and systematically dispossessed of the property, dignity and representation of Native Americans through forceful mediatization. Native American tribes aren’t just any immigrant minority. They are a separate quasi-independent political entity, exempt from various local and state laws and benefits. One of the reasons why proper health care has yet to reach Indian Reservations is because of the ambiguity and common misconceptions regarding the political status of Indian Reservations. Native Americans have consistently been treated as second-class citizens, and the pitiful state of federal health coverage towards Native Americans is not, as you seem to imply, the exception but the norm in Federal-Native American relations.
Yes Kevin, “every government program” is “underfunded”. But even amongst such “underfunded programs” there are those that get more scrutiny, attention, and help from the Federal Government and those that are simply left in the margin counting pennies. And between being “underfunded”, and being underfunded by more than “$1.7 billion short of parity with the benchmark mainstream health plan” is a big difference, don’t you think?
According to the Indian Health Service website (http://www.ihs.gov) and the Federal Disparity Index (FDI), “tribal health care delivery sites are funded at less than 60% of the benchmark cost.”
In fact, some of the main reasons why the IHS is having so much trouble catching up to par are listed as “rising medical prices” (at a rate of “approximately 5% per year”) and “adequacy of funding.”
Furthermore, under the 1975 Tribal Self-Determination law, Native American Nations can choose whether to allow the IHS to provide its services directly or to opt for self-determination and receive services on a compact/contract basis. As of 2007, only 42.6% of Tribal Nations were receiving direct services from the Federal Government. 42.6%, that is, of the Nations that HAVE coverage, since IHS currently only provides services (direct or contractual) to “1.9 million of the nation’s estimated 3.3 million American Indians and Alaska Natives.”
I’ll say it again. Don’t take things out of context. Native Americans and Alaska Natives have had to suffer from disproportionately high disease rates and lower life expectancy due to “inadecuate education, disproportionate poverty, discrimination in the delivery of health services, and cultural differences”, not to mention that the Native American/Alaska Native population is generally “younger, because of higher mortality” and “predominantly rural.”
I think the real question here isn’t why are we putting so much “blind faith” (as you so kindly pointed out) in universal health coverage, but why you are being so insistent on salvaging a system that is iniquitous and lucrative?
Anonymous
Well Kevin, since this is so baffling to you, let me explain a few simple aspects you are obviously missing.
First, the goal of the insurance companies is profit oriented, where a national system would be care oriented. Each system has pressure applied to perform well, in one system share holders want their profits, in the other the voters want their care.
Next, I understand why you might have a negative, even cynical, outlook on our government. It seems you have overlooked one of the many hidden expenses of our insurance system. Our health care dollars are being spent on multiple PR campaigns against ‘National Health Care’. For example, Devon Herrick a “fellow” from “National Center for Policy Analysis” is on the job right now, and paid to portray government in a negative light. It’s OK that you missed this, I know that just because you’re a doctor does not mean you have any education in psychology, propaganda or the ability to recognize it. In fact your heavy lean to the right would indicate just the opposite.
Ah, but you have looked at our “failed” government programs and they are not great. Since we are comparing apples to oranges, let’s attempt to understand the difference by placing the shoe on the other foot. Imagine if you will, a government program that only accepts the healthy people. Now, lets also imagine the insurance companies are forced to except everyone else, even if they can’t pay. I know you were not trained for this, but give it a try. The insurance companies would be a miserable failure wouldn’t they? And if there was any opportunity for profits to be skimmed off the top, the government system would be corrupt and wasteful. Yes?
The problem you are having with understanding the benefits of a single payer system is that you missed the fact that the government would have all of the funding that comes with covering all of the people. You also missed the corrupting influence of our health care dollars being spent on campaign contributions, lobbyists, and PR, all for the purpose of securing more of our health care dollars. With this corrupting influence in place, I sadly must agree with you, our government can not perform well. My suggestion is that we eliminate the problem.
Finally, Kevin, one last bit you seem to be missing. “Single Payer” simply means that the whole bill gets paid. What that means to you is that the whole bill gets paid, and you do not have to negotiate with a bankruptcy attorney for the remainder.
James Hovland, a product of freedom
Kathy
I am single mother. I am a cancer patient and I am probably a good resource for the pitfalls of insurance. That said, I am 100% completely AGAINST the government taking over my healthcare. First of all, I am tired of the issue getting muddled. What we are talking about is health insurance not health care. Health CARE is not the problem and single payer would simply transfer all the issues of health insurance from multiple entities to ONE entity. What is compromised is choice by such a system. If I have an issue with one insurance carrier, I have the option to switch to another. With one show in town, who exactly do we hold accountable? Roe V Wade was about privacy rights. Where is the right to privacy if the Federal Government has my most private medical info at their fingertips? This is the same as the Government entering my home without a warrant, imho. As the Federal Government cannot pay for the USPS which is something they are CONSTITUTIONALLY obligated to fund, SOcial Security which is nothing more at this point than a government sponsored Ponzai scheme, and has not shaved one single bad government program from the budget, the idea that they can do healthcare cheaper and more efficiently is the most ludicrous supposition I have ever heard and those that support such a system are simply selfish. To advocate the firing of millions of Americans, force Dr’s to become Government employees, cap salaries, deny coverage to those of us that don’t lead lifestyles that the government deems fit, place a price on my head as to what they feel is not too expensive, deny my rights to fight for my own life, and deem me a BURDEN TO THE TAXPAYER when I AM one of the 40% that pays taxes every year IS the most selfish thing I have ever heard. Advocates are stuck on FREE, not on compassion and it is just another case of wanting the few producers to pay for the many non producers and call it “Compassion”. True compassion lies in charitable contributions to hospitals that waive bills for patients who can’t pay, setting up fundraisers for these systems and passing legislation such as in LA that sets up charity hospitals funded by CHOICE not by MANDATE. As the government is responsible for the high cost of healthcare in the first place, we can fix the private system by removing the RIDICULOUS government interference in the private sector. Single payer is not a solution and will cause more problems than it’s worth. Even England has Private and those that can prefer the Private than the public. My Aunt who lives there, finds their system cumbersome, intrusive, degrading, demoralizing and way too expensive for the services provided. She is taxed at 50% of her income for this “cheaper” solution. After looking at all the paperwork caused by that Medicare everyone seems to want, I have come to the conclusion that Americans don’t know what they asking for and will trade liberty for safety. Those people, per Benjamin Franklin, deserve neither.
Kathy dx Sarcoma 2006
Amy
Medicare is short funded because it has no young healthy people. All sick and old people.
Taxpayers cover the old people, and private insurers are allowed to accept premiums but then deny coverage to the young. Doesn’t that bother you at all? You’re a doctor, right?
Nothing you’ve said convinces me that a public plan would be as bad as we have now. A federal buyer’s club, not AIG. There needs to be one nonprofit insurance company, or one government agency, either way could work.
And as a side effect, this new nonprofit payer / independent or for-profit provider sub-economy that would actually give capatism a real test, in that everyone involved would have the information they need to make decisions.

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