America’s failed attempt at a single-payer system, the Indian Health Service

Contrary to what you may have been led to believe, the United States has already tried its hand at a pseudo-single-payer system. The VA is one example. Another, albeit less highly publicized, is the Indian Health Service. (via WhiteCoat)

Based on an agreement in 1787, the government is responsible to provide free health care to Native Indians on reservations. And, as you can see from this scathing story from the Associated Press, that promise has not been kept.

The numbers don’t lie:

American Indians have an infant death rate that is 40 percent higher than the rate for whites. They are twice as likely to die from diabetes, 60 percent more likely to have a stroke, 30 percent more likely to have high blood pressure and 20 percent more likely to have heart disease.American Indians have disproportionately high death rates from unintentional injuries and suicide, and a high prevalence of risk factors for obesity, substance abuse, sudden infant death syndrome, teenage pregnancy, liver disease and hepatitis.

And, after Haiti, where in the Western hemisphere do men have the lowest life expectancy? It’s on Indian reservations in South Dakota.

The primary reason, not surprisingly, is lack of money, compounded by a difficult time recruiting physicians and other clinicians. Indeed, many Indian health clinics cannot “deal with such high rates of disease, and poor clinics do not have enough money to focus on preventive care.”

So, if you’re in the camp that supports a Medicare-for-all-type solution to our health care woes, consider how that same government, whom you’re entrusting to be the single-payer, has neglected the Indian Health Service.

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  • anonymous

    Not sure I agree with your conclusions. Have you ever been on a reservation? I have. The level of poverty is striking. Reservations often are located in some of the most remote, rural regions of the U.S. There are issues with unemployment, alcoholism and loss of cultural identity and traditions. While it’s true that some tribes are making money from reservation-owned casinos, the wealth is not spread equally. Many of the tribes – the Mdewakanton Dakota, for instance – have been using their casino money just to catch up with basic infrastructure needs.

    I would say the real roots of the disparities go far, far deeper than how the Indian Health Service is funded.

  • Chukwuma Onyeije

    I’m surprised to see such a blatant “straw-man” argument on a blog that I read daily and have come to respect. You (via Whitecoat) conveniently mention the VA but then do not detail the fact that they get similar health outcomes to private hospitals with a 3 percent overhead (as opposed to the 30% overhead elsewhere).

    Obviously there are clear cut and readily recognizable confounding variables which account for the poor health outcomes on Indian reservations. I could easily make the statement that their outcomes would be WORSE if they were to have privately funded insurance for coverage. (Don’t expect Blue Cross to jump at the opportunity to prove me wrong on this one).

    Indeed, it is not fair to say that the outcomes seen in the IHS would be transferred the US population if we changed the way in which health care is funded. I think you would see similar statistics only if the US population as a whole fell to similar levels of abject poverty, illiteracy and institutionalized underprivilege.

  • Duncan Cross

    If you’re in the market-reforms camp, consider how the health insurance industry has utterly failed to provide Native Americans with affordable alternatives to the IHS. Left to the market – without IHS – many would have no health care at all. As much as IHS sucks, half a year’s care is better than none.

    Yes, the way our nation treats Native Americans is shameful and embarrassing, but it’s not that we’re incapable of doing right by them.

  • been there

    Anon 11:13. Much of you say is true and is certainly a component but having worked in the IHS, the system is definitely a huge part of the problem as well. And much of the problem, as Kevin says, is due to underfunding and even more bureaucratic interference than with Medicare. I have worked in all of our single payer systems (VA, military and IHS) and my comments about them would have to be less than complimentary.

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  • Chukwuma Onyeije

    been there: Clearly there will be criticisms for any “health care system”. This should not allow us to avoid the obvious fact that thre are no viable “market-based” alternatives or ideas for those currently in publicly financed healthcare (Medicaid, Medicare, VA, Military, IHS). And, as I have stated elsewhere, in SOME respects Medicaid, Medicare and the VA put private insurance to shame.

  • PNHP doc

    Your dogmatic dislike of single payer leads you to ignore the complexities of the situation with the IHS. The Indians’ culture has been systematically destroyed over the last 4 centuries. They have rampant rates of diabetes, thanks in part to genetics and in part to their over-reliance on processed foods (since in the past they were prohibited from growing their own produce). They live in some of the most remote locations. They have an understandable mistrust of Western medicine. They have horrific rates of poverty.

    I’m really losing respect for your blog with your persistent bashing of single payer.

  • JPK

    Seriously, because single-payer is really going to turn our country into indian reservations? This is an argument from a third grade civics class. Might there be some confounding factors there, to use the medical lingo? Let me see: a history of poverty and racism, social ills, rural issues,…

    By the same reasoning you’re using: amongst developed countries, which countries have the highest life expectancy? All of those with single-payer healthcare systems. And you mention the VA, pretty good healthcare last I checked.

    You’d best stick to medicine if your policy arguments are going to be like this.

  • Anon

    Did the government fail or did physicians? They talk about how if they get this protection or that protection then people will get more and better care. Does the government not pay enough and is there not plenty of liability protections for physicians to work on a reservation?

    Is it possible that physicians are pretty full of crap and that they’re not heading to rural areas like reservations no matter what you give them? Almost certainly.

  • Aftercancer

    Are you kidding me? You’re going to determine whether we can have coverage for all based on the hideous way we’ve treated Native Americans? I don’t need to say much more on that subject as commenters 1, 2 and 3 have covered it.

    Perhaps you can explain to me why the health and life of a 65 year old white man is so much more valuable that the health and life of a 64 year old anywhere else in the country? Because I sure don’t see people screaming to be taken off of Medicare.

  • not kevin

    It’s really too bad that these posts sneak through because I like about 70% of what you post. Your argument about the IHS is disingenuous and dismissive and makes me wonder if I should continue reading this blog.

  • K

    “compounded by a difficult time recruiting physicians and other clinicians.”

    It seems to me that doctors have let the Native American population down. Money is everything.

  • Reality Rounds

    So you are using an example of how America has decimated an entire race of people, and pushed them to live in abject poverty and sickness, to further your own agenda of arguing against a single payer system?

  • Kevin

    Thanks all for your comments. Nothing like a dissenting single payer post to incite the fury of my readers.

    The concern is that in the two major systems where the government is relied upon for providing health care, namely, the IHS and the VA, both those systems are seriously underfunded, and especially in the case of the IHS, to the patient’s detriment.

    Is there no worry that that same government won’t also underfund an entire, nationwide system? I don’t think that’s an unreasonable question to ask.

    There’s something to be said for past performance.


  • been there 2

    So let me get this straight; because there are “confounding” issues for Native Americans, the single payer crowd lets the IHS ( Feds) off the hook for the poor quality of care that their patients receive? We can ignore that example of federalism because it really does not (or cant POSSIBLY) apply for the rest of us?
    I have worked on the Yankton Sioux reservation, the Rosebud Sioux reservation and the Navajo reservation (at Chenle) as a primary care physician. I have also worked for the uninsured migrant farm workers (read illegals) in Colorado. Health care delivery is abysmal for all groups due to indifference, bureaucratic infighting and lack of funding from the Feds. If it were not for the “safety net” of private institutions in Rapid City, Denver or Phoenix, where specialty care is available, the numbers would be worse. For those who think the private sector should do more, you know little about the private sector surrounding the IHS/migrant systems.
    If you believe that the care is good but the numbers are bad because of “confounding issues” why are there no lines of people from Rapid City, Denver and Phoenix to go to the IHS clinics and receive their high quality care and not have the “confounding issues” of reservation life?

    Kevin’s post is spot on. And the best predictor of future performance is past performance. Only when the Feds can take care of their current responsibilities, will I encourage them to take on new ones.

  • Tom

    Here in Canada we have trouble providing decent care for Natives, too. However, it’s just an indictment of how we care for our Natives, not of the system as a whole.

  • R Watkins

    A single payer system does not require, as in the examples you have chosen, that the physicians, nurses, etc. be employees of the system and that the system own and manage all health care facilities. Isn’t Medicare a single payer system for a specific population that works well, with high patient satisfaction?

  • Chuck Brooks

    So the US Government does not honor it’s committments? I’m shocked, utterly shocked! But, they’ll do it better this time around, really they will; they told us all they would.
    Chuck Brooks
    FutureWare SCG

  • Anon


    What would you consider adequate funding? Is it a certain $ per patient? Without knowing that it’s hard to put much stock in your fear.

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  • Repair teh all system.

    I don’t believe the solution to the health care problems in the USA is going to be solved by simply “attacking” the insurance companies.

    If the hospital charges me 2 thousand dollars for an emergency room visit when I had a fever then the insurance company has to get this money from me, or it has to beat the price down.

    Isn’t it the problem that the hospital charges too much?

    Is it the insurance company’s fault that the hospital told me to do 5 different tests before I even saw a doctor? Should I have refused these tests?

    Is a public insurer going to be able to beat the prices down better than the privet insurances? Yes! The government will control it. It will become the biggest insurance monopoly. All the other insurance companies will loose out. And then the government will control the money going to the health system.

  • IVF-MD

    Let’s agree that we can’t say 100% for sure whether a single-payer would be overall BETTER or WORSE. What is feared is that if we switch over and things go down the tubes that the harm will be irreversible and we’d be stuck with a terrible system and we couldn’t recover our previous system. How about this? Experiment on a state level. Choose 1 or 2 states to go to a single-payer model. Ideally, if possible, this would be done randomly. Wait two years and see if there is a difference in quality of life in those states as compared to those which stay in the current system. That would go a long way to learning the truth rather than having people continue to state their opinions as if they were facts.

  • been there 2

    R Watkins:
    A single payer system pays somebody. To whom does it pay? The housekeepers? It pays the nurses, physicians, and all health care personnel involved with health care. We all become employees of the Feds or their designated middlemen.
    “Isn’t Medicare a single payer system for a specific population that works well, with high patient satisfaction?” Works well for whom? Not for the patients if you want a physical examination anytime after age 65 (read rationing) or for the providers who get 39 cents on the dollar, denied claims for services and a nightmare of coding. Have you not heard of the annual congressional debates about medicare funding?
    Anon 2:25 How about just enough to bring the infant mortality, physician/patient ratio, premature death from untreated diseases (forgoing the alcohol, tobacco and firearms premature deaths) in line with the surrounding White communities. If the Feds do that, then I will sign on.

  • SIllIMMD

    I have reservations about single payer, but this post’s argument really threw me for a loop.

    p.s. I’ve been in the military system. I don’t think it is worse than my current private insurance.

  • Ayse

    i agree that we need to consider the possibility of underfunding issues but i am not sure if your va example is well-founded. during my mph training, my 3 military physician classmates (2 army, 1 navy) constantly argued that va sytem was far superior health care delivery system than the outside va. in addition to delivering up to snuff medical care, they insisted that their emr system allowed them to conduct state of art studies hence established evidence-based cost effective care. maybe we should look how these systems manage with less funding so we reduce the unnecessary spending in our health care delivery. by the way, i think your north dakota example of ihs is also a bit flimsy. there must be some regional differences because the wa state ihs officials are very proud with their system, which apparently provides access to its citizens even outside their jurisdiction – don’t quote me on that because i heard not verified it. i believe picking one region and showing that as an evidence of failure of a system is not a sound way to go because there may be found numerous pockets of areas where the current system also fails to deliver adequate health. in any event, an assertion of comparing the health outcomes of two distinct groups of cultures and attributing the result to one variable without controlling for all the other variables is just an anecdote.

  • R Watkins

    Been there 2:

    I see your points. Just a couple of thoughts:

    1. Many private insurances are now paying at 85-90% of Medicare, with much greater hassle factors;

    2. Physicals are a non-covered service for Medicare patients, so they are free to privately contract with the physician of their choice at a mutually agreed upon price. I wouldn’t consider that rationing;

    3. My private insurance premiums have increased at a much greater rate than Medicare funding over the past 20 years.

  • David

    This has been a fun series of comments.

    I think the underlying health and wealth of the population has been appropriately pointed out to Kevin as a confounding factor in this case.

    Interestingly, that same argument should be applied to the ridiculous evaluations of the American health care system. Our world ranking (#16 I believe) is in part due to obesity and lack of exercise in our population. We have, in fact, the best health care system in the world. Cancer survival rates give you a good view of this – and they are the highest in the world.

    As to the native americans – the establishment of reservations was truly their downfall. They should have been encouraged to integrate into society as a whole – not to fester in useless reservations – specifically set aside so they could do nothing. They should have been encouraged to establish productive lives – not live off the teat of the US government. Finally, they should be distrustful of their own mystical/irrational heritage – not that of modern medicine!

  • lifeethics

    What is, is. The IHS and the VA are underfunded.
    The fact is that except where subsidized independently by the more prosperous tribe, the IHS runs out of money and does not provide adequate care.

    My experience with the VA is that it’s harder and harder to care for the patients who prefer to come to me rather than drive the 20 or so miles to a VA “provider.” And I hear that those “providers” are not likely to be doctors – they’re nurse pracitioners or physician assistants.

  • been there 2

    The Dawson Act did exactly as you proposed. It took children from their families, integrated them into white culture (at boarding schools thousands of miles away) and even forbade their use of their own language on the reservations. This was done all in the name of “bettering and integrating” the native population. The concept was if they “learned” White culture they would be better able to self sustain when they return to the reservation (or not). It succeeded only in dividing families and in their losing their own culture.
    The reservations are sovereign nations, no different than France or Germany. We have provided Marshall plan aid to most of post-war Europe. We provide continuing aid to multiple third-world nations with their respective governments deciding where to apply the funds. We do not ask the Germans to integrate. We just make a conscious choice not to provide sufficient aid for Native Americans. We blame the failure of the IHS on “confounding factors.” All of which seemed not to be present before the whites. But still it gets asked why they don’t integrate.
    Before you denigrate their “irrational/mystical” heritage, be invited to and spend some time in a sweat lodge. It may change your thinking.

  • Dr. Mary Johnson

    “Been There Too”, been there too . . . in the National Health Service Corps (NHSC).

    No oversight. No accountability. All government.

    And it’s our future, unless the reformers take the rose-colored glasses off.

    P.S. The postal service is about to tank too. Doesn’t bode well for government-run healthcare does it?

  • jenga

    If what obama is pushing isn’t good enough for his own family. I don’t want it for my patients.

  • David

    Been there 2,

    I guess we’re off the main subject but…

    I would never propose taking children away from their families – that sounds barbaric.

    I know these reservations are considered as sovereign nations – I just think it was a mistake to establish them.

    If they are established, then they should fend for themselves, not expect the surrounding country to provide health care to them.

    If their heritage is of such value, instead of adopting American values, then let it create jobs, wealth, and health care for them!

  • Anonymous

    Isn’t Medicare by far the biggest of the government medical insurance companies, dwarfing the IHS and VA and whatever else?

  • Anonymous

    Dr. Mary Johnson is exactly right. The Postal Service is a terrific example of how government run systems can disassociate cost/price from service. To mail a letter from LA to NY costs 44 cents and most American’s are irreverently frustrated with the price hikes. Fact is the “fair” price of moving a piece of mail that far is much higher, but we’ve convinced ourselves that Uncle Sam should float the bill for our mail.

    The same is true in health care. We’ve convinced ourselves that care has no cost…only co-pays. Government run systems perpetuate that illusion and will ultimately lead to awful rationing since, after all, care does have a cost.

  • jenga

    I think we are getting a far better deal than they are by just providing healthcare. We could and should do better by them. Think of it as incredibly cheap rent for the 99.9% of land that we took from them.

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  • David


    The American Indians didn’t really have a well-developed sense of property ownership. There were many competing tribes, some of whom were more peaceful than others, but, from my memory, they were nomads. Property (including land) ownership was established by the settlers, and is a very beneficial and productive way of doing business. It allows for long-term farming. It allows for towns and cities. It allows for nuclear power plants and hydroelectric plants. it allows a civilization to arise.

    All of this benefits everyone (including individuals who happen to be Indian). What is not beneficial is turning them into a welfare state. That is the motivation robbing and soul-destroying approach. Disaffected people are not benefited by putting a line around where they are living, saying ‘poor them’, and turning them into a welfare state – it only makes them worse (witness, Palestine).

  • Friend of Indians


    Old American Indian saying — if you think the U.S. government can take care of people — ask an American Indian.

    Like the VA? Just ask someone who’s waited in a very long VA line.

    To deny these realities is to be horribly blinded by facts. Also:

    - “A universal plan will reduce the cost of health care.”

    Think a moment. Suppose you are in an apple market with 100 buyers and 100 sellers every day and apples sell for $1 a pound. Suddenly one day 120 buyers show up. Will the price of the apples go up or down?

  • rezmed09

    Spending 1/2 the rest of what the USA spends :
    Free medications – free Lipitor, free Humira, pioglitazone.
    Free kidney transplants.
    Free Dialysis on 88 year olds – anybody no matter how sick.
    Free transport to major cities for the third cardiac cath and stent in a year. ($25K transport each time!)
    Free unlimited visits to the ER, urgicare clinic and primary care clinic – anywhere in the country where there is an Indian Health Clinic.
    Free consultation with cardiologists, hepatologists, neurologists, Mayo clinic, university medical centers….

    No fighting with insurance companies by physicians and mid levels.
    No fee for service incentives to do extra procedures – salaried staff.
    No drug company games with samples of expensive drugs.
    Evidence based formulary
    Less wandering care. Single medical record- a medical home before it was ever dreamed up, with all provider notes available in one chart and records going back often to birth.

    Downsides: frequently under trained and under qualified leadership – federally mandated.
    Isolation and living in impoverished communities -limiting retention and recruitment.
    Old buildings without carpeting

    The IHS is a government system of hospital in clinics in mostly isolated areas, caring for mostly impoverished populations that are often sicker than than those in suburbia. It is not a single payor system, not a government run insurance plan. Be careful how you compare it to other systems.

  • Rezmed09

    IHS is not a single payer system, it is a government run system – no comparison.

    But while your at it, it takes care of patients for half the price of the rest of the country. I would think that for half price off an insurance premium a large portion of americans might choose their care at the VA or some other system like it:
    Free medications: Lipitor, Actos, Humira
    Free dialysis – no matter how old or sick
    Free renal and liver transplants
    Free home visits by community health techs and nurses
    Free unlimited ER visits, Urgie care visits and free primary care (if like the rest of the country you can find a primary care doc)
    Free hospitalizations
    Free unlimited cardiac caths and stents and bypasses
    Free air transports to tertiary care centers for the above
    Free CT’s., MRI’s, Nuclear testing, screening tests, diabetes management, physical therapy, and some dental care —– Free.

    Of course it is not fee for service, everybody is salaried and there are pros and cons with that. Of course the IHS suffers from underqualified management and underfunding. Of course we don’t have carpeting in our clinics, or fresh flowers in the waiting room.

    Let’s be clear about this: IHS is not what most people are proposing. It is a health system run by the government in mostly isolated, impoverished communities caring for a very sick population of people. It is not an insurance plan. I sure am glad that there is a private sector out there, but I wonder how many people paying huge insurance premiums in the cities would like to pay less and get the care I get with my family here?

  • MHodak

    “Experiment on a state level. Choose 1 or 2 states to go to a single-payer model. Ideally, if possible, this would be done randomly. Wait two years and see if there is a difference in quality of life in those states as compared to those which stay in the current system. That would go a long way to learning the truth rather than having people continue to state their opinions as if they were facts.”

    Massachusetts and, to a lesser extent, California have already provided those preliminary results, and they look grim. If this is set up as an honest experiment, we need to look at those results comprehensively, i.e., not just the costs, quality, or access, but all three together.

    While the quality of care under RomneyCare may not have noticeably deteriorated, the costs have ballooned, and access is marginally better (i.e., far less than “universal”).

    And these results ignore a huge detriment to socialized medicine–its impact on innovation. If you’re counting on most cancers becoming treatable in another generation, under government “cost controls” you’ll have to recalibrate your expectations. When the U.S. government has turned our national health care into a giant, non-profit exercise, the world will have lost the last big market able to provide a return on investment in new treatments, especially for less common diseases.

  • PNHP doc

    Kevin, you’re right that the VA and IHS are woefully underfunded, and that Medicare doesn’t pay primary care doctors nearly enough, and your skepticism that something better can be created is understandable. But our government certainly does pay ridiculous amounts for medical equipment, unnecessary procedures and lab tests. And despite the government’s stinginess in certain kinds of payment, the VA’s superb EMR has allowed immensely valuable studies to be done, and has been able to decrease unnecessary care.

    So, if we can make a system that takes the best parts of public programs (covering everyone, having a uniform way to submit claims, employing a well-designed, proven, nationwide EMR) but improves upon them (for instance, by increasing payment for primary care and other cognitive services, by decreasing payment for procedures, by streamlining hospital stays by investing in discharge planning services, and by declining unproven and unnecessary procedures), we just might come up with something great.

    For instance, if we had a VA-like system, we could fairly easily figure out which GI docs are doing more colonoscopies than others, and examine why. Do their patients really need them or are they just padding their belts? Do the stable cardiac patients getting yearly echos really need them or are the cardiologists simply referring to their on-site imaging suite routinely? Are certain doctors doing a lot more imaging studies than others?

    Doctors don’t want anyone interfering in the care they give, but we need to really look at this overusage and try to address it, because it’s bankrupting our country. I’d rather be at the mercy of the government than at the mercy of capricious insurance companies.

  • Rezmed09

    “Massachusetts and, to a lesser extent, California have already provided those preliminary results, and they look grim. ”

    Is Massachusetts a single payer system. I don’t think so. It is a complex, multi-tiered health coverage morass.

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  • MHodak


    True, RomneyCare is not single payer. It is, however, much closer to “ObamaCare” than any other live system, and therefore more relevant to the current debate about our health care system. Also, there is a strong argument to be made that any private system that is forced to compete with a public one will invariably degenerate into a (government) single-payer system, so a critique of RomneyCare as a proxy for ObamaCare is highly relevant on that score as well.

    Fundamentally, though I was agreeing that it is a good idea to pursue more local experimentation with any idea than to go all in with a federal plan for insurance, care, etc.

  • IVF-MD

    I can’t help but conjecture that the reason the powers-that-be are opposed to tiny reversible experimentation is that they wish to push their agenda, regardless of whether it’s actually better for the people or not. They fear that careful state-by-state experimentation will reveal the truth, that a system not founded on free-market incentives will breed patients who are not as motivated to limit their utilization (when possible), doctors who are not as motivated to provide their best effort, researchers who are not as motivated to work towards new technology and administrators who clog up the system with inefficient bureaucracy.

  • alex

    “So, if we can make a system that takes the best parts of public programs (covering everyone, having a uniform way to submit claims, employing a well-designed, proven, nationwide EMR)”

    This is how I know you don’t work at a VA. Vista is an archaic piece of crap compared to modern EMRs. It’s painful to have to go from using something designed after 1990 back up to the VA to wade through the 50000 useless “nursing instruction” notes and other detritus.

  • Bohdan A. Oryshkevich, MD, MPH

    I would agree with the fact that IHS care is substandard. I trained in Canada in the single payer health care system and my first job upon returning was on the Sisseton Wahpeton Indian Reservation in South Dakota. That was better than Rosebud where I also worked. I witnessed the tragedies there. Diseases that did not receive the most basic diagnoses. I felt like an angel of death in which I made diagnoses on illnesses that had not been made for years. There was a backup of such cases.

    The ultimate responsibility and failure of the Indian Health Care System is the lack of primary care physicians to screen patients and provide basic care and an efficient referral system. The IHS “medical home” is a clinic with no competent physician present or at most a NHSC provider who is there temporarily and is paying his time (just as in prison) to deal with his loans. That medical home may be well equipped but without a doctor it is pretty much worthless.

    It is unfair to compare the IHS to a single payer system or at least what a single payer can accomplish. Unfortunately, there are very few people in this country who understand what health care reform would entail let alone what a single payer would entail. That includes the PNHP people whose presentation is more like a Hare Krishna mantra than a dialogue with American society. They have little or no legislative and/or implementation experience. They do not understand what universal health insurance with global budgeting means. They are like 1989 Russian liberal communists wishing for capitalism and a market economy. But they have no way of getting there. So Russia ended up with a business mafia and oligarchs and massive corruption.

    ingle payer requires a certain political and social culture. It also requires a leadership that can speak to the American people and deal with its fears. People do not want Medicaid and they do not want the VA and they do not want the HIS. We would have to all understand what the preconditions and rules are. You cannot jump a queue in Canada like Steven Jobs just did. He would be the scum of the earth in Canada. No politician could do it. A politician or a millionaire can go for some marginal treatment in the USA at his own expense, but that is it. I know I treated NHL players and they got the same treatment as anyone else. I treated the Molson’s and they got the same treatment as anyone else. I had a distinguished Senator and Minister and he was in a four bedded room with three ordinary patients.

    Also, if our fourth column in society and in health care works to sabotage a single payer, we may end up with an IHS type “single payer” from which people will flee. The single payer can become a football (soccer type) between the Republicans and Democrats. At great cost we may abandon it.

    There is some logic to a public plan as proposed by President Obama. But that is a half way solution that probably will not work. It is simply not holistic.

    The reality is that the private insurance companies here are just as bad as the IHS. We do not have the discipline to create a Dutch type system where productive (actually subsidized and heavily regulated) market style competition works to provide universal health care.

    I am not optimistic.

    Bohdan A. Oryshkevich, MD, MPH

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