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.
Related posts:
- Single-payer and the Indian Health Service
- Indian Health Service needs reform
- Single payer ills, part 2
- Single-payer: Forcing health care down people’s throats?
- Administrative costs and single-payer
- Single-payer in Sweden: A cautionary tale
- Single-payer: Read the fine print
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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.
http://www.google.com/hostednews/ap/article/ALeqM5ib68vdWk5593qkAQFLj5-f1k9GnwD98QK5NO0
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.
david
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.
“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?
If what obama is pushing isn’t good enough for his own family. I don’t want it for my patients.
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!
Isn’t Medicare by far the biggest of the government medical insurance companies, dwarfing the IHS and VA and whatever else?
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.
David,
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.
Jenga,
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).
KEVIN IS RIGHT
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?
http://online.wsj.com/article/SB124640626749276595.html
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.
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?
“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.
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.
“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.
Rezmed09,
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.
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.
“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.
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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