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

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.

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.

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

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. 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.

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?

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.