Single-sayer

I rise yet again to speak of health care reform. In part, it's because I've begun to hear from Obama tiny echoes of parts of what I've been saying; and, in part, because I still believe I'm right (and I'm not sure he does): the solution will require a single-payer system.*

Among physicians, I'm part of a small minority who share this view. So let's address the objections of doctors: dressed in one kind of finery or another, they really boil down to one thing. If there's a single payer, they worry, we'll lose all control. Well, the thing is, we already have. And in having dozens of insurers, it just makes the screwing more of a cluster-f*ck.

Here's my point: Medicare is the US version of a single-payer system, and overall it works pretty well. Its administrative costs are low, it handles millions of patients fairly efficiently. And, if it needs pointing out again, it's NOT the same as the Canadian or English system: single-payer does NOT imply a nationalized system, with only public hospitals and public employees. But here is my point: in the US we have, in addition to Medicare, countless private insurers; yet Medicare is still the ruling force. When it changes fee schedules, so do private insurers. When it establishes certain performance criteria, so do the others. As an interesting example, when the outpatient surgery center at which I worked was seeking certification that would allow it to receive payment from private insurers, it had to get Medicare certification first, even though it did not, nor intended to, have Medicare patients. No private insurer would accept it until it had Medicare approval. We already have, in other words, a single entity that calls the shots. Except it's worse than that, because there's all these other sub-entities with more rules and layers adding cost and hassle to the operation (while expropriating money out of it). Loss of control to a single payer? We're already there. So why not simplify the system?

I have no idea how many billions of health care dollars are sucked away from the bedside by the morass of private insurers, but it has to be a ton. A ton of billions (!?) From the salaries and bonuses of insurance executives, many/most of whom make WAY more than doctors, to the profits of investors (how does it make ANY sense that people can invest in health insurers and make money from it, pocketing patients' dollars that were spent with the understanding they'd be spend on their health care?), to the tens of thousands of workers in cubicles of hospitals and businesses and carriers all across the country, doing nothing but data-entry and/or permission-getting and receiving in the convolutions of countless plans and regulations; while money intended for the provision of care is going to anything but. In elimination of redundancies, in ending the siphoning off of profits to people who have nothing to do with providing health care, with a single set of rules a single-payer system will save billions.

Properly constituted, the control issue can be addressed, and it must be. As I've written elsewhere, my concept includes a sort of board of directors composed of "providers" (great bureaucratic word, that) as well as consumers. Ideally, there'd be meaningful regulations allowing effective input on reimbursement and rules, and avenues for reevaluation and recourse. But here's the thing: I'm feeling a little less sympathetic to docs and their money worries than I once was, and it's not just because I'm retired. They have it pretty damn good now, way more than I ever did, and the trends are that it'll get even better. I refer to lifestyle. Hours worked. Stresses. If I'd had it then like they have it now, I'd never have burned out. I'd still be working.

Okay, I realize it's not yet universal, and that many docs still work like I did, and that they're burning out in the same ways, flaming in sputters as they spin into despair. But the ground is shifting. As I've described, in more and more hospitals there are round-the-clock hospital teams caring for all inpatients and covering emergency room consultations. Working predictable hours, well-paid for their efforts, they have a damn fine lifestyle: no calls at home, an orderly and planned life. And for the office-based docs in those communities, it's the same. Since someone else is admitting their patients and making the hospital rounds, seeing all comers in the ER, their lives, too, are orderly and predictable. No more going to the emergency room in the middle of the night. No more hospital care at all. Pretty sweet. Practically bankers' hours. (Of course primary care docs, given their much greater numbers compared to specialists, never had to do that very often anyway, assuming they were in a call-sharing situation.)

My former surgical partners, in addition to making more money than I ever did, no longer have to worry about interrupting their office schedule with a run to the emergency room, nor to break out of their operating list to take stairs two at a time (I could do a whole set of stairs in one motion, leaning onto the rails way down and swinging to the bottom in what was, for a lummox like me, a pretty acrobatic move. I have long arms and legs) in a rush to the ER to find god-knows-what. Not even, if they so choose, to worry about an emergency take-back on one of their own operative cases. It ain't a bad life. Ain't a bad life at all. If a single-payer system would be in some ways onerous to them, well, it's not as if they're suffering that much any more, in the ways that matter.

I've heard it said that Barack Obama, politics aside, prefers a single-payer system but feels it's not politically doable. Don't know if that's the case or no, and it'd take a hell of an effort and lots of political capital, as they say. But the idea to which I referred at the beginning of this post, and to which I heard him allude recently, is the other reform requirement I've also advocated: the need to identify those docs who provide the best care, to figure out why it is, and to spread the word. Not as a way to reward them and not the others (although that, I think ought to be part of it), but simply as a way to find out what's working and what isn't and to educate those who need it. For that, I'd be happy to sign up. Because, naturally, what I did was coster effective and resulter producing than most of my colleagues. So I aver.
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*On cue, the House Republicans -- in addition to skewing the tax burden even further away from the wealthy than Bush did -- propose in their latest late budget to privatize Medicare! So they'd take the one deliverer of medical care that does so efficiently and lard it with private insurance, which, most clearly, would increase the costs!! It's as if they want to be seen as irrelevant and incapable.


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