December 19, 2003

Single-payer opponent Rangel quotes Sam Gamgee

Anyone who can manage to quote Sam Gamgee in a post about single-payer health insurance is certainly deserving of a response.

But rather than "nit-pick every detail and nuance" of Chris Rangel's most recent attack on the idea of a single-payer system, I'll stick to rebutting the general themes.

First, there is a lot that Dr. Rangel and I agree on. Most importantly, I think we agree that it would be easy to design a system of universal health insurance that would be a disaster. I, like Chris Rangel, have little faith in bureaucrats.

The question, though, is not whether or not our health system will suffer the indignities of lazy, self-important functionaries. They will plague us under a public single-payer system and under any version of our current private/public compromise system. The advantage of a national system, at least from the perspective of total health-care spending nationwide, is that the current duplication of bureaucratic functions would be unnecessary under single-payer. A physician who sees a patient in his office wouldn't have to wrestle with all the different forms he has to deal with now, and which sometimes require that he hire more office assistants just to deal with the paperwork.

Of course, if the system were designed poorly there might be more necessary paperwork, but the argument that mistakes are possible should not be dispositive.
At some point, we have to weigh the risks of trying something else with the continued harm of continuing along our current path. Perhaps Dr. Rangel and I simply disagree about where we should jump off our current health-care train.

Another general theme I'd like to emphasize is rationing. We both agree that rationing takes place under either system--it has to, since we don't have the resources to meet the demand. We disagree, perhaps, about whether rationing would be done better under single-payer than it's done now. Some thoughts:

First, it seems odd to me that we have on one hand what seems like extravagant overspending and overuse, and on the other hand we have underavailability and underuse. Dr. Rangel points out the cases of possible extravagance very well, both in his original post and in his follow-up. But I don't feel that he acknowledges the extent of the opposite problem. One of the reasons that people seem to "love" their ERs is acknowledged by Dr. Rangel--the ER is overcrowded with "people without insurance as their only point of access to health care, [and] up to a third of these visits are unnecessary or inappropriate for what the ER was intended to be."

One of the strongest arguments for single-payer national health insurance is that it would relieve the burden on our nation's ERs. Patients with access to a primary-care physician who has seen them before and knows something of their medical history don't choose to go to an impersonal ER and wait for hours to be seen by an overworked doctor who is primarily interested in turning over the bed to make room for a sicker patient. Although ER nurses and docs are routinely abused by patients who act demanding and entitled, I believe it's short-sighted to simply say "that's how indigent ER patients 'are.'" Put yourself in their position. They're just as frustrated as we are. But they usually don't have blogs or other avenues for rationally airing their grievances, so they (unlike us) tend to take it out on the ER staff. Admirable behavior? Certainly not. But it is understandable.

Under a single-payer plan that gave these patients access to a more appropriate health-care arena, I don't think they'd "love" the ER as much as they do now, when it's their only option. The immediate effect would be a more rational and efficient use of health-care resources, even assuming no changes in overall spending. This would be better for all of us, whether we're indigent or not.

Dr. Rangel is also correct that health care spending doesn't correlate perfectly with measures of public health such as life-expectancy and infant mortality. I specifically do not mean to imply that we should reduce spending for Medicare and Medicaid; contrary to the implication in Dr. Rangel's most recent post, I would advocate increased spending for measures within both programs that went to the heart of what does influence life-expectancy and infant mortality: preventive health care. Why? It's cheaper, for one thing. Presumably we can both agree that efficiency is a good thing. But the chances of significantly increasing spending on preventive care under our current system is much less than under a single-payer system.

A private insurance company does not have much incentive to pay for preventive care. Unless a given patient will be covered by the company long-term, the insurance company's incentives are merely to deny payment for medical treatment of whatever variety. That's why utilization review is so heavily favored by private insurance carriers. Especially if the coverage is provided through an employer, and the employee is likely to change jobs every five years or so, why should any given insurance firm pay to prevent the diabetes that may develop twenty years from now? From the firm's perspective, preventive care is mere expense that can never be recovered.

Under a single-payer plan, all this changes. A citizen, by virtue of being a citizen, is covered. The incentive is to prevent costly illness through the judicious use of preventive care, and to ensure that the patient's years of productive good-health are as long as possible. This incentive will have to be transmitted to the decision-makers in some way, of course. In a private system the incentives show up in pure profit, but public systems have equally effective ways of communicating incentives. Especially if the national system covers everyone, there will be very powerful lobbies which work to keep costs down by spending adequately on preventive care.

What about catastrophic care, and (arguably) esoteric care like implantable defibrillators? Here's where the nitty-gritty rationing has to happen. Under our current system, if you're rich, and you want one, you get a defibrillator. If you're not, you don't. This method of rationing is sensible to the extent that it takes the preferences of the rich into account (you don't have to have one), but it doesn't make much sense medically. Think of the rich patient who doesn't exercise and smokes too much. If he can pay, he'll get the defibrillator regardless of how much he tries to render it useless. Meanwhile, the guy who works hard at a low-paying job and tries to stay healthy, but needs the defibrillator because of a congenital defect, doesn't get it. That's how advanced treatment is rationed under our current system.

Under a single-payer system, we might try to divvy up the defibrillators like we divvy up the transplanted kidneys and livers now. Patients who could benefit from them medically would get them faster than patients who would benefit less.

Admittedly, some people will get nervous here. In America, we're much more comfortable with unjust results that arise from providential inequities in the distribution of wealth than we are with any result that arises from our affirmative efforts to make things fair. But the unjustness of the result is not less for our comfort level with it. So here I'll have to dig in my liberal heels and say that we can do better. The fear of communism is simply overblown. We manage to ration organs, and we can likewise ration implantable defibrillators.

I won't address here the question of drug costs and the pharmaceutical companies, since Dr. Rangel chose not to respond to my arguments about this subject. I think it's rational that the drug companies learn to live with the lower profits that a single-payer plan would likely impose. Today's drug companies are the poster children for a single-payer plan, and "the conservatives" haven't been able to show why this isn't the case. I don't expect them to do so, either, since the drug companies' position is indefensible.

Posted by Carey at December 19, 2003 04:08 PM

Carey makes several well-reasoned points here. I happen to disagree with most of them, and base my friendy disagreement on the nature of governments in general and our government in particular. I have worked in socialized medicine (military).

To pick on my own little area of expertise, I do not think that giving everyone a primary care doc will fix the ED crowding problem, it'll just make it worse. When medicine gets socialized, so do the docs. Docs will do well, don't get me wrong, but it'll take all the incentive out of seeing patients. When you get paid up front, more patients is just more work, and that traditionally doesn't motivate anyone.

Office based docs won't be staying open any later or longer when health care is a "right", they'll be closing earlier. Pressure will be exerted on them to hold down costs and tests, so the patients will be coming to the ED.

Also, I fear for the budgets, and taxes, involved in socialized medicine. Every politician will add a pet project of some group to their campaign platform, and nobody is going to run on 'let's be fiscally responsible and stop paying for "x"'.

Many countries are trying socialized medicine, and are trying hard to pay for it. Given this country's aging demographics, and our politicians' proclivity to spend for votes (it works), we'll be at the mercy of the politicians who want to spend the most.

And I rant about bad behavior by ED patients, by the way, because my government has made it a law that we have to see everyone who walks in until they have had a "Screening medical exam", which they cannot adequately describe but are entirely willing to define after the fact. Oh, and dissuading anyone from having their exam is penalizable by up to a $50K fine, and loss of medicare money. I cannot limit, in any way, who I see or how they treat me, my colleagues or my co-workers. And I see about 40% of them for free.

Posted by: GruntDoc at December 19, 2003 04:52 PM