Healthcare: Public or Private?

Amid all the hullabaloo about repealing the Affordable Care Act a little noticed meeting took place in Dallas in June.

Dr. Tom Price, the Secretary of Health and Human Services and former Georgia Congressman, met with eight Dallas doctors. How they were chosen is uncertain but the mix was representative of one of the things wrong with healthcare in America. Six of the doctors were male and represented surgical subspecialties or anesthesia. Two members were female and were family practitioners. The minimalizing of primary care input into the debate is regrettable.

The HHS website reported on the meeting that it was very long on complaints but very short on suggested solutions. Sort of like the majority party in Congress.

I have contended for some time that if I gave anybody a magic wand and said “Fix healthcare in America.” That person would be unable to come up with a solution acceptable to all.

President Obama reportedly said,” If we were starting from scratch, a single payer system would make sense.” But we aren’t starting from scratch. Our health insurance system evolved as a way to give workers benefits without raising wages. Then unions fought for it and it became an expectation. Then President Nixon introduced the Health Maintenance Organization Act of 1973 and the “BUSINESS” of Medicine was off and running. And thus we have large hospital organizations that one doctor said are really only construction companies funded by sick patients. It is hard to pass a hospital these days without a crane in the sky signaling more building. And those buildings must be utilized and thus the other thing difficult to escape is advertising billboards on major thoroughfares. Did you know the United States is only one of two industrialized country that allows direct advertising of prescription pharmaceuticals to consumers? (New Zealand is the other)  “Ask your doctor…”   has become as ubiquitous as “This Bud’s for you.”

Say what you will Big Pharma, Big Insurance, and Big Hospitals are not going away. I have always believed that single payer with its lower administrative overhead and universal coverage was the best solution in a perfect world. And it still may be the solution America ultimately comes to. But what do we do about all those health insurance executives and employees?

Consider this before you answer. According to CMS (the agency that administers Medicare/Medicaid) there is roughly one Medicare/Medicaid employee for every 21,800 insured lives. For Health Insurance Companies there is one employee for every 340 insured lives. In other words a CMC employee handles 64 times as many lives as does an employee of private insurance. Score one for single payer.

But are we going to put over 500,000 people out of work? I think not. So is there another way to consider? Many students of healthcare policy advocate for a system like Switzerland’s which utilizes private insurance. Although it is the second or third costliest of the industrialized nations it is still 6% lower as a percentage of GDP than the U.S. (17.3 % for U.S. and 11.5% for Switzerland). So a Swiss system might save 6% of our GDP, a significant amount. So what are the tradeoffs to an annual saving of upward of a trillion dollars? The tradeoffs are: 1) Coverage is mandatory. 2) The Government defines the basic minimum policy that must be offered. 3) The Government controls prices for hospitals and doctors.  And 4) although now only a Swiss healthcare proposal, Government negotiation of drug prices will produce further savings.

For conservatives the “G” word is anathema. But they must face the facts that no profit driven system for healthcare has ever worked without some control on usage and pricing. Somebody has to decide how we use these resources. The doctors who met with Price want unfettered ability to treat and charge what they like. I did too when I was in practice. But we are only a small part of one of our nation’s obligations to its citizens: to promote the general welfare. To solve the problem of healthcare we are all going to have to give up something. If we can agree on that then maybe a compromised solution will be possible.