Why I Don't Support Medicare For All

I’ve been an advocate for universal healthcare since the ‘70s when I first became aware of such issues. But Medicare for all is a baaaad idea. There are better ways to achieve universal coverage and cost containment. Our federal government cannot be trusted with something as important as healthcare. A perfect example is Trump’s recent unilateral decision to stop paying insurance companies their cost sharing reduction subsidies, causing insurance premiums to soar for millions of people. Just think what he would do to a federally-run single payer system!

Even though there are government run single payer systems in other developed countries, such a system in the US would be a total disaster. Why? Those other systems work in countries where the federal government has the best interest of the people at heart. We have no proof this is the case in the US. Our federal government has the best interest of corporations at heart. (And, even though corporations are people (right?), that’s not going to help you any.)

For example, during the G.W. Bush years, he passed a law prohibiting Medicare from negotiating with drug companies for better prices. That’s pretty blatant. Drugs are so much cheaper in Canada because their medical system negotiates for better prices. (By the way, you can take advantage of that by having the prescriptions you have to pay out of pocket for filled through an on-line, mail-order Canadian pharmacy. Still perfectly legal. Bush tried to make that not so but couldn’t get it through.)

And when have you ever seen a government social program that wasn’t chronically under-funded? With the current conventional medical mindset dominating medicine, there is no way that we would not have rationing of healthcare. And the first to go would be anything conventional medicine considers alternative, the next would be the “less necessary” surgeries, such as those for pain from herniated discs. MRIs and expensive blood work would be regulated and more patients would be harmed and more physicians would get sued for missing diagnoses they couldn’t make because they couldn’t get the tests run.   

How could such a system be protected by the vagaries of whatever administration was in power? What would Regan, the Bushes, and Trump have done to such a system if it were already in place when they took office? What would happen to it if the radical right continues to gain momentum?

A single payer system would stifle medical innovation. If Ma Bell hadn’t gotten broken up, we’d all still be using rotary dialing.

Supporters of Medicare for all are also using funny numbers to support their arguments. They say that Medicare is so much more efficient than private insurances, with a 2-4% overhead compared to the 20-26% overhead for private companies. But that efficiency is achieved because they farm out most of the work to administer their plans to the private companies. And what they pay the private companies for that work is not included in their administrative overhead.

On the possible plus side, with a single payer system, it is easier to see that real wellness and prevention makes sense. It may motivate major societal changes, such as stopping the taxpayer subsidization of junk food, decreasing air and water pollution, outlawing cigarettes, taking real steps to make the workplace less stressful, expand parenting classes, and other such measures. But these advantages can also be gained by other ways to achieve universal coverage and cost containment that are not dependent upon the government. I have blogged previously about such a system.

So, please, give the matter some careful thought. If we adopt Medicare for all, we’d be jumping from the frying pan into the fire. You deserve better.

A Better Way to Pay for Healthcare

The insurance mindset is the wrong perspective to use to pay for healthcare. Insurance was designed to be a way to help people, corporations (I know it is redundant to list them separate from people) and other interests “manage” risk. Insurance is for situations that are supposed to be fairly rare but would have catastrophic consequences if they happened to you, such as your house burning down or suffering a long-term disability. The idea is to spread the risk out over a large number of people, charge each person covered a defined amount of money each month and pay out when a covered loss happens. These situations lend themselves to probability theory. Statisticians calculate the probabilities of said events, their projected costs and set the rates so that the company is assured a profit. Conceivably, you could go your entire life without your house burning down, getting in a major car accident or suffering a disability. But you buy insurance to cover your bets. The job of the insurance company is to take in as much as possible in premiums and pay out as little as possible in damages. That is why they often put up so many hoops to jump through when you have to make a claim.

But what are the chances that you’ll need healthcare at some point in your life? If you include preventative services, the screening tests that we’re all supposed to get, for example, the chance is 100%. So what is the risk that is being managed? Perhaps the insurance mentality got applied to healthcare in the early days because at that time people didn’t go to the doctor that often. They were much more versed in home remedies and many believed that hospitals were places to go to die.

Early health insurance plans were almost exclusively catastrophic. Regular healthcare wasn’t that expensive and wasn’t covered. Over time, our society’s relationship with healthcare has changed, and what we want our insurance to cover has changed. Health insurance is no longer just covering catastrophic events; it is paying for regular services. By moving toward larger and larger deductibles, insurance companies are trying to move their role back to that which is more appropriate for insurance, only covering potentially ruinous catastrophes, but is that what we want?

Goals to Aim For –  

Healthcare costs have increased. People’s expectations have increased. It is time to reassess what we are doing and devise a better, more appropriate way to pay for healthcare. These are the goals I think we should aim for:

  • Universal access – that is, everyone is covered
  • Everyone has access to the same quality of care. No one gets discriminated against because of how their care gets paid for.
  • The cost gets spread out over the entire population
  • People who utilize more healthcare pay more
  • Financial incentives for everyone to be healthy are built-in
  • Competition and innovation are encouraged and rewarded
  • The system remains in the private sector and is not run by the government
  • Health insurance companies as we know them go away. They have done incalculable damage to our society and have abused too many people. For them, we need to institute a corporate death penalty.

Communal Services –  

There are several communal services that we as a society have decided to offer to each other and pay for communally. We have public roads, public education, public water, public utilities, public transportation, public libraries, police and fire protection and a public military. What would it take for us as a society to decide that healthcare is also something we are going to offer to each other?

If you look at any given stretch of road, you don’t know when or how it is going to need to be repaired, but you know that it is going to need to be repaired at some point. So government agencies in charge of that stretch of road set up a repair fund. Every time you buy gas, a certain percentage of what you are paying for the gas goes into that road repair fund. When you buy your gas, do you feel like you’re buying road insurance? (Public tax money also goes into those funds.)

A similar argument can be made for an individual. We don’t know when or how much healthcare that person is going to need, but we know that they are going to need some healthcare at some point. Instead of private health insurance companies to pay for healthcare, we ought to have public utilities that pay for healthcare.

One Idea –

One idea is to divide the country up into five or six geo-cultural regions. Within each region, three public utilities would be licensed to offer healthcare plans. The utilities would be not-for-profit and would be run by public boards and all their financial records would be open to the public. Each utility would devise plans that they think would meet the needs of people. The bare minimum plan would offer the same level of services that Congress votes for themselves and get fancier from there.

We would achieve universal access by compelling each person in each district to choose the utility and plan that best suits their needs. (Such compelling has already passed Supreme Court scrutiny.) Then each person, each month, would get their “health utility bill.” If your employer wanted to give you a perk, it could pay your health utility bill for you. If you qualified for public assistance, the government would pay your health utility bill.  There would not be different coverage for different classes of people, just as rich and poor alike drive on the same roads. We would be able to do away with Medicaid, Medicare, the VA, Basic Health and many of those similar levels of complexity that just add cost to the delivery of healthcare.

A simple way to build in “user pay” and at the same time financially incentivize healthier lifestyles would be to add a “poor choice tax” to foods, alcohol, tobacco, motorcycles and such in the amount statisticians calculate that using that item adds to the burden of healthcare for the population. For example, the lifetime healthcare cost of a pack of cigarettes is estimated to be around $10 per pack. That tax would be added to the price of the cigarettes. Each month, the poor choice tax that was collected in each region would be divided among the health utilities proportionately to the percentage of people in that region that are signed up with that utility. This money would be used to help defray the cost of healthcare for everyone. Organic fruits and veggies would have no or low poor choice tax, while foods full of processed junk would have a higher tax. We have the data now to calculate lifetime healthcare costs of most lifestyle choices.

When we all have healthcare and it is easy to trace the money through the system, the financial incentive of the whole society would shift to real prevention. Right now, nearly every player in the healthcare system profits more the sicker you are. This is the real, unspoken reason for run-away healthcare costs that no one can seem to get a handle on.

Could something like this really work?

For a system like this to really work, though, we would have to also heal healthcare. People would need choices. I do not think it is right to compel people to participate in a system of healthcare that is currently the major cause of death in our society. That’s right. Today, going to your doctor for conventional medical treatment is now the third leading cause of death in our society. What would the medical profession look like if it were ethical to compel us all to participate in it? To be continued.

Copyright 2012 Steven M. Hall, MD

Insurance Companies and Healthcare

There are powerful and wealthy forces within the Healthcare industry that are working hard to keep your healthcare costs rising and the quality of your care substandard. And they’ll keep doing it as long as we all put up with it. Drug companies are one of those forces and it’s easy to understand their motivation. They are about sales. If you get better and don’t need to take medicine, they don’t make any money off of you. Therefore, they like treatments that reduce symptoms but don’t heal and resolve the core issues. That way, you get relief from the drug so you have good reason to take it, but then you have to keep taking it. Allergies, asthma, diabetes, hypertension, heart disease, strokes, hypercholesterolemia, osteoporosis, auto-immune diseases, thyroid problems, Alzheimer’s, depression, addictions and such fall into the category of conditions for which you would be given medications for the rest of your life even though there are proven cures and/or preventions that are steadfastly ignored (and even demonized) by conventional medicine.

As part of their business plan, the drug industry now has major control over medical research, the medical literature and medical education. It is an ingenious and very successful business plan. Train a carefully selected corps of caring practitioners to follow your every order then tightly control what information they have access to and manipulate your market to suit your purposes. Your poor health is their market.

But even though the tactics of the pharmaceutical industry are deplorable, their motivation is clear from the perspective of corporate behavior. But there are many more players in the healthcare industry who are equally responsible for the healthcare crisis but are even more devious in their tactics.

Hospitals, pharmacies, drug companies, surgical and medical supply houses, labs, physicians, naturopaths, chiropractors, rehab centers, supplement manufacturers and distributors…these are also obvious players who make more money the more people are sick and the longer they stay that way. And we wonder why healthcare costs are so hard to control.

I used to think that the only factors in the healthcare equation that wanted to cut costs and increase quality were 1) the people who bought their own insurance and/or healthcare, 2) the employers paying for insurance and 3) the insurance companies. I was wrong.

(People who get their insurance paid for have no incentive to save medical resources. As an extreme example, here in the Northwest, people with Microsoft’s Cadillac plan are at high risk for being over-tested, over-exposed to x-rays, over-scoped, over-surgerized and over-medicated. Microsoft is self-insured and they’re getting taken to the cleaners, not only by their employees and their families, but also by the medical community.)

I thought it was strange that the insurance companies didn’t do what the drug companies did and take control of medical research and education, pay for studies of the preventative strategies and start to really support preventative measures that are proven to keep people healthy and reduce healthcare costs. They certainly give a lot of lip service to cost containment. But I recently had an experience that opened my eyes to another major corporate force working to increase healthcare costs and degrade care. They’ve pretty effectively stayed hidden behind the smoke screen they’re spreading with all of their advertising.

My practice is very different from most physicians’. I’ve gotten interested in getting to the root of people’s problems and searching for ways to treat those roots so that people’s issues resolve. I’m not satisfied with just helping someone limp along with their health issues if there is anything in our power that will help that person.

Over time, I’ve moved away from the regular family practice model: running madly between exam rooms; to spending an hour with each patient, deeply listening, tackling multiple, complex and interrelated issues, doing a lot of education and such. As you might imagine, my practice stood out in the insurance companies’ data mining. They audited me to see what was going on. They couldn’t understand the one hour visits. They wanted me to do the ten-fifteen minute visits like everyone else.

I told them that I was saving them a lot of money, that when these complex patients started seeing me, they often didn’t have to keep seeing their expensive panel of specialists. I thought they’d be happy to hear that. I was shocked by their response. When they heard that the way I practice might be decreasing how much their enrollees are spending, their faces actually blanched at the idea. After that meeting, they redoubled their efforts to drive me out of their networks.

In that moment I realized just how wrong I’ve been all these years. I learned that the insurance companies make a percentage of what you spend on your healthcare, especially if they just administer the plan, as with Microsoft. All of their “cost-saving procedures”, such as prior authorization, just add layers of paperwork and administrative overhead to the costs of healthcare, giving them the public image of wanting to cut costs, but in reality just giving them a bigger slice of the pie. Arguably, the most powerful and most subversive force keeping your costs high and eroding the quality of your care are the health insurance companies, not the drug companies

If you’ve ever gone to your practitioner with a list of problems and been told to pick one to work on today and come back another day for the rest, thank your insurance company. If, during your visit, your practitioner interacts more with their computer than with you, thank your insurance company. If you’ve ever felt herded through your doctor’s office, thank your insurance company. If you feel like your physician never has time to really consider the details of your case, thank your insurance company. If your physician has low morale and is over-burdened with paperwork, thank your insurance company. Short of corporate profit, there is no excuse for the damage they’ve done to the healthcare profession.

And if your insurance company calls themselves non-profit, don’t believe it for a moment. All that means is that they keep all the money for themselves. Those executives are paid exorbitant salaries and bonuses. Most insurance companies run a 26-28% administrative overhead. Obamacare is going to require them to keep it to 20% (still much higher than most other industries). That is one reason the insurance companies are fighting Obamacare so vigorously.

If your insurance company is for-profit, well…there are lots of other ways to make money in this economy, why should some investor be getting a share of your hard-earned premiums? The answer is absolutely clear in my mind: health insurance companies need to go away. There are much better ways to deliver healthcare, ways that incentivize wellness and high-quality healthcare. We’re not a third-world country. Why do so many Americans continue to suffer from a lack of quality healthcare as if we were? I see two reasons: corporate greed and a kowtowed populace.

Corporations’ primary purpose for existing is to make money. Any product or service they provide to do that is secondary. Greed is in their nature. It’s not bound to go away any time soon. But just like any good citizen of the community, corporations need to learn to control their bestiality. That’s what laws and regulations are for. If, on one side of the equation, a corporation doesn’t want to be regulated, then, on the other side of the equation, they have to choose to do the right thing. I’ve got some ideas about how to help corporations do that, but that’s a topic for another blog. Right now, I’d like to speak more about the kowtowed populace. That is something we can all do something about.

When insurance companies misbehave and screw you over, they protect themselves by throwing up as many paperwork roadblocks as possible. Millions of hours are spent each year by people just trying to get their insurance companies to meet their obligations. The insurance companies set up a gauntlet, hoping that you won’t survive the running of it and thus give up and go away.

Don’t give up. If you have a grievance with your insurance company, please make it your business to be the biggest burr in their bra they’ve ever seen.

  • Write formal letters to the state Insurance Commissioner (One of my patients did that during my audits and the insurance company actually wrote their own letter to the Commissioner asking him to please disregard my patient’s letter. It was groveling and pathetic. If the Commissioner received dozens of similar letters asserting the same complaint, they’d investigate.)
  • Lodge a complaint with your employer and their benefits department, if you have insurance through work.
  • Write letters to your state and national representatives.
  • Write letters to the editor of your newspaper.
  • Write a blog.
  • Post on your Facebook page.
  • Get the word out any way you can about how your insurance company is treating you.

Stories have power. You have power.

Believe it or not, medicine is a consumer-driven industry. If enough consumers demand it, eventually medicine will change.

Steven M. Hall, MD

Copyright 2012 Steven M. Hall, MD