Petition to expand Medicare to be the Single Payer Healthcare System for the USA

[monadnocky]

We have a government run health care system, VA. As a person in the VA system (I only see VA once a year for wellness check), I can tell you it's a terrible system staffed by people who for the vast majority, want to do the right thing. They're hindered by levels of administration, outdated record keeping (because the gov is always several generations behind), and about 1% of the career civil service workers who believe that VA exists to give them a job. A single payer system would have to be run by a private entity that is required to show transparency and accountability.

Bill, I'm aware different VISNs (that is, different VA hospital systems grouped geographically) are notoriously heterogeneous when it comes to quality of care. I'm aware of a few that are quite poor (usually in states that one might expect care to be of poor quality in general), and several in the Northeast along the West Coast (i.e., VA Palo Alto) that are known to be superb. Certainly the recent fiasco shed a very negative light on the system, and the wait times for disability determination is maddening and doesn't appear to be improving anytime soon.

Also, their electronic record keeping system is known to be among the best of the best - I was stunned by how amazing it was when I used it. I don't know if it's used across all VISNs, though, so perhaps your VA doesn't use it?

I've heard time and time again that quality of care across the VA system - especially at VAMCs - has been found to be somewhat better than the private sector in general. No, I have no idea of the metrics involved with this, or if it's just myth, or what, but I do hear it repeated. Anyone?

[jclay]

Although I agree with you on the single-payer as being part of the solution, your 200k is just a deck chair on the Titanic. There is a segment of the population of about 5% which is so unhealthy and such heavy consumers of healthcare that your 200k, my 200k, everyone's 200k doesn't go very far. The financial challenge is very large. We have to address end-of-life spend and other sensitive issues to find answers.

Different issue and we have to do that regardless of our HC financing system; better to tackle it with what is fundamentally a more efficient financing and management system rather than one which is less so. I suggest looking at how other countries manage to provide cradle to grave, world class care, for their entire populations for roughly 60 to 70% of what we pay. I have family who has long been receiving care in some of those systems. They vastly prefer those systems to ours. The links I provided are a gateway to lots of good information.

Losing the benefit of $200k worth of contributions due to our use of what amounts to serial term insurance policies provides poor value. Under funding the system tasked with providing HC in old age makes no sense. Having all of our contributions, notably those in our prime earning years, be made to a cost effective HC financing system, from which we are never separated, provides maximal value and makes a heck of a lot of sense.

[vertical_doug]

JClay, I don't disagree with you. I lived in Japan for 17 years and have first hand experience with their NHS which spends only 8.5% per capita GDP vs 17% for US which makes it the most efficient in spend for industrialized countries. Japan also has a 3% obesity rate vs 30% for U.S. This is the driver and efficient spend only gains you some room when the fundamental problem is your population is so unhealthy.

D

[monadnocky]

...Most of the guys (and 99% of them were guys) I worked with were Vietnam era or later (into the 70's and early 80's, a few Desert Storm guys in the mix) and there was a smattering a Korea vets and even a few WWI guys...

Errr. I meant WWII of course.
Doy.

[jclay]

We have a government run health care system, VA. As a person in the VA system (I only see VA once a year for wellness check), I can tell you it's a terrible system staffed by people who for the vast majority, want to do the right thing. They're hindered by levels of administration, outdated record keeping (because the gov is always several generations behind), and about 1% of the career civil service workers who believe that VA exists to give them a job. A single payer system would have to be run by a private entity that is required to show transparency and accountability.

There is no reason the mechanics couldn't be farmed out to the private sector but I think it's a mistake to equate quality of care or operation with govt vs private. You can find good to bad in both.

[roseyscot]

JClay, I don't disagree with you. I lived in Japan for 17 years and have first hand experience with their NHS which spends only 8.5% per capita GDP vs 17% for US which makes it the most efficient in spend for industrialized countries. Japan also has a 3% obesity rate vs 30% for U.S. This is the driver and efficient spend only gains you some room when the fundamental problem is your population is so unhealthy.

D

This is the key. There is no other country in the world with such an "advanced" yet terribly unhealthy population. Therefore, comparing what could be, based on other countries is not possible.

[stackie]

I grew up in a country with single-layer healthcare. It's true that most of the doctors drove Volvos, not Mercedes, but I'm not convinced that the quality of care necessarily is in line with physicians' practices profitability.

As a physician, I feel compelled to respond to a few of these comments.

Why is the car one drives relevant to the cost of the service they provide? True story, I went down to Sherwin Williams yesterday to get a couple of gallons of paint. The manager, a young man in his early 30's maybe, gets out of his car as I am walking in. His car? A Porsche 911 variety. Not old. Maybe 5-6 years old. OMFG, that paint is so overpriced. He is raping me. I can't believe what a crook he is. I'm going to write my congressman... Or, maybe, he spends all his money on his car. Lives in a small apartment, does not have girlfriend or kids. I have a colleague who drives a 1996 Porsche 911. One car for 19-20 years. Ammortize that over the years. I drive a BMW 135. I bought it used two year old for $30,000. I'll keep it 10 years as I have every other car. So, sure maybe it looks like I'm rolling in cash because I have BMW, but I paid less for my BMW than my brother, the electrician paid for his truck. The car stereotype is really not an accurate measure of one's under or over compensation for their career choice.

Jon

[stackie]

The single payer systems mentioned, medicare, medicade, and tricare and not equivalent. I'm retired Navy and working a second career as an engineer. I have BCBS, Tricare, and VA. Tricare is equivalent reimbursement-wise to Medicare, it's relatively easy to find a doctor that will accept it. Medicaid is not widely accepted due to a low reimbursement. VA is VA, it's a self contained and very inefficient system, but it's nothing out of pocket. I use BCBS for my primary with Tricare paying the copay and covering the gap. For Veterans in the VA system, I'd like to see a program where VA pays the gap and copay for Medicare when we reach 65 so we can move out of the VA system and free up resources. I don't see single payer anytime in the near future as long as insurance companies can make a profit and influence politicians.

Tricare pays like MediCal in California, the worst reimbursement of all. I take all comers in my practice of anesthesia, however. I treat servicemen and their families like royalty for what they do for our country. Actually, scratch that, I take care of all my patients to the best of my ability regardless of their insurance. That is my ethical composition as a physician. But, I do have a soft spot in my heart for the military people.

BigBill, kudos to you for using BC as your primary. That will allow your physicians to get a wage for their work that will allow them to keep their practice open. As monadnocky has alluded to, all gov't pay is insufficient to keep the doors open on a medical practice, unless, of course, one resorts to fraud. Which may be one reason why we see gov't medical insurance fraud.

The system as we have it is collapsing. Personally, I blame this on everyone. The patients who continue their unhealthy sedentary lifestyles and their lethal habits with the full understanding that society will take care of their ills at little or cost. The doctors who defraud the system because they feel they have the right. The pharmaceutical companies who will extort the US healthcare system for a $1000 a pill when they sell it in Egypt for $10 a pill (Yes, Gilead, I'm talking about you). The insurance companies who measure their success in their ability to provide as little care as possible for the dollars you pay in your hard earned premium. Wonder why you can't get appointments to see a physician who is on the panel with your Obamacare plan? Well, the first guy you called is dead. The second guy retired a few years back. The third physician doesn't take it because the reimbursement is so bad. Well, that worked out well for the insurance company. You paid them and you can't get the care you need. Win win for them.

Personally, as a physician who works in an area with a high percentage of gov't pay patients, I would be happy to take all gov't pay patients all the time. I just have one caveat. I would like a Gov't issued physician card that allows me to buy my goods and services at a 80-85% discount as well. New car at $30,000? Sure, but I have my gov't discount card so I get 80% off. I'll just write you a check for that $6000. $100 of groceries? I've got my Gov't discount card, so that's only $20. Cash ok? BTW, is that filet mignon "Prime"? I only want the best. None of that "choice" filet for me.

Let's go single payor. Pay physicians a compensation that is appropriate for the level of education, dedication, and stress level.

Let me ask you this? How many of you people held someone's life in your hands today... and almost lost it? Well,, I did, and this lady did her best to die on me today and I prevented it with the benefit of strong education, work ethic, practice and just sheer determination. Anyone who thinks their day was more stressful than mine is welcome to chime in.. Pilots who had 3 out of 4 engines crap out halfway across the Atlantic welcome to apply.

Thanks for letting me vent.

Jon

[ldamelio]

I grew up in a country with single-layer healthcare. It's true that most of the doctors drove Volvos, not Mercedes, but I'm not convinced that the quality of care necessarily is in line with physicians' practices profitability.

8% of the US health care dollar goes to physician salaries. A much more staggering amount of the health care dollar goes towards the overhead of the byzantine reimbursement scheme, inefficient care due to poor IT infrastructure, defensive medicine in a litigious society, and futile end of life care (a complex social problem with lots of blame to spread around among providers, attorneys, the media, and patients/families). I might also throw a dart at Big Pharma and their relentless marketing, but my good friend MarkC might be reading this :)

Your 'Volvos/Mercedes' line completely misses the real problem - US/Canada physician salaries aren't that far apart (if at all) when you compare apples to apples for specialty and hours worked. Also, check the doctor's lot at your local US hospital these days. Not as exciting an automobile selection as you'd like to portray with this trite one-liner. Plus, the subset of physicians who are high earners a) work in difficult specialties with 7-9 years grueling training after medical school and b) work 80 or more hours a week even in middle age due to a shortage of docs willing to do this difficult work. Do you really begrudge the guy who's going to take out your wife's brain tumor his Porsche after he's spent four years in college, four years in medical school, and eight years in residency/fellowship and still works 80 hours a week?

I'm all for single payer and eliminating the middle man and wasteful overhead that he brings. As others have said, reimbursements under a single payer system would have to be sustainable for hospitals and providers. Medicare (and Medicaid) don't even cover cost for many procedures - when you count overhead, there are a number of operations that I do that lose money under Medicare for my hospital. That's on top of caring for 38% uninsured patients in an urban setting. It's only sustainable (but always barely and always threatened) because of a bizarre societal cost-shifting where other services are over-reimbursed. This whole insane system has to go, but I don't see it happening. The real problem with eliminating the middle man is that he (the insurance industry) is a powerful lobby and no way our leaders will have the clout/balls to cut him out of the health care picture and put in an appropriately fair, simple system.

BTW, I don't own a Mercedes but I do have a Spectrum, Sachs, and Parlee. The last two I bought used here on the Salon.

[jclay]

This is the key. There is no other country in the world with such an "advanced" yet terribly unhealthy population. Therefore, comparing what could be, based on other countries is not possible.

I don't agree with that logic at all. Statistics, epidemialogical studies and the like are powerful tools.

What seems obvious to me includes:

1) Pumping the lions share (by orders of magnitude) of the contributions made during your working life into a series of time limited policies that periodically evaporate (the ones that come and go with employment or immediate financial circumstance) and under funding the system tasked with care in old age is financially idiotic....except for the insurance industry. Is that how you'd like your investments to be arranged? You pour money in during your working life, only to have it disappear periodically and go away entirely upon retirement. Of course not but that's exactly the structure we use for health care financing here. It's complete lunacy!

2) A national Single Payer system would have substantially lower administrative overhead costs than our multitude of disconnected private insurance companies.

3) A national Single Payer system, with its single set of procedures and administrative framework would be simpler and less expensive than the multitude of same that we have now. An integrated digital records keeping system would be much more feasible than at present; another cost savings.

4) Purchasing power would be unmatched.

5) By being tax based even lower earners would contribute a portion. Freeloading would be drastically reduced if not eliminated.

The result I had hoped for would be for folks, particularly those who aren't familiar with this issue and the alternatives, to visit those websites and start becoming more informed about this important issue that that most rarely consider but which has such huge ramifications to us individually and as a country. It's to our detriment that it turns into a political, ideological football; good thing airliners and nuclear generating facilities aren't designed in the same fashion.

[Too Tall]

Very compelling conversation, I'm learning here.

[CXinNH]

The fundamental problem in the US current system is that the interests of patients on one side and that of physicians and health care institutions on the other side are malaligned.
Oversupply of physicians in a given area leads to overdiagnosis, unnecessary procedures and a decrease in the local populations health and outcomes. This variation in care has been well documented (the Dartmouth atlas, TDI).

We need to align the interests, single payer will help - but is not nearly enough to get us there. Payments and incentives must take quality of care into account, not volume. CMS has been trying to go into that direction recently.

BTW, Elliot Fisher is a local rider and quite fit.

Going riding now.

[ldamelio]

This would be an excellent conversation to have over a cup of coffee. There has been a generally high level of discourse on a controversial subject. I certainly agree that some incentives are currently misaligned in US healthcare and acknowledge/agree with the data you presented. However, this misalignment doesn't extend to all aspects of healthcare. To a certain extent, recent changes have aligned hospital and physician incentives. This has driven improvements in care and outcomes to the mutual benefit of patients, hospitals, and physicians. CMS quality initiatives are another story altogether. Some are indeed well-intended and evidence-based to improve outcomes and drive quality. Others (perioperative beta blockers) oversimplify complex clinical decisions and have resulted in checklist medicine without thought. These have been shown to actually worsen outcomes in the peer reviewed literature. Some are thinly disguised attempts at population control (recommendations to decrease screening initiatives for breast and prostate cancer) being foisted on an unsuspecting public to save federal dollars.
All this is about on a par with peace in the Middle East in terms of complexity and ability to solve. I actually have 36 hours in a row off now for the first time in weeks, so I'll politely bow out of this discussion and get to my family and bikes.

[bigbill]

Bill, I'm aware different VISNs (that is, different VA hospital systems grouped geographically) are notoriously heterogeneous when it comes to quality of care. I'm aware of a few that are quite poor (usually in states that one might expect care to be of poor quality in general), and several in the Northeast along the West Coast (i.e., VA Palo Alto) that are known to be superb. Certainly the recent fiasco shed a very negative light on the system, and the wait times for disability determination is maddening and doesn't appear to be improving anytime soon.

Also, their electronic record keeping system is known to be among the best of the best - I was stunned by how amazing it was when I used it. I don't know if it's used across all VISNs, though, so perhaps your VA doesn't use it?

I've heard time and time again that quality of care across the VA system - especially at VAMCs - has been found to be somewhat better than the private sector in general. No, I have no idea of the metrics involved with this, or if it's just myth, or what, but I do hear it repeated. Anyone?

The administration I'm referring to is the paperwork required to get into the VA system. I couldn't do any forms on line, I could just download a pdf form fill it out by hand, and then fax it in. I was lucky that I was able to do most of my paperwork at my new job which has a copier/scanner/fax just a few feet away. VA has an 800 number that you use for just about everything, good luck with that. The quickest I've ever gotten to speak to a person was 40 minutes. The VA has a website, my ebenefits, which is supposed to keep me updated on my status. It's not updated, I received my VA letter (disability rating) in September of 2013, I had started the process 12 months earlier, and the website said no decision had been reached for another 6 months even though I had letter in hand.

Appointments, the VA has metrics that require that a Veteran be able to get an appointment within 2 weeks of requesting one. I needed an appointment with my PCP (who is very good) to get referrals for podiatry and mental health (I have neuropathy and PTSD). I was given an appointment for two weeks later including lab work so the PCP could do a wellness check. The day before the appointment, I got a reminder call. The day of, I did my lab work and went to the reception desk for my PCP. They told me that my appointment had been moved to 6 weeks later. I was being gamed, someone met their metric by scheduling me within 2 weeks and the fact that my appointment was moved wouldn't be reported. I went to the hospital ombudsman and told her what was going on and that I was going to report it to my congressman. Somehow I got my appointment as scheduled and I'm not aware of anyone who was bumped.

Once I was in the VA system and got to see someone, the care was good. I like my PCP, she is thorough and has good bedside manner but I can tell she is stressed by her patient load. All of the PCP's at the clinic about an hour away are immigrants, English is not their first language. Most are Indian including mine. The new laws concerning medical care and my location relative to a VA facility means I can call and get referred to a local doctor if there isn't a VA doctor within 40 miles. Before that, If I needed a specialist it meant a 2.5 hour drive (each way) to a clinic in Ft Worth. More importantly, it won't cost me a day of vacation from my job to see a specialist.

[roseyscot]

I don't agree with that logic at all. Statistics, epidemialogical studies and the like are powerful tools.

What seems obvious to me includes:

1) Pumping the lions share (by orders of magnitude) of the contributions made during your working life into a series of time limited policies that periodically evaporate (the ones that come and go with employment or immediate financial circumstance) and under funding the system tasked with care in old age is financially idiotic....except for the insurance industry. Is that how you'd like your investments to be arranged? You pour money in during your working life, only to have it disappear periodically and go away entirely upon retirement. Of course not but that's exactly the structure we use for health care financing here. It's complete lunacy!

2) A national Single Payer system would have substantially lower administrative overhead costs than our multitude of disconnected private insurance companies.

3) A national Single Payer system, with its single set of procedures and administrative framework would be simpler and less expensive than the multitude of same that we have now. An integrated digital records keeping system would be much more feasible than at present; another cost savings.

4) Purchasing power would be unmatched.

5) By being tax based even lower earners would contribute a portion. Freeloading would be drastically reduced if not eliminated.

The result I had hoped for would be for folks, particularly those who aren't familiar with this issue and the alternatives, to visit those websites and start becoming more informed about this important issue that that most rarely consider but which has such huge ramifications to us individually and as a country. It's to our detriment that it turns into a political, ideological football; good thing airliners and nuclear generating facilities aren't designed in the same fashion.

I am definitely not trying to defend the current, very broken system, but what you describe in #1 and #4 is basically social security, which many of us that are under 40 have serious doubts about as a tool for our future retirement needs. It's not to say a single payer system can't be done correctly, but given our current government's (in)ability to manage social security (robbing Peter to pay Paul) and the government's terrible management of the Medicare/Medicaid/Tricare systems, I am doubtful of their ability to get the single payer solution in place without major problems in my lifetime.

Getting the financially powerful private insurance lobbies out of politics is another massive obstacle.

[Will Neide]

It's not to say a single payer system can't be done correctly, but given our current government's (in)ability to manage social security (robbing Peter to pay Paul) and the government's terrible management of the Medicare/Medicaid/Tricare systems, I am doubtful of their ability to get the single payer solution in place without major problems in my lifetime.

Getting the financially powerful private insurance lobbies out of politics is another massive obstacle.

I think this touches on some of my feelings. It's not so much that I wouldn't want it, but HOW and WHO will fund it and run it efficiently. I don't see it happening.

[vertical_doug]

This is slightly dated, but weekend beach reading.
http://www.uta.edu/faculty/story/231...ndAndGreed.pdf

Bitter Pill

[roseyscot]

This is slightly dated, but weekend beach reading.
http://www.uta.edu/faculty/story/231...ndAndGreed.pdf

Bitter Pill

Haven't finished reading it, but what a maddening display of how broken our whole system is.

[Eric Siepmann]

I think this touches on some of my feelings. It's not so much that I wouldn't want it, but HOW and WHO will fund it and run it efficiently. I don't see it happening.

This. Name one well run Government Program. Just one. Then sit back and ask yourself do you want a post office like entity presiding over your health? No thank you. And most single systems are not as efficient as presented. Ask some Canadians what is covered and when they actually are able to access said health care procedures...There are waiting lists for such banal items as routine dental procedures.

Sounds great on paper and over the internet. The solution is not in the HC provider or system. It's what others have alluded to. Living a healthy lifestyle. Just imagine if everyone gave up fast food, junk food and rode their bike to work. That's the solution, not tilting at windmills for some mythical single pay system, ATMO.

[randonneur]

There are waiting lists for such banal items as routine dental procedures.

I doubt it. Dental isn't covered in our healthcare system. Knee surgery and hip replacements are another thing altogether though. The wait times vary greatly from province to province however and I find that the message in the US media around waitlists in Canada overall is exaggerated.