Sunday, January 27, 2008

So . . . what's this here single-payer health care thing all about anyway?



"I�m going to tell you something -- we have fabulous health care in America, just so you know. I think it�s very important -- before people start griping about the health care system here -- and of course there�s always grounds for complaint -- just to compare it with other systems around the world." --George W. Bush, December 17, 2007, eruditely discussing his own single-payer coverage, courtesy of the US taxpayer.



Note: please pardon all the weird characters -- like question marks where there should be quotation marks. I'm a writer; not a coder. However, if you know how to fix this crap, please shoot me an email and tell me how. ALso looking to truncate posts to show the first 500 words, then show a link to the rest at the bottom of the opening section. Again, if you know how to make that work, please tell me how. And now, on with the show...


But first, a moment of silence

A teenaged girl died some time ago because Cigna HealthCare, a for-profit medical insurance provider, did exactly what it's compelled to do by law: it chose to maximize its profits by refusing to pay for a liver transplant for 17-year-old Nataline Sarkisyan, whose doctors warned that she would certainly die without the organ replacement.

And they were correct. She did in fact die, just hours after Cigna relented and agreed to cover the costs of the procedure after all. This, too, was a move intended to maximize profits, since the terrible PR that news of its denial of coverage generated could have affected Cigna's bottom line as well, as could damages awarded as the result of a wrongful death suit. So it wasn't a rekindling of the human spirit on Cigna's part that caused the company to reverse its position; that was the result of a serious internal disaster management campaign, run by corporate lawyers and high-level spinmeisters, designed to reduce the impact on Cigna's image and minimize the company's financial exposure.

By law, the only obligation of a publicly owned, for-profit US corporation is maximizing return for its shareholders. That's it. Nothing about good corporate citizenship, the public good, saving lives or anything else that isn't related to jacking up the price per share and maintaining a reasonable price-earnings (P/E) ratio.

If Cigna had been operating outside the rules, perhaps we could simply discipline that one company, levy stiff fines, jail a couple of high-ranking execs and serve notice to the rest of the industry that such behavior won't be tolerated. But that's not the case. Cigna was following the rules. The problem is that the rules are insane. That's why this profit-driven disaster of a medical system must be replaced.

We need to dump this murderous system entirely. It's too far gone to tinker around the edges. We simply have to get rid of the profit motive as the driving factor in determining who lives and who dies. We need to decouple the idea of health care from the idea of health insurance, since the two have absolutely nothing in common. For example, listen to Cigna president David Cordani defending the decision in an internal memo that was also made available to mass media.

Nataline Sarkisyan's request was evaluated on an expedited basis using "evidence-based guidelines published by independent physician and medical organizations, as well as expert scientific journals," Cordani said. Translation: We made a life or death decision based on a quick scan of "Liver Transplantation for Dummies" and we backed that up with a little reading on WebMD. Oh, and JAMA, too, and Lancet maybe . . . And don't forget Dr. Rudinski's best-seller, "The Home Guide to Major Abdominal Surgery."

Now back to our regularly scheduled programming . . .

The pinko commie plot to ruin the American way of debt and dying


Now that "Sicko" is available on DVD, millions of people will see it for the first time. If the film's run in theaters is any indicator, most of them will be infuriated as Michael Moore exposes a greedy US medical insurance system run amok, drunk on profits, willing to abandon any last traces of human decency to fatten the bottom line and adept at filtering out patients with acute illnesses that might cost the insurers real money.

The solution Moore advocates is a national health care program, funded by a modest and progressive tax, and generically called "single-payer," meaning that the insurance industry's multiple payers are replaced by a single entity, usually a state or the federal government.

This system would provide universal access to health care for all Americans without the need for private, for-profit medical insurance and the huge financial burden that currently imposes in insurance premiums, deductibles, co-pays, pharmaceuticals, non-covered procedures and "negotiated rates" which somehow never seem to cover the entire bill.

And those people are the lucky ones; they have medical insurance of some sort and, therefore, aren't usually sentenced to die (Nataline Sarkisyan excepted) or be forced to use the local ER as their primary care facility. That happy fate falls to an estimated 47 million of their fellow Americans, who have no medical insurance at all and must therefore game the system to survive.

And we're not talking solely about the chronically unemployed (although why employment is a condition for receiving medical care remains unexplained and undiscussed). We're talking about Wal-Mart greeters and checkers, burger flippers, cab drivers, the self-employed, retail clerks, waiters, bartenders, most non-union workers in most trades and an endless list of service economy employees.

These people all have jobs; many have two or three. But they work for employers who can't afford today's obscene medical insurance premiums. Or they work for world-class cheapskates like Wal-Mart, which rakes in many billions each year, whose billionaire Walton family owners occupy a special pedestal among Forbes magazine's list of richest Americans, but who just can't seem to spare a few bucks to help keep their workers healthy and free from medical debt.

The very words "single-payer" give many of our more delicate citizens the vapors and drive many more into an apoplectic rage. These magic words also cause the last of the cold warriors to dissolve into a frothy lather of anti-pinko invective about subverting the invisible hand of the free market.

Considering the massive propaganda campaign waged non-stop by for-profit medicine and seconded by stern warnings of the "evils of socialized medicine" intoned by well-insured right-wing politicians and TV pundit hucksters, those kinds of adverse reactions aren't all that surprising. The buzzwords and visual cues and code phrases are hard-wired by the time kids hit the sixth grade. Go here for a scholarly treatment of the single-payer/for-profit debate.

In the case of the US medical system, we've been taught by our leading opinion-shaping institutions -- public relations, marketing and advertising -- that health care is a privilege to be auctioned off to the highest bidder and not a universal right to be shared by and for the general welfare of society.

Single-payer butts heads with the American archetype

We're so steeped in the rugged individualist, go-it-alone archetype that the idea of making common cause with "those other people" -- working toward a shared objective of improving quality of life for all members of society, not just those who can afford it -- is anathema and, increasingly, un-American. I fully expect some gasbag GOP presidential candidate, before primary season mercifully ends, to come up with something like, "If we go to a non-profit health care model, the terrorists win." Any bets?

class="MsoNormal">In fact, our apathy or antipathy toward those who don't share our looks, background, ideals, language, income, education or culture is driving the US toward an endgame that bears an uncanny resemblance to the Friedman/GOP-style unregulated free market model, with peace for none and antagonism toward all.

We're becoming a society of 300 million disconnected, semi-autonomous city-states, constantly at war with one another for the same dwindling supply of goods and jobs, and services and money, and square feet of pavement. A society too distracted and exhausted by the process of battling each other to notice the class war being waged -- and won -- against us all by the very people who designed and sanctified this system in the first place.

They've divided and conquered very well. No surprise, given the massive resources of the entire insurance industry, along with an approving pat-on-the-back from our "representatives" in Washington; it would be odd if they hadn't done a good job of keeping us at each others' throats and away from theirs.

The insurer as friend and savior

Distraction also helps produce the suspension of critical thinking required to believe in the most illogical premise of all: that America has the best medical care system in the world and has achieved that lofty position because the most voracious, profit-hungry, inhuman corporate institutions routinely ignore their very reason for existence, as well as a file cabinet full of SEC regulations and case law precedents that demand a publicly held corporation pursue profitability with single-minded, sociopathic disregard for basic human values. This is nothing less than a case study in the impossible, but it's the core tenet of the great American health care fairy tale nonetheless.

So are these corporations portrayed in media and pop culture as the enemy, as one would expect? Of course not; they're the solution. The US, unique in the world in its child-like belief good citizenship from corporations, expects these rapacious profit machines to completely abandon their chartered mandates requiring them to churn out ever more money for their stake-holders and, instead, act in the best interests of their customers.

Never mind that those two objectives are locked in inexorable conflict. Never mind that medical insurance is a zero-sum game and, when the insurer pays a claim, that's money grudgingly subtracted from the bottom line. Never mind that the insurance industry employs an army of obstructionists -- known ridiculously as claims adjusters -- whose main job it is to find some quasi-legal way to avoid paying out any money at all. Never mind the inevitable outcome of those conflicts: that the US isn't even in the top 30 according to the landmark 2000 World Health Organization study. Nope, never mind all that. The industry is our friend and savior, and where would we be without it? Other than healthier and happier, with more disposable income, that is.

As one California psychologist who serves on several managed care rate negotiating teams in the Santa Cruz area told me a while ago, �They have become adept at providing the illusion of health care, while avoiding the messy and expensive reality of having to actually deliver it -- to the extent legally possible. And you�d be amazed at what�s legally possible. Most of the time you can�t even sue them so, at some point, the consumer literally has no recourse but to beg for his or her life. Increasingly, those pleas fall on deaf ears as the race to maximize profits obliterates what�s left of basic human kindness.�

So much for the bad news. We now need to examine the nature of single-payer, universal-access health care: what it is, what it isn't, how it compares and contrasts with the US for-profit model.

So what exactly is single-payer and why is it better than what we have now?

Well, surprise, surprise, it's not socialized medicine. The federal government won't set up shop in every doctor's office and medical facility. Unlike the current system, in which privatized pests occupy a permanent position overlooking every doc's shoulder, governmental bureaucrats won't be making harassing calls to doctors offices every five minutes to second-guess whether a patient actually needs that procedure, or that test, or that prescription.

Let's say your doc has his own small family practice, which he runs as an LLC. He probably accepts payment from a couple dozen different insurance carriers. Does that mean he works for, say, Blue Cross or Cigna or Aetna? Of course not.

Under single-payer, he would no more work for the government than he now works for an insurance company. He gets paid by the feds, but runs his own business exactly as he has for many years.

So docs and hospitals continue to operate as they always have, although for-profit facilities must convert to non-profits. The truly revolutionary change is that now the feds foot the bill via a progressive tax that hits the rich hardest and the poor not at all.

In fact, if a patient just looks at the outward signs, things are very much as they've always been. You see the same doctors and support staff. You have blood drawn at the same labs. If you're seriously injured or suddenly become ill, you end up at the same ER. You see the same specialists. If surgery is required, the same group of medical professionals handles the entire process -- from pre-op to rehab. You find that service is about as fast, or as slow, as ever. And if you want a tummy tuck or nose job, you're still going to have to pay for it out of your own pocket.

The payer changes -- from any of hundreds of private insurance companies to a single entity -- but the process of providing and receiving medical care remains the same. Actually, it improves because single-payer eliminates the armies of bureaucrats the insurance industry employs in an effort to squeeze the last mil out of every penny by denying coverage or illegally reducing benefits.

Single-payer: the basics

The following is the nature of any single-payer health care system. Simple, direct, universal, free. And having tried the alternative and found it wanting in that it's currently killing around 18,000 people a year because making gobs of money is incompatible with covering subscribers' medical costs, it seems about time to admit our errors, dismantle the current tragicomedy and move all the way into the 21st Century.

Single-payer means:

  • One nation, one payer

  • Everybody in, nobody out

  • No exclusions for pre-existing conditions

  • No doctor bills

  • No hospital bills

  • No deductibles

  • No co-pays

  • No in network

  • No out of network

  • No corporate profits

  • No more medical bankruptcies

How to get there from here

The relationship of health care to health insurance is manufactured out of thin air by the US obsession with applying market-based, privatized solutions to nationalized, systemic problems. Therefore, it seems that to get to single-payer, we first need to abandon the propaganda and separate the idea of health care from the idea of health insurance.

Health care is what happens when patients and health care professionals interact to successfully diagnose and treat a medical condition or injury.

Health insurance is the protection money you have to pay the middleman to enable this transaction and keep you out of bankruptcy court.

Why would anyone want to give a single penny to some parasite intermediary that skims billions while doing absolutely nothing to provide health care?

Unfortunately, it takes a lot more than pennies to keep the beast fed. While Medicare, our unofficial single-payer system, runs at an annual overhead of about 3 percent, for-profit insurers typically squander between 25 and 40 percent of an estimated $2.2 TRILLION annual market. And that 25 to 40 percent -- which translates into between $550 billion and $880 billion each year -- does absolutely nothing to enable these companies to perform their alleged jobs, which is supposed to be covering medical expenses for their ratepayers.

The unbearable lightness of Democratic politicians

Equally unfortunate is the unwillingness of our elected representatives to even consider single-payer among the options for US health care reform. Among the Democratic presidential candidates, only Dennis Kucinich has advocated single-payer from the start. The rest are all talking about something called "expanded coverage," which is just code for "let's invite the single most destructive element in the old system to play a key role in the new one."

That's a bit like expecting a shark to develop qualms of conscience, renounce killing and turn vegan, despite millions of years of evolution that dictate its natural role as a rapacious, heartless, omnivorous predator. Kind of like an average American for-profit corporation.

Any new system that subordinates health care to the for-profit model carries the seeds of its own destruction. If insanity is doing the same thing repeatedly and expecting different outcomes, then allowing these soulless gatekeepers to continue preying on the people of this country is truly insane. Such a system is virtually guaranteed to evolve into a new version of the same old deadly scam once the insurers stop glad-handing and get down to the serious business of making money. They may play nice at first, promising to mend their rapacious ways and act like humanitarians, but once they're inside the tent, they'll revert to form as certainly as that shark will continue to eat seals.

But that hasn't kept our alleged representatives in Congress and on the campaign trail -- Kucinich the lone exception -- from avoiding any mention whatsoever of the single-payer option. In 2003, Rep. John Conyers of Michigan introduced H. R. 676, dubbed the United States National Health Insurance Act, in an effort to remove private insurers from the US health care maze and install a national single-payer system in their place. The new system is essentially a well-funded version of Medicare, minus the age restriction.

It languished in committee for two years; Conyers then re-introduced H. R. 676 in 2005 and, according to information gleaned from Thomas.loc.gov, it has resumed its slow fall to the bottom of the House agenda. Like impeachment, single-payer remains "off the table," despite the poll numbers that say more than 70 percent of Americans want an end to for-profit medicine and want to replace it with single-payer.

And why is it off the table? For one outstanding example, let's take a look at Hillary Clinton's campaign contributors. The probable Democratic nominee and odds-on favorite to become the next president is an insurance industry money magnet. According to campaign finance figures submitted to the Federal Elections Commission and reported by Opensecrets.org, through the first nine months of 2007 she leads all presidential candidates, Democrats and Republicans, in money accepted from the insurance industry ($2.675M). She also leads the pack in money accepted from hospitals and nursing homes ($375K); from HMOs ($247K); from pharmaceutical companies ($274K); and from medical industry lobbyists ($570K).

As Bob Dole said way back in 1983, before he became the Senate's leading recipient of special interest money, "When these political action committees give money, they expect something in return other than good government." So that just about takes care of any possibility of true health care reform in a Clinton presidency, and virtually guarantees that any Clinton-sponsored health care "reform" plan will bend over backwards to accommodate the needs of the for-profit medical insurance industry.

What about quality of care?

Corporate mass media is ever busy safeguarding the interests of their masters and advertisers, so it's hardly surprising that there's serious opposition to single-payer spewing forth from the television sets and radios of America. People who watch network and cable TV, and actually believe they're well informed, internalize and then repeat industry claims that a single-payer system would lower quality of care, create shortages of medical staff and facilities and result in long waiting lists for even the most mundane procedures. Worst of all, it would be run by demon spawn employed by the federal government.

But, as usual, corporate mass media is lying through its bleached teeth. If that vision of health care hell were true, all other Western democracies would exhibit shorter average life spans, higher rates of cancer and heart disease, higher infant mortality rates, lower birth weights, fewer average healthy years, failing mental health programs and far more serious epidemiological incidents than does the US. Since the opposite is true in all cases, it seems fair to conclude that single-payer, universal-access works, this cobbled together disaster we call a health care system is not getting the job done and that we're being ill served by US media yet again. (Go here for 2004 data on how US per capita medical spending and health care outcomes rank against three of the major single-payer countries.)

The big con: we've already got national health care but the peasants don't get to use it

Perhaps the most galling stat of all: A Harvard Medical School study showed that, back in 1999, the US taxpayer shouldered the burden for just under 60 percent of all medical costs nationwide by being forced to fund health care for federal, state and local government employees. That included programs such as the federal employees health plan and those for state and local employees as well (through state, local and property taxes); the Cadillac coverage our fine representatives and Senators enjoy (which they say we can't have); the costs of covering ER expenses for those without insurance; the costs of running the Medicare program; and the state and local costs of various Medicaid programs.

That 60 percent represented $2,604 per capita at the time, which means government spending per-person on health care in the US was higher than total per capita health care expenditures in any other country in the world -- including those with single-payer, universal-access national health care systems. So we're paying for national health care; we're just not getting it.

This must end; single-payer is the answer, a well-funded Medicare system is the model, greed is the obstacle. Eliminate profits as a factor in life and death decisions, run the entire system based on serving human needs rather than those of shareholders and CEOs, and the profiteers will go elsewhere for their money.

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This article first appeared in Online Journal on January 4, 2008

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