The cartoon penned by “Toles” dated from 1994. Yet its relevance even today remains such that John McDonough, veteran health care reformer and consultant for Health Care for All, began his PowerPoint talk last weekend by showing it to a roomful of state legislators from around the country.
A Clinton caricature asks an assemblage of health care stakeholders (doctors, insurers, hospital executives, nurses, HMO officials, patients, etc.) sitting around a committee table what their goal is. In unison they shout “Health care reform!” but bubbles rising from their individual brains repeat over and over what they each really want: “Money!”
McDonough used the cartoon as an illustration of why, 15 years after Bill and Hillary Clinton set about reforming health care in this country, we are no closer to completing that elusive quest than we were in 1992.
Then he and his fellow presenters spent the following three days scarcely mentioning the approach that many of us have been advocating for years, the “Single Payer” option.
On the last morning of the conference (“State Health Care Policy, an Introduction”) the audience pushed the topic, questioning the panelists aggressively as to why nothing had been included on the agenda about an approach that the entire rest of the developed world (except Switzerland) has adopted: Single Payer.
The panelists had just explained, in excruciatingly complex detail, how Massachusetts, Vermont, Kansas and California were each in their own fashion going about trying to deal with the three huge health care dilemmas facing our country: expanding coverage to all, lowering costs to manageable proportions and improving the quality of care as measured in enhanced outcomes.
The effect of hearing about the lengths to which these states were willing to go to prop up, with intricate Rube Goldberg-esque mechanisms, the floundering private insurance approach made many in the audience angry. The questioning got more and more pointed.
“What value does the private insurance industry add to the system?” the group asked. “We see all it takes out (skimming profits, wasteful duplication, added complexity), but what does it bring to the table that makes it worth pouring so many resources into it instead of going the only other route that makes sense: creating one national insurance pool with the government serving as the single payer?”
Finally, McDonough had enough. “Look,” he said. “I know a national health system would be better. I spent 10 years of my life beating my head against the wall trying to get one implemented when I was in the Massachusetts legislature.
“I’ve researched the Canadian, the British, the Australian and the German systems and they’re all better than what we’ve got. But after all that effort I looked back and saw we were no closer than when I began. I’ve got to tell you that my conclusion is it isn’t going to happen here in the foreseeable future so I’ve decided to invest my time in trying to help people actually get health care.
“If you want to go after a Single Payer system, go for it. More power to you. My own conclusion is that the political climate simply won’t permit any single state, let alone the federal government, to go down that road. Every time it’s been put on a ballot as an initiative, the voters have turned thumbs down.”
Then he rattled off five reasons why the idea of eliminating private insurance from the health care financing equation (which all by itself would amount to a savings of anywhere from 15 to 20 percent) and combining all Americans (or all Kansans or New Mexicans) into a single risk pool the way national health systems do it, won’t happen here any time soon.
Americans don’t trust government agencies to make good decisions about health care. Opponents will immediately insert the idea of “rationing” into the discussion and that will kill any further debate.
Doctors and hospitals won’t go for it because in their experience the very worst (i.e. cheapest and slowest) payers are the two big government health programs, Medicare and Medicaid.
The constituency for a sea change of the sort Single Payer would require is not in place—at least it isn’t strong enough to resist the kind of “Harry and Louise” scare-mongering campaigns that the insurance industry can be counted on to resort to.
The opposition comes from many angles: doctors, hospitals, insurers … but also from all those ordinary citizens who have health insurance and who can be expected to get panicky at the thought that their coverage might be changed, diminished or restricted in any way.
Finally, no one looking at the situation believes the Bush administration will ever permit a state to convert its Medicaid (let alone cooperate in changing Medicare, a system the feds run on their own) program into a significant piece of a Single Payer plan.
All five of those reasons, of course, amount to the same thing: In our country, politics is the biggest barrier to implementing what all the experts who’ve studied the matter acknowledge is the simplest, most economical and most efficient way to provide health care coverage to our citizens: a Single Payer model.
Until that political climate shifts, our system will continue to spend twice as much of our GDP as other countries do for health care outcomes that fall way short of theirs, while leaving large numbers of our citizens completely uncovered. Go figure.