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July 13, 2009 10:50 AM   Subscribe

A concise article in support of a single-payer health care system written by an East Tennessee family medicine physician.

And let's not forget that Tennessee is a dyed-in-the-wool Red State : )
posted by pwedza (79 comments total) 15 users marked this as a favorite

 
Robert Funke, M.D., eh?

I call shenanigans.
posted by shmegegge at 11:00 AM on July 13, 2009 [1 favorite]


Somehow, I think the views of a single physician in Kingsport, TN is going to go utterly unnoticed by the powers-that-be. On the other hand, it will be interesting to know what, if any, fallout is heaped upon him by the local medical community.
posted by Thorzdad at 11:01 AM on July 13, 2009


He mentions that the Massachusetts plan (that mandates people to get their own insurance "or else") is failing. Does anyone know what he means by that? It seems to be the plan that Obama is pushing, so I'm curious what the problems have been.
posted by Blazecock Pileon at 11:02 AM on July 13, 2009


Great article. Thanks for posting.
posted by grounded at 11:07 AM on July 13, 2009


shmegegge: I know of a woman named 'Dixie Funk' in the SW Virginia area. I kid you not.

Thorzdad: Agreed that it is one small voice. However, that this voice is published in a widely read regional newspaper known to heavily lean conservative in the reddest area of one of the reddest states is of some significance.
posted by pwedza at 11:10 AM on July 13, 2009


funky yes, shenanigans no.
posted by Edward L at 11:11 AM on July 13, 2009 [1 favorite]


From the essay: "Doctors and nurses are deprofessionalized as “providers” while patients are depersonalized as “consumers.” "

That's an important underlying difference between how I feel as a patient in the US and other systems (Canadian is my other significant experience), and how my relatives feel as Canadian health care workers (half of whom have worked in the US system as well). The "free market" approach to medicine treats doctors (or, more precisely, hospitals) as mercenaries and patients as renevue streams, which leaves little room for care, concern, empathy, comfort, and all the other things that historically have made the doctor-patient relationship special (and different from the buyer-seller one). That's not to say that there are none of these things in doctor-patient relationships in the US system, but that they are there despite the system's abstracting, depersonalizing effects.
posted by LMGM at 11:15 AM on July 13, 2009 [8 favorites]


However, that this voice is published in a widely read regional newspaper known to heavily lean conservative in the reddest area of one of the reddest states is of some significance.
posted by pwedza at 2:10 PM on July 13


It won't take persuasion in the south. All it will take is a deepening recession, rising unemployment, and an aging population, and self-interest will motivate them to demand that the government pay for what they can't themselves.
posted by Pastabagel at 11:16 AM on July 13, 2009 [2 favorites]


Does anyone know what he means by that?

The old plan in MA:

Sick, poor person: I need help.
Doctor: Do you have insurance?
SPP: No.

The new plan in MA:

Sick, poor person: I need help.
Doctor: Do you have insurance?
SPP: No.
Doctor:: Well, you're supposed to.

Generally speaking, forcibly removing money from poor people to hand over to millionaires does not lead to noticeably better health.
posted by DU at 11:16 AM on July 13, 2009 [14 favorites]


Kingsport, TN is one town over from where I grew up. And it's just about 50 miles from Wise, Va which is where the free public health clinic was held that so affected Wendell Potter (from this recent thread). My mom still lives in the area, and rather than give to charities, she is always contributing to help various co-workers and friends who are in dire straits because of some medical problem or another. And most of these people HAVE health insurance, but find themselves reaching caps or unable to work or afford COBRA.

Yes, it's a red state, but people know for sure that the system is broken. The key is to help them sort through the dis-information that's being put forth by the multi-billion dollar health insurance industry. So the words of a local doctor can go a long way in helping people understand that a single payer plan isn't the fourth horse of the socialist apocalypse. It may not mean much to "the powers that be", but it can certainly start help a grassroots swell of support.
posted by kimdog at 11:20 AM on July 13, 2009 [7 favorites]


Generally speaking, forcibly removing money from poor people to hand over to millionaires does not lead to noticeably better health.
posted by DU at 2:16 PM on July 13


A healthy diet and regular exercise are the only things that lead to noticeably better health.
posted by Pastabagel at 11:20 AM on July 13, 2009


BP, I don't think there's any consensus that the Massachusetts plan is "failing", but everyone pretty much agrees that the big coverage expansion didn't do much in terms of containing costs, and it has had mixed results in terms of ensuring actual access to care among the newly insured (there's a lot of specialists in the state but not nearly enough primary care physicians, and that has only become more acute now that more people have the coverage to seek regular preventative care). People who like the Massachusetts model say that while these things are problems, they don't invalidate the model, because politically the only way to really get costs under control and expand the capacity of the system to provide good primary care (the two things are very interrelated) is to first get everyone in the system then deal with the entrenched interests that make controlling costs so hard right now.

The state is definitely currently moving much more aggressively on the cost piece, but there hasn't been enough time for major changes yet--those will probably be coming out in the next year. I imagine the current economic climate makes those cost reforms even more urgent, as it's going to be hard for any state to maintain current benefit packages and eligibility levels for Medicaid and other health subsidy programs. It'll be even harder for Massachusetts, as it provides direct coverage and subsidies to people much further up the income ladder than most other states, and so will be hit particularly hard by rising unemployment and falling wages.

A nice concise summary of the positions among people that are optimistic and pessimistic about the MA model can be found here and here.
posted by iminurmefi at 11:21 AM on July 13, 2009 [2 favorites]


The Massachusetts plan is in trouble because the state doesn't have sufficient leverage to get costs under control. As a result, it is costing too much, and on track to cost way too much. That's not to say it will fail utterly. But it's not a walk in the park.

A national plan could be in a very different position, provided that it generates sufficient cost savings. There are a variety of things the federal government can do that a state cannot. These include establishing efficacy and treatment standards that reduce overutilization of expensive treatment, and establishing a government-run insurer to compete with private insurers.

There are also some steps that Massachusetts could take but has not yet. For example, we haven't had any malpractice reform in our state. So you have a C-Section rate running at about 33%, at an added cost of about $10,000 per C-Section birth, because hospitals are so freaked out about the possibility of a $20 million trial verdict that they have established standards of care based on lawsuit avoidance rather than best medical practice.

There are lessons from Massachusetts, but not a final judgement on the feasibility of a national plan.
posted by alms at 11:22 AM on July 13, 2009 [3 favorites]


The idea in MA was that by mandating that everyone buy insurance, it would spread out the risk pool and decrease costs. That hasn't really happened.
posted by miss tea at 11:22 AM on July 13, 2009


Thanks, iminurmefi.
posted by Blazecock Pileon at 11:23 AM on July 13, 2009


Generally speaking, forcibly removing money from poor people to hand over to millionaires does not lead to noticeably better health.

Why are you dragging Social Security into this?
posted by Kwantsar at 11:26 AM on July 13, 2009


A healthy diet and regular exercise are the only things that lead to noticeably better health.

Stop trolling. And tell us that again when you need chemo.
posted by le morte de bea arthur at 11:28 AM on July 13, 2009 [40 favorites]


Bluntly, there is no rational argument against some kind of universal single-payer health care system for the good ole US of A. There just isn't. Expecting profit driven, stockholder beholden businesses to somehow place compassion over cash is like expecting a hungry crow to NOT eat a baby robin that just fell out of the nest.

So, the issue here is how to deal with a helluva lot irrational thinking and believing.
posted by philip-random at 11:28 AM on July 13, 2009 [4 favorites]


A good op-ed, but I don't see why a doctor from a conservative state would have more success for health care reform than, say, a climate scientist from a conservative state advocating for GHG emissions reduction (ie, Dr. Lonnie Thompson is from West Virginia). What is important is how the debate is framed, and right now the status quo side have managed to get any single payer option framed as 'socialism'. The expert opinion does not seem to carry much weight in the US lately.
posted by nowoutside at 11:28 AM on July 13, 2009



Generally speaking, forcibly removing money from poor people to hand over to millionaires does not lead to noticeably better health.
posted by DU at 2:16 PM on July 13

A healthy diet and regular exercise are the only things that lead to noticeably better health


Funny, I thought that access to demonstrably effective long-term curative, preventative and palliative care for congenitally and environmentally induced ailments helped. Silly me!
posted by lalochezia at 11:28 AM on July 13, 2009 [13 favorites]


I think he's right in that this will uncover some interesting problems which are already present. My big question is, why does health care cost so much? The inflation in health care costs is enormous. I would love to know how it breaks down amongst some things I've pulled out of a hat:

1) Hospitals know that J. Random Indigent won't be sending in a dime, so those costs are passed on to groups who do pay.

2) Lawsuits

3) Malpractice insurance (see #2)

4) Certifications in the safety process for various products

5) One-use products

Items 6-1001) Stuff I haven't thought of.

And we will need more doctors, nurses, and other health care professionals. We'll need them fast. If we want to have more health care for more people, we're gonna need a bigger profession. Perhaps to that end we might consider a period in which one's education (with reasonable standards for admission) is free and the process is not ridiculous. How many people might have gone into medicine if not for loans they'll be paying off for the next twenty years, and the bizarre, frat-like hazing ritual of keeping interns awake far longer than is reasonable for someone who will be putting substances into someone else's body?

I like single-payer, but we're gonna need some interesting infrastructure to roll it out.
posted by adipocere at 11:30 AM on July 13, 2009 [1 favorite]


It won't take persuasion in the south. All it will take is a deepening recession, rising unemployment, and an aging population, and self-interest will motivate them to demand that the government pay for what they can't themselves.

You must be familiar with a different south than the one I live in. I know many, many people who consistently espouse political positions that go against their own self-interest out of fear of atheism, gun control, socialism, illegal immigration, or whatever other bogeyman the preachers, politicians, and media come up with. Rational thought never enters into it.
posted by TedW at 11:30 AM on July 13, 2009 [3 favorites]


The expert opinion does not seem to carry much weight in the US lately.

Lately? The American public has had a deep-seated antipathy to anyone who knows more than they do about anything for a very long time.
posted by dirtynumbangelboy at 11:31 AM on July 13, 2009 [4 favorites]


So, the issue here is how to deal with a helluva lot irrational thinking and believing.

A majority of the US already wants single-player or at least a public option. (I don't remember the actual numbers and which it applied to.) So the problem isn't irrational thinking, the problem is misinformation and, worse, the ones who set policy being in the pocket of the insurance industry.
posted by DU at 11:32 AM on July 13, 2009 [2 favorites]


From the essay: "Doctors and nurses are deprofessionalized as “providers” while patients are depersonalized as “consumers.”

Also, "reaming you in the ass" is now called "meeting your deductible."
posted by mattbucher at 11:34 AM on July 13, 2009 [8 favorites]


Single player. Heh. That's a gov't run socialist program where one man (in a gray suit) hits on all women in bars. If you are gay, or a woman yourself, you are out of luck because there's only one player.
posted by DU at 11:34 AM on July 13, 2009 [1 favorite]


I linked this in one of the other threads, but it's worth mentioning here:

US Health Care Spending in an International Context
posted by electroboy at 11:35 AM on July 13, 2009 [2 favorites]


Bluntly, there is no rational argument against some kind of universal single-payer health care system for the good ole US of A.

Sure there are. Just off the top of my head:

1. The real problem of rising medical costs has little to do with who writes the checks and everything to do with a fragmented delivery system that incentives overtreatment through fee-for-service payment arrangements (in both the private sector and Medicare), and moving to single-payer does nothing to remedy that fundamental problem;

2. Many insurance companies may be evil--or at least put patient health below profits--but you have to be a real idealist to believe that Congress or any body subject to Congress's political pressures is going to be a better or even a mildly effective negotiator against large for-profit hospital chains, pharmaceutical companies, and medical device makers, who already exert enormous pressure around Medicare policy, so we could well make the cost problem much much worse by implementing single payer;

3. Health care (and particularly reproductive health care) is immensely politicized already and there's way too much danger in moving to a single-payer system where the party in power has the ability to arbitrarily decide certain procedures or medicines just aren't going to be covered, which may be enough to drive abortion providers out of business entirely.

I'm not particularly opposed to single-payer, and I'm sure I could put together a pretty good list in favor of it. I do disagree strongly with the idea that there's absolutely no reason anyone could in good faith oppose single-payer or advocate for a different approach, though. It's not like there aren't decades and decades of research and debate among some very, very smart people about what is wrong in the American health care system and how to effectively remedy it, and there are very few of those people who propose that swapping one financing system for another is going to solve all (or even some) of the major problems.
posted by iminurmefi at 11:50 AM on July 13, 2009 [3 favorites]


A healthy diet and regular exercise are the only things that lead to noticeably better health.

That would have been handy to know when my 9 month old son needed thousands of dollars in medical care.
posted by anastasiav at 11:52 AM on July 13, 2009 [11 favorites]


"With almost 20 years inside the health insurance industry, Wendell Potter saw for-profit insurers hijack our health care system and put profits before patients."

Interesting interview (via BoingBoing)
posted by Midnight Rambler at 11:53 AM on July 13, 2009 [3 favorites]


THATS the same doctor that over-charged me for all that Teamocil!
WHICH I didnt need by the way.
posted by Senor Cardgage at 11:58 AM on July 13, 2009 [1 favorite]


Stop trolling. And tell us that again when you need chemo.
posted by le morte de bea arthur at 2:28 PM on July 13


I appreciate that it's easy to score points off me in healthcare threads, but under no rational medical practice is anyone who receives chemo considered 'healthy'. Cancer patients are never declared to be "cured" of cancer after they undergo chemo. Their cancer is said to be in remission.

And the single payer and other systems are not about making people healthier. They are about allowing people to access the health care system with less of a financial burden. Even using your definition, healthy would be about improving medical technology, spending more on pharma research, etc. But that isn't really the point of single payer either.

Healthy is what keeps you out of the hospital to begin with.
posted by Pastabagel at 12:00 PM on July 13, 2009


Healthy is what keeps you out of the hospital to begin with.

Healthy AND lucky. You forgot luck. The kind of luck that doesn't have something shift and you break a bone, or you develop kidney stones or gall stones, or someone runs a red light and hits you while you cross the street or even just stand on the corner waiting, or get cancer. You can eat healthily and exercise, and one bad luck moment puts you in the hospital, and then you're screwed.

But hey, you've eaten healthily and exercised regularly, so at least you have that, right? Too bad random chance shoved its vibrator up your butt.
posted by mephron at 12:09 PM on July 13, 2009 [8 favorites]


And the single payer and other systems are not about making people healthier. They are about allowing people to access the health care system with less of a financial burden.

Wider and easier access to healthcare options makes people healthier, which is the end goal. It's not difficult to understand why people don't take your views seriously when you say stuff like this.
posted by Blazecock Pileon at 12:09 PM on July 13, 2009 [1 favorite]


To be clear, the Massachusetts system requires that everyone buy *health insurance*, NOT that everyone is covered.
The reason it is failing is because this just forces everyone into the insurance industry's hands, and allows the industry to continue to raise costs, unfettered by any controls on the State's part.

The Obama plan is a blended plan, which would provide a "public option" - i.e. Gov't provided coverage, which would provide *real* competition against the insurance industry, and some benchmarking of costs.

Interestingly, the arguments against this plan are at odds with one another:
"Too many people will leave the private plans and Insurance Companies will go broke!"
and:
"No one is going to want to use a bureaucratically controlled, government-run health plan!"
posted by dbmcd at 12:10 PM on July 13, 2009 [4 favorites]


Healthy is what keeps you out of the hospital to begin with.

Well, that and being smart enough not to be born with a medical condition or an increased risk of developing genetic diseases. And having the integrity not to get hit by a drunk driver.
posted by dirigibleman at 12:12 PM on July 13, 2009 [4 favorites]


Thanks for the link, Midnight Rambler. What a staggering interivew.
posted by Shepherd at 12:15 PM on July 13, 2009


You have to have *serious* foresight to avoid those genetic diseases!

I'm all for single-payer here. It just seems like one of those things where what's good for everyone is, well, good for everyone. So everyone kicks in a little to fund it, and The Health Fund pays the bills. I guess it's a bit anti-capitalistic to remove profit from the equation, but there's plenty of room for capitalism elsewhere. If I could rewrite the entire system with one simple premise it would be: socialize what people need, privatize what people want.
posted by jamstigator at 12:22 PM on July 13, 2009 [11 favorites]


And the single payer and other systems are not about making people healthier. They are about allowing people to access the health care system with less of a financial burden. Even using your definition, healthy would be about improving medical technology, spending more on pharma research, etc. But that isn't really the point of single payer either.

Healthy is what keeps you out of the hospital to begin with.


No. Single payer demonstrably keeps people healthier and out of hospital. In the USA, so many people are forced to let trivial issues go untreated until they develop into very serious conditions that end up in the emergency room (under a false name of course).

In developed nations with single payer, people are healthier than those in the USA by most or every indicator, and a big part of this is because people have no trouble taking care of things before they get nasty.

(And it even shows up in non-medical studies: not only are single-payer people healthier than Americans, they're taller. The researchers were surprised at how much taller, and on investigating, their leading hypothesis was the effects of Americans having so little access to basic healthcare.)
posted by -harlequin- at 12:27 PM on July 13, 2009 [4 favorites]


Single-payer is government-sponsored health insurance like Medicare. Single-payer is not socialized medicine — socialized medicine is government-owned hospitals and government-employed doctors such as in the military or the Veterans Administration. I have yet to meet a doctor who loathed his time in the military.

I'm having trouble understanding what this short paragraph is to mean. I expect that he's assuming the words 'socialized medicine' are a red flag to his audience, and by redrawing the boundary to not include single-payer systems it makes his suggestions more acceptable to them. But in doing so he implicitly reaffirms the phrase as a useful and legitimate part of the political discourse on health care. 'Socialized medicine' is an empty and pejorative term not really used outside the US, and just like 'gay marriage' or 'pro-life' it should be quietly but forcefully ignored and replaced. Trying to renegotiate a frame never works because you hands its originators power every time you mention it.

Doctors and nurses are deprofessionalized as “providers” while patients are depersonalized as “consumers."

This is quite an interesting statement in the health care debate, as LMGM also points out. Health costs are high, and overtreatment is (supposedly, and at least in some places) chronic. But you can't deconsumerize health care without deconstructing the patient as a consumer, and nor can you reprofessionalize doctors and nurses without giving them a scientific-rational grounding. This means that some power passes from the patient to the doctor, which is fine and acceptable, but has to be explicit. The patient has to accept that they are mostly unable to decide questions of health care because they lack the requisite knowledge, and the doctor has to be free to base their treatment on medical need and not insurance or patient requirements. But then, the author of this article also writes:

What about choice? Single-payer would improve choice. No longer could insurance companies divide doctors and hospitals into exclusive, competing networks. Every provider would take your insurance because there would only be one insurance. What about rationing? We have rationing now. Your tests and surgeries can be denied, your medication choices are restricted. The cruelest rationing of all is that faced by the uninsured. Waiting times? Canadians are currently complaining less than we are.

He doesn't grasp the nettle of saying, 'If we're going to cover everybody, it has to be at a reasonable cost. We're only going to get reasonable costs if decisions are made according to needs and not wants."
posted by Sova at 12:29 PM on July 13, 2009 [1 favorite]


To be clear, the Massachusetts system requires that everyone buy *health insurance*, NOT that everyone is covered.
The reason it is failing is because this just forces everyone into the insurance industry's hands, and allows the industry to continue to raise costs, unfettered by any controls on the State's part.


the politics of the Massachusetts system are especially toxic... remember that Mitt Romney had a hand in it. it was passed with essentially a coalition of people like Mitt Romney who thought it would stave off an actual universal public health care system and those who thought it would put the state on a slippery slope to universal health care. in short, it was designed to fail.

it's ominous to note that the politics of Obama's plan are quite similar.
posted by geos at 12:31 PM on July 13, 2009 [1 favorite]


Bluntly, there is no rational argument against some kind of universal single-payer health care system for the good ole US of A.

Sure there are. Just off the top of my head:


To fix that, "there is no rational sound argument..."
Of those three candidates listed, the only one with any legs is #3, and not even that one has been a problem in other countries, it's just that my expectations of the US political system (in all its corruption and entrenchment) are so spectacularly low that I just can't put it past it to not find a way to out-fail any failsafe.
posted by -harlequin- at 12:36 PM on July 13, 2009


So because I disagree with you, I must be a backwards nutjob deserving of ridicule? Stay classy, OC!
posted by Pastabagel


No, you're deserving of ridicule because you say ridiculous things. Even with proper nutrition and exercise, people still get sick. And sometimes, because they literally cannot afford it, they put off medical treatment. And then instead of us collectively paying for a $75 office visit for preventative medicine, we collectively wind up paying tens of thousands of dollars when they finally go to the emergency room because they might actually die.

Not to mention all the people with insurance whose claims are denied, even for life-threating illnesses.

And so, your brilliant solution to the American healthcare crisis is: "eat right and exercise." So I maintain that yes, you are precisely like a silver-swallowing fuck-you-got-mine conspiracy nut in your willful blindness to reality and the horrifying consequences of your conclusions.
posted by Optimus Chyme at 12:37 PM on July 13, 2009 [24 favorites]


Just to be clear, that excellent interview by Bill Moyers of an ex-insurance exec, which was cited above by Midnight Rambler, was posted on the blue July 11.
posted by borborygmi at 12:45 PM on July 13, 2009


The Obama plan is a blended plan

Actually, there's no such thing as "the Obama plan." There's the bill coming out of the Senate HELP committee, the Affordable Health Choices Act; there's Baucus's plan that will come out of the Senate Finance committee; there's Wyden's Healthy Americans Act. Presumably these bills will somehow be merged into the "Senate version" of health care reform that has enough support to get 60 votes. Then it will somehow have to be reconciled in conference committee with whatever version of health reform the House has passed.

Obama has taken the exact opposite tack compared to Clinton, who got a bunch of health policy experts together in a room for a month or two and put together something (some BIG 1,400 page thing) that could be termed "the Clinton plan," that was then presented to Congress with a polite request to pass said legislation. You can tell how well that worked by the fact that it's 15 years later and we still have no health reform. Instead, Obama has said he wants health reform; he's pushed Democratic leaders in the House and the Senate to pass something by August; he's suggested a number of financing options (e.g., taxing employer-provided health benefits) to pay for whatever comes out of Congress; he's secured promises from lots of provider groups and manufacturers to cut costs if health reform passes; but the one thing he most definitely hasn't done is put forward his own plan. If you check the White House website there are nice platitudes about working with Congress to pass comprehensive health reform; the HealthReform.gov website is also very short on specific proposals, instead pushing the need for general reform. In the words of Rahm Emmanuel, "the only thing that's non-negotiable is success." Whether you think it's good strategy or bad strategy to push for health reform without drawing a lot of lines in the sand about what will "count" as health reform (and make no mistakes, some progressives really don't like this strategy), it does make it so it's impossible to really talk about the Obama plan. Obama's plan is whatever makes it out of Congress.
posted by iminurmefi at 12:48 PM on July 13, 2009 [2 favorites]


Sova: No, his point is that right now, people's choices in which doctor they can see is greatly curtailed compared to single-payer countries, yet one of the wingnut misconceptions about single-payer is that the government would assign you a doctor (like school districts?) or similar micro-management of your care via some vast bureaucracy. This is incorrect (and firsthand, I had much more freedom of choice when I got my healthcare in a single-payer country.)

Further, right now, Americans get care according to neither their needs nor their wants, but instead according to the decisions of healthcare companies. So even at the micro-level, there is plenty of scope for costs to be reduced while at the same time increasing choice, because the decisions are no-longer being made by a third party whose primary motivation is at odds with both patient and doctor, and whose additional administrative overhead alone costs more than half the healthcare actually received at the end of the day.
posted by -harlequin- at 12:48 PM on July 13, 2009 [2 favorites]


1. The real problem of rising medical costs has little to do with who writes the checks and everything to do with a fragmented delivery system that incentives overtreatment through fee-for-service payment arrangements (in both the private sector and Medicare), and moving to single-payer does nothing to remedy that fundamental problem;

Respectfully, it has everything to do with no checks and balances. The health care market is a little unique in that, a lot of the time, price doesn't enter the equation; you need the service no matter what it costs. A manufacturer of a product like cars can't charge whatever they want because too high a price will stifle demand. So the health care "consumer" is over a barrel. Single-payer consolidates price negotiation into one "super-consumer". It evens the playing field.

2. Many insurance companies may be evil--or at least put patient health below profits--but you have to be a real idealist to believe that Congress or any body subject to Congress's political pressures is going to be a better or even a mildly effective negotiator against large for-profit hospital chains, pharmaceutical companies, and medical device makers, who already exert enormous pressure around Medicare policy, so we could well make the cost problem much much worse by implementing single payer;

Wrong for government-as-advocate, but OK for corporations with bottom-line interests ? There are reams and reams of evidence pointing to the sleazy lengths corporations will go for profits. At least the government is accountable, in that they are elected. They would have to be more interested in keeping the electorate satisfied.

3. Health care (and particularly reproductive health care) is immensely politicized already and there's way too much danger in moving to a single-payer system where the party in power has the ability to arbitrarily decide certain procedures or medicines just aren't going to be covered, which may be enough to drive abortion providers out of business entirely.

I would argue that it's only politicized because the providers choose to make it so. As for arbitrary changes - that hasn't been the case in other countries and there's no reason to believe it would be different here. Insurance companies already specialize in arbitrary decisions, anyway. And they are not accountable (see above).
posted by Benny Andajetz at 12:58 PM on July 13, 2009 [2 favorites]



In the U.S. healthcare is first and foremost a business.
In the U.S. health insurance is first and foremost a business.
posted by notreally at 12:58 PM on July 13, 2009 [1 favorite]


It won't take persuasion in the south. All it will take is a deepening recession, rising unemployment, and an aging population, and self-interest will motivate them to demand that the government pay for what they can't themselves.
posted by Pastabagel at 2:16 PM on July 13 [+] [!]


Except in Appalachia you have many rural poor who stubbornly refuse any government hand out. Pride is a powerful thing.
posted by caddis at 1:02 PM on July 13, 2009


notreally: "In the U.S. healthcare is first and foremost a business.
In the U.S. health insurance is first and foremost a business.
"

So is crack dealing and prostitution. Am I missing your point?
posted by KevinSkomsvold at 1:09 PM on July 13, 2009


"Canadians are currently complaining less than we are."

If you'll pardon me for a second: BAHAHAHAHAHAHAHAHAHAHA. In this context, in any context, no. We complain. It's a national pastime. That being said, our complaining is not stating that our system is bad.

notreally: "In the U.S. healthcare is first and foremost a business.
In the U.S. health insurance is first and foremost a business."

KevinSkomsvold: "So is crack dealing and prostitution. Am I missing your point?"


The argument is that businesses, by long history (and pretty much by definition) will do what they can to maximize profits, whether or not that is best for the people (with exceptions). The incentive to anyone in the health care field should be solely to keep people healthy. In a business-oriented health system, it's better for providers to charge the patient, which they do by unnecessary testing, or lack of preventative medicine (which is cheap) so as to encourage hospital stays (expensive).

This need not be true in a single-payer system. Especially with a cap on billing, there are incentives (mainly at the administrative levels beyond individual doctors) to get people to need minimal health care. Exercising, preventative medicine, checkups, are good for the single-payer administration. Thus they're encouraged, which keeps people healthy.
posted by Lemurrhea at 1:28 PM on July 13, 2009


At least with crack dealing and prostitution you're pretty much aware how fucked you are.
posted by mephron at 1:29 PM on July 13, 2009 [1 favorite]


Sova: No, his point is that right now, people's choices in which doctor they can see is greatly curtailed compared to single-payer countries, yet one of the wingnut misconceptions about single-payer is that the government would assign you a doctor (like school districts?) or similar micro-management of your care via some vast bureaucracy. This is incorrect (and firsthand, I had much more freedom of choice when I got my healthcare in a single-payer country.)

Further, right now, Americans get care according to neither their needs nor their wants, but instead according to the decisions of healthcare companies. So even at the micro-level, there is plenty of scope for costs to be reduced while at the same time increasing choice, because the decisions are no-longer being made by a third party whose primary motivation is at odds with both patient and doctor, and whose additional administrative overhead alone costs more than half the healthcare actually received at the end of the day.


I understand that the practices of insurance companies, or even the complete lack of insurance, reduces choice, leads to rationing, and lengthens waiting times. But the author uses these as arguments for a single-payer system while also decrying the patient-as-consumer. Questions of rationing, waiting, and choice need to be (for the largest part) medically based, and not driven by the patient. Even if the removal of insurance companies leads to profits/overhead costs being diverted into health care, controlling the costs of treatment will be difficult or impossible without placing that treatment on a non-consumer basis.

As mentioned upthread, a single-payer system will find it both possible and necessary to rationalize care on medical grounds: establishing national guidelines for care pathways, tariffs for treatments, and bodies such as NICE. A national system would be able to impose itself on health care providers and control costs due to its size and power. If it fails to do so, the alternatives are an inefficient system with either too much built-in slack and continued overtreatment, or one where individual providers maximize profits at the expense of government. The patient has to be constrained to needs, and the doctor to costs. The question isn't so much 'who pays?', but 'why?': is the treatment needed, and is the cost reasonable?

I'm not in favor of removing power from individuals without reason, but a single payer system or 'public option' that can't control costs won't last. Hence, and this is really my problem with a lot of the arguments for single payer: nobody should be pretending that choice, rationing and waiting times can be taken from insurance companies and put into the hands of the patient, as it's not sustainable. Patients will still have some level of control over their treatment in a single payer system, but for many it may feel like a constraint compared with currently.

Sorry, this is a bit of a tangent now, and by steps divorced from the original point.
posted by Sova at 1:36 PM on July 13, 2009 [1 favorite]


A healthy diet and regular exercise are the only things that lead to noticeably better health.

That's as may be, but "better health" isn't the only reason people need to see doctors. They also might:

* be the victim of an attack/accident and break a bone or receive a laceration

* be a woman in labor

...Diet and exercise is one thing, but I doubt you can accurately set a broken arm just by eating beets.
posted by EmpressCallipygos at 1:37 PM on July 13, 2009 [2 favorites]


Lemurrhea, I think you're comparing the most negative possible outcomes in the current system and the most positive outcomes with the single payer system. While currently you can't exercise much choice about which health insurance provider your employer chooses, you can surely pressure your employer to switch providers if they deliver poor service. Keep in mind that management also has to live with their choice of policies. Also, insurance providers tend to shorten or eliminate hospital stays in favor of outpatient procedures, rather than encourage them.

Similarly, the positive pressures in a single payer system, like a cap on billing could be equally likely to lead to a decrease in the quality of care by incentivizing cutting corners in the name of efficiency. Encouraging exercise could also be helpful, but I don't imagine it to be particularly effective. Most people are generally aware of what a healthy lifestyle looks like, it's sticking to eating right and exercising that's the difficult part.
posted by electroboy at 1:44 PM on July 13, 2009


As for arbitrary changes - that hasn't been the case in other countries and there's no reason to believe it would be different here.

I think this is where single-payer advocates and I part company. I'm not against single-payer--I just happen to think it won't really make much of a difference, and am more interested in reforms aimed at the delivery system where the root of the problem resides--but I can't understand the argument that "because it works this way in Europe, it will work the same way in America."

Given that the U.S. government already foots the bill for 50% of healthcare, I prefer to look at its actual track record in this stuff, rather than pointing to totally different political systems. The fact that abortion and birth control aren't politicized in France didn't prevent Congress from passing the Hyde Amendment (still in effect), which prohibits any federal funds from paying for abortion. No Democratic administration or Democratic-controlled Congress has been successful in overturning it over the past 30 years; as far as I'm aware there's no proposal to overturn it in whatever version of health reform the Senate passes this year, which I'd argue is a pretty clear indication that a single-payer system would not cover abortion, one of the most common surgical procedures performed every year. You can argue that the current situation is worse, and that trading off abortion coverage for the guarantee that everyone is covered for high-cost life-saving things like cancer treatment is the lesser of two evils, but I find it hard to take seriously the argument that Congress is all of a sudden going to follow Europe's lead and decide that paying for medical care doesn't entitle them to make moral decisions about things like abortion.

On a broader level, Congress has shown itself to be pretty unable to muster the political will to pass the payment reforms recommended each year by MedPAC, the independent body of experts that advises it about issues relating to Medicare payment and delivery policies. (Medicare is the largest single-payer system currently operating in the US, and any single-payer system is pretty likely to look like that program, for better or for worse.) There is a lot of recognition that Medicare is a fiscally unsustainable path; that using fee-for-service reimbursements means that any cut in provider rates is usually made up with volume increases; that end-of-life care in hospitals is tremendously expensive and doesn't lead to lower mortality rates. Despite all of that, Congress has shown itself again and again unable to make even moderate changes to the program to control costs.

I certainly wish that Congress was a less dysfunctional organization, less captured by special interest, better able to make hard choices that are in the best long-term interests of the entire population even if not wildly popular among constituents. (Even the most fair rationing system in the world requires some unpopular choices, and the ability to say no.) I think all of these things are prerequisites for a single-payer system to function effectively, and as far as I can tell most countries with functioning single-payer systems those conditions are satisfied--or at least they've set a system in place that prevents politicians from meddling with the system. If that's not the political system we have, though, I think it's a huge mistake to believe that passing single-payer is going to lead to an outcome similar to other countries. It's going to look pretty similar to what we already have.
posted by iminurmefi at 1:46 PM on July 13, 2009 [2 favorites]


Lemurrhea: ""This need not be true in a single-payer system. Especially with a cap on billing, there are incentives (mainly at the administrative levels beyond individual doctors) to get people to need minimal health care. Exercising, preventative medicine, checkups, are good for the single-payer administration. Thus they're encouraged, which keeps people healthy."

I'm with you 100%. I'll even go 110%. I just wasn't picking up on why it was necessary to point out that the health-care industry is a business.

It is fascinating to me how managed care was a relatively noble venture when it first started out but then got raped, pillaged and pimped out by every administration since Nixon.
posted by KevinSkomsvold at 1:50 PM on July 13, 2009


Old law says that if aging parents cannot pay for their healthcare in Pennsylvania, then their adult children must do so: "If Mom and Pop can't pay, you pay. If they have the money but refuse to pay, you pay. If you don't, watch your credit rating sink under the weight of a legal judgment that will haunt you for life." Good times!
posted by GuyZero at 2:01 PM on July 13, 2009


I certainly wish that Congress was a less dysfunctional organization, less captured by special interest, better able to make hard choices that are in the best long-term interests of the entire population even if not wildly popular among constituents.

Amen to that.
posted by Benny Andajetz at 2:16 PM on July 13, 2009


"Somehow, I think the views of a single physician in Kingsport, TN is going to go utterly unnoticed by the powers-that-be"

Ask Shona holmes,
posted by NiteMayr at 2:44 PM on July 13, 2009


In Australia, all primary care physicians are small business people. When you visit a doctor you may present your healthcare card for full payment, or the doctor may charge a fee higher than the prescribed schedule, in which case you must pay that amount (about $40 is common) then present the receipt to the government insurer for reimbursement of the scheduled fee (about $25).
This arrangement leads to some doctors (calls bulk-billers) who charge nothing, and others, typically family GPs who charge a fee. There is also the option to blend this, with say children and the elderly bulk-billed and others paying the fee.
In this system there is plenty of competition between doctors, and you can choose your doctor as you want. You can even see your regular family GP for serious stuff or regular check-ups etc. and go to the bulk billing doctor when you just need a prescription repeat or other low impact service.
This is what single payer health care is like. It remains confusing to me why the USA is so resistant.
Admittedly, there are a bunch of other aspects to do with specialists, hospitals and supplementary private insurance, but this is the health system for most people. I'm not sure what the argument against it is?
posted by bystander at 3:15 PM on July 13, 2009 [1 favorite]


And let's not forget that Tennessee is a dyed-in-the-wool Red State : )

I think it's time we disabused ourselves of the notion that Democrats are earnestly trying to enact compassionate reform while Republicans are defending the greedy-corporation-dominated status quo.

The way I see it, the American people on average would be happy to do away with the profiteering insurance corporations & switch to a government-financed national plan that covers everyone.

But the political class, which includes the Democrats, who control the executive and legislative branches of the federal government, is beholden to corporate interests.

That is why the so-called "serious" reform proposals are designed to protect the profits of the insurance corporations first and foremost - whether by simply perpetuating the gatekeeper-for-profit role of insurance companies by preventing discussion of reforms that don't include private insurance or, most egregiously, by forcing Americans to purchase insurance products, thereby employing the power of the state to serve industry profit-seeking.
posted by univac at 3:18 PM on July 13, 2009 [3 favorites]


The argument against single-payer? Let me see if I can channel Sarah Palin and explain it.

"See, up here in ALASka (wink), we work for what we have, and those who don't work for what they have and can't afford medical care then they wanna take money out of the pockets of hardworking real Americans, and that road leads to communism and terrorism, and I'm so tired of finding Russians in my back yard, because where are they gonna go when they cross over the North Pole except here, to ALASka (wink). And that's why we can't have socialism. And by the way, I quit. You can read about it on qwitter."
posted by jamstigator at 3:25 PM on July 13, 2009 [1 favorite]


Would you all just stop for a minute and think of the insurers, please. They alone stand to lose in all this if the US adopts a single payer plan.
Have you no empathy for how scary this kind of talk is to them?
posted by Fupped Duck at 4:29 PM on July 13, 2009


Since it looks like corporate interests will defeat a national single-payer plan, some folks are pushing for an option to let states establish single-payer plans:

Sen. Sanders of Vermont and Rep. Kucinich of Ohio each have sponsored legislation in their respective chambers allowing states to create their own single payer systems, something not allowed under current law. Support for both bills is in line with single payer goals and could lead to a national single payer system if passed.

Send a fax supporting these bills to your legislators and to the relevant committees today.


To send a free fax: http://www.1payer.net/faxapp/senders/add/cid:19
posted by shetterly at 4:35 PM on July 13, 2009


It remains confusing to me why the USA is so resistant. ... I'm not sure what the argument against it is?
posted by bystander at 8:15 AM on July 14


The arguments against it aren't rational though; they're a confusing mix of scare campaigns that rally around cries of "waiting lists", "lack of choice", and "socialism", paid for and driven by the monied interests: "health" insurance companies, whose real motive isn't ensuring the health of humans, but protecting and increasing their revenue stream.

If there were a single-payer system in the US (as there is here in Oz), those "health" insurance companies would suffer great losses. Bribes contributions to the politicians would be reduced accordingly, so there's a huge incentive both from the corporate and political angles to prevent actually caring for the population at any measure.

It's sad, watching this from the outside. I feel sorry for those friends of mine l left in the US, but I'm very very glad that, when one of my little girls gets sick, I can just go to the doctor or even the hospital without having to worry about going bankrupt.
posted by nonspecialist at 4:40 PM on July 13, 2009 [2 favorites]


It seems appropriate to link to another op-ed in favor of single-payer, this time from a registered nurse.

The piece links to a National Journal article, which reports on several polls that show broad support for Medicare and for Medicare-style reforms.

Some salient information:

  • These opinion pieces just might be persuasive, since they were penned by a doctor and a nurse, whose respective professions are felt "to put your interests above their own," by 78 percent (doctors) and 74 percent (nurses) of respondents, according to a Kaiser poll.

  • The "Medicare program" scored 68% on the same question.

  • Very strong majorities - 62% to 72% in various polls - favor a government-administered health insurance plan similar to Medicare for the under-65 population.

  • Medicare's consumer-satisfaction ratings dwarf those of private insurance.

    However, the Kaiser poll was able to flip support for a Medicare-style "public option" by framing it as likely to present unfair competition for private insurers, or as a "first step toward single-payer, government-run health care." I don't really get the fragility of support for a larger government role in health care, given the margins of support on some of those questions, and the explanation in the article didn't help much, I don't think.

  • posted by univac at 5:12 PM on July 13, 2009


    A healthy diet and regular exercise are the only things that lead to noticeably better health.

    I tried buying baby spinach to make salads at home back in 2006 when I was living in Nashville.

    Then I got E. Coli from the pre-packaged spinach and spent 3 days in the hospital.

    I didn't have insurance. I'm still paying this off.
    posted by lazaruslong at 5:20 PM on July 13, 2009 [4 favorites]


    Oh, and now I have a garden. Fuck Dole.
    posted by lazaruslong at 5:20 PM on July 13, 2009


    A healthy diet and regular exercise are the only things that lead to noticeably better health.

    What about vaccination? What about preventative care like early diagnosis of correctable conditions?

    What about fixing you up after accidents - perhaps an accident you got during your regular exercise?

    Can't believe you're defending that statement!
    posted by lupus_yonderboy at 6:35 PM on July 13, 2009


    Would you all just stop for a minute and think of the insurers, please. They alone stand to lose in all this if the US adopts a single payer plan.
    Have you no empathy for how scary this kind of talk is to them?


    Not in the slightest!
    posted by Pope Guilty at 10:51 PM on July 13, 2009


    Can't believe you're defending that statement!

    Um, it was a joke son. I know that much bile has been churned over that statement in this thread, but it was just a joke and not really that serious.

    Anyway, what is really funny is how much attention is being paid here to a single payer option when it is not even on the table. We may get some form of health care reform but that option is not even being discussed. It is not going to happen. Why are there three threads over a pipe dream and why is everyone basically ignoring what is really happening? This is not the reality based community that is for sure.
    posted by caddis at 12:18 AM on July 14, 2009


    Anyway, what is really funny is how much attention is being paid here to a single payer option when it is not even on the table. We may get some form of health care reform but that option is not even being discussed. It is not going to happen. Why are there three threads over a pipe dream and why is everyone basically ignoring what is really happening? This is not the reality based community that is for sure.

    You know, this is really sad. I mean, the attitude that people should just shut up and accept whatever crumbs are offered by the politicians and their corporate sponsors who decided what's "on the table" for us.
    posted by univac at 1:24 AM on July 14, 2009


    You know, this is really sad. I mean, the attitude that people should just shut up and accept whatever crumbs are offered by the politicians and their corporate sponsors who decided what's "on the table" for us.

    Yeah. There are three attitudes toward US politics that I pity: "I've got mine, Jack," and "It's hopeless. Give up," and "I'm bored. Who cares about this stuff, anyway?"
    posted by shetterly at 12:24 PM on July 14, 2009 [1 favorite]


    caddis, just for you, I have ALL THE PURE, LIP-SMACKING, REALITY-BASED HEALTH REFORM DELICIOUSNESS one person can handle. Are you excited? You should be, because the House just released their version of health reform about an hour ago. Now if Baucus can get off his butt and release the Senate Finance Committee, the real work can begin.

    From the lower house of our fine bicameral legislature, we have America’s Affordable Health Choices Act (full text of bill here), released on July 14th. This bouncing baby legislation weighs in at about $1 billion over 10 years--but it will get us to 97% coverage!

    From the upper house, we have the Health, Education, Labor & Pension (HELP) Committee's entry, the similarly-named Affordable Health Choices Act. (For an extra bonus, see here for the terrible CBO scoring it received--adding a billion dollars to the federal deficit, without even achieving universal coverage? Ouch, that'll hurt its chances for passing! Never fear, though: HELP was down but not out, and convinced the CBO to re-score the bill with some modifications. The new result? Comprehensive health reform, at a 43% discount, with a price tag of only $597 million!) For those following along at home, the conventional wisdom is that HELP, chaired by liberal lion Ted Kennedy, represents the most progressive health reform bill that will come out of the Senate.

    A renegade entry from Oregon's own Senator Ron Wyden (D) and Robert Bennett (R-Utah): the older (finely aged?) Healthy Americans Act. Just because it's been around and unpassed since 2006 doesn't mean this isn't the year FOR VICTORY! (A nice cheat sheet of the major aspects and FAQ for those who find reading through actual legislation as boring as watching paint dry. I feel your pain.) This is the bill that moderate bipartisan Senators love to support, even as they go on Sunday talk shows and make clear that they haven't read the damn thing. But really, who can be expected to actually wade through this stuff? Not me, and certainly not the fine Senators who have important things to do, like show up on the teevee.

    The laggard in the group is the Senate Finance Committee, without whom reform cannot move forward. (Do I hear you asking why, my dear reader? It's because any legislation that requires new funding must find its way through the Finance Committee. Since, alas, nothing in life worth having is free, the Finance Committee is a necessary pit stop on the road to health reform.) They dither, they dather, they release white papers on expanding coverage, financing health reform, and reforming delivery (the last one being my hobby horse, as you can cut costs and make people healthier at the same time), but no legislation as of yet. The white papers give some idea of where they might be heading, though. For those still following along at home, the Finance Committee's reputation is kinda like your practical no-fun older sister: since they deal with boring but necessary questions of revenue and spending and balancing budgets, they are not expected to release a terribly progressive bill. Instead, it'll be a sensible but perhaps timid thing that will have to be merged with HELP's bill and possibly the Healthy Americans Act to come to the final Senate bill.

    All of this perhaps less interesting than a SLOE about single-payer, but you ask, I deliver!
    posted by iminurmefi at 2:25 PM on July 14, 2009 [7 favorites]


    iminurmefi you should make that a fpp. great stuff. (but in the process correct those typos - that is one trillion, not one billion, but then why not throw out how many trillion we spend each year, not ten years, on health care already, and it is $597 billion - are you British?)
    posted by caddis at 9:25 PM on July 14, 2009


    For every UK or Canadian MeFi who states on the Blue that there are no long waits for treatment in their country, I see an article like this. Will a single-payer system in the US mean almost year-long waits to see a rheumatologist?
    posted by Oriole Adams at 2:23 AM on July 16, 2009


    I think that article misrepresents the study and is overly sensational, harly surprising for the Daily Mail.
    posted by caddis at 4:04 AM on July 16, 2009


    In Australia, there can be long waits for free consultations with specialists for chronic, non-life threatening conditions. In this case, you may pay cash to see the specialist of your choice ($220 for an allergy specialist for my daughter was an example a few years ago). If you choose to pay for additional private insurance, a portion of this fee is refunded.
    No drama, everyone really unwell gets treated, even if you cannot afford the cash/private insurance, you just don't get seen immediately if you can wait.
    The idea that a society would *choose* to leave many untreated (except in an emergency room that could bankrupt them) because they can't have a single payer government insurer that gives immediate care for any niggle is abhorrent.
    Because Australia has a single payer system for the bulk of health care, costs remain reasonable. The dollars per person we pay for 100% coverage of everybody, plus enhanced private insurance for those choosing to pay it, plus the money paid directly by those choosing to skip any waiting list is still only about half of what the USA spends.
    posted by bystander at 7:13 AM on July 18, 2009


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