Reforming Healthcare: A New Push for Single Payer

Remember health care reform? In 1993 Congress debated itself into gridlock over Bill and Hillary's "managed competition" plan for getting more people insured. Since then, the new buzzword in health care circles has been not "reform" but "corporatization," as more and more of the health care industry is wolfed up by for-profit mega-corps.One of the most convincing voices against corporatization is the 7,000-member national doctors' group, Physicians for a National Health Program (PNHP). PNHP wants to kick both the profit motive and the insurance companies out of health care, and instead adopt a government-financed "single-payer" system, with health care a guaranteed right of all Americans.The group will hold its national convention here this weekend. PNHP's new national president is Dr. Susan Steigerwalt, who lives in Detroit's Rosedale Park and practices at Henry Ford Hospital. She specializes in treating patients with high blood pressure, and she is leading PNHP because, she says, "I felt that I had an obligation to do this work in the best way that I could."I have patients who work but their insurance is inadequate; they have no money for their blood pressure medication. Some of my elderly patients spend up to 20 percent of their disposable income on health care over and above whatever insurance they have. It was looking around the city that I live in and work in that made me decide that we have to have universal access to care."PNHP members don't fit the stereotype of the golf-playing entrepreneur-doc who treats his practice as a business. Steigerwalt grew up in Ann Arbor and went to the University of Michigan's undergraduate and medical schools, where she was involved in the student movement and the Human Rights Party.She moved to Detroit "because I wanted to work with other people who also believed that health care is a right, not a privilege." She interned at Detroit General Hospital, a city-owned facility, and was involved in the losing battle, back in 1979, to keep the city from selling it.Steigerwalt says the PNHP convention will discuss a national "anti-for-profit campaign to inform the public of the connections between the for-profit health maintenance organizations (HMOs), the politicians in Washington and the insurance giants. We want to work with other groups to raise the issue of banning for-profits in health care."It would seem to be obvious for consumers, for physicians, for nurses, for everyone except Wall Street and the CEOs and stockholders of the companies, that profit and health care should not be mixing."Steigerwalt says that even since 1993, when the state of health care was last on our TV screens, "there has been a tremendous transformation in the way health care is delivered. Almost 60-70 percent of insured individuals are now in some kind of managed care."Managed care typically means that your insurance policy allows you to choose only from a selected panel of physicians and hospitals. Some managed care plans emphasize preventive medicine, and all try to cut down on "unnecessary" care. Most assign primary-care physicians as "gatekeepers" who decide whether patients should see specialists or receive other services.An executive of a very profitable California HMO explained it to Time magazine this way: "What's shifting is, patients can't drive it anymore; patients can't decide, 'My ear hurts, so I'm going to the doctor today.'""Managed care in the sense of having one physician coordinate care and organize preventive care isn't bad," explains Steigerwalt, "but we're talking about for-profit managed care. We're galloping toward oligopoly, where only a few giant companies will enroll everyone who has insurance, and that severely limits consumer choice."For example, with the recent merger of Aetna and U.S. Healthcare, that group is now going to be controlling the care of one in 12 Americans. U.S. Healthcare is famous for financial arrangements that encourage physicians not to take appropriate care of their patients because they'll lose income if they do. When Aetna bought U.S. Healthcare, they paid 25 percent more than what the stock was worth on the stock market, and the CEO of U.S. Healthcare stands to gain almost $1 billion dollars in the merger."At U.S. Healthcare and other for-profits, each doctor is given a certain amount of money for each patient every month, to take care of that person and 'keep them healthy.' This is called capitation. But if you refer your patients to specialists more often than what the company considers to be acceptable, or if your patient goes to the emergency room more than they think is acceptable, then a portion of the money that they pay you is withheld."Conversely, if your patients don't go to the emergency room and your average per month cost for specialty care is low, you'll receive a bonus at the end of the year. We call it 'fee-for-non-service.' So, taking care of the same group of patients, you could either make no money, theoretically, or up to $250,000, depending on how you practice."Even your ethical physician has a difficult time, particularly if they're being asked to see more and more and more patients, to not think about that when their kids need braces, they need to go to college, etc. It pits the patient's interests against the doctor's."And that sort of system is happening not only in the for-profits. It's happening in some not-for-profit HMOs as well. "By the way, U.S. Healthcare was also made famous by their 'gag clause.' That's a clause in the physician's contract which prevents them from revealing these financial arrangements, or from criticizing U.S. Healthcare to anybody, on pain of firing."Steigerwalt sees the loss of trust between physician and patient as one of the worst results of the squeeze on the way doctors practice."That trust is destroyed if you have an insurer looking over the physician's shoulder saying, 'No, you can't do that, you can't even tell them that treatment is available.'"Bad as these changes are, Steigerwalt says, the other side of the problem is that more than 40 million people have no insurance at all; a third of these are employed full time, and a quarter are children.That's the other reason PNHP looks to a "single-payer" model based on the Canadian system. Their convention will take place in Windsor partly for easy access to health care professionals there. In Canada, money is collected through a progressive tax and deposited in a health care trust fund. Local health boards administer the funds and pay hospitals and doctors for their services.Every Canadian receives a health security card which is all they need to receive free care at any facility in the country. Everyone is under the same system -- from the prime minister to the unemployed.PNHP says this system actually saves money -- in spite of the fact that far more people are receiving health care -- because the wasteful insurance company middlemen are removed from the equation. The U.S. Congressional Budget Office says that in this country, a single-payer system could cover everyone and still save $14.2 billion per year."Single-payer works," says Steigerwalt, "because all the money that is now spent on bureaucracy is spent on providing care instead." She points out that in the United States, a quarter of every health care dollar goes to administration -- including profits and huge salaries for top executives -- while in Canada the figure is only 11 percent. For our own Medicare system, it's 7 percent. Steigerwalt says single-payer's popularity is growing among doctors."Many physicians have patients who are having a more and more difficult time paying for their health care. Or they lose patients when the patients lose their insurance coverage and cannot afford to come see them. So there are a number of physicians who come to the idea of single-payer as a way of stabilizing their income."For minority physicians, who tend to practice in underserved areas, single-payer is particularly appealing because a higher percentage of their patients are uninsured and therefore unable to pay for care. In fact the National Medical Association, which is the major association for African American physicians, came out in favor of single-payer in 1993."The other group that's particularly hard hit is people who work in teaching hospitals and researchers, because for-profit companies are not particularly interested in funding research or teaching -- it slows them down."For the time being, Steigerwalt recognizes that sweeping reform is not on the political agenda. She sees her group's role as educating about the abuses that will grow as for-profit HMOs become the norm. Up till now, she says, for-profits have not penetrated Michigan. But "the not-for-profits are being forced to behave like the for-profits because of the financial pressure of the for-profits."In Ohio, Blue Cross/Blue Shield was bought within the last month by Columbia/HCA, which is one of the largest national chains. In many other places Blue Cross/Blue Shield is turning for-profit in order to compete with the for-profit managed care companies, which have tremendous resources to come in and buy up hospitals and practices. They say to doctors: either you join our panel at the amount we're willing to pay you, or you don't belong at all."Steigerwalt is also active in a group called Michigan Universal Health Care Access Network (MichUHCAN). The group advocates state "patient protection" legislation that would outlaw gag rules and guarantee HMO patients the right to a second opinion, to information on all aspects of their coverage and to appeal when care is denied. It plans to investigate and publicize insurance and HMO abuses, while still educating about the long-term goal of a single-payer system. "We think it's important to touch people where they live, with the problems they're having now," says Steigerwalt. "The thing is to make the connection between the need for everybody to be insured, at the same time that you're working with people who already have insurance who are being pushed against the wall by their insurance companies."I'm very fortunate, because I'm in a situation where I'm allowed to take really excellent care of my patients. I don't want to lose that."

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