Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD


It's Time for Doctors to Speak Out

By Rob Tenery, MD on November 27, 2017

Bernie Sanders keeps up his clarion call for Medicare for All. Although single payer delivery systems look good on paper and often get high marks by patients who are participants, single payer models are a distant second even to this country’s current ‘patchwork’ system. Single payer models address cost containment, but they fall short in delivery protocols and reimbursements to providers.

Tackling the reimbursement problem first.  Does it matter that caregivers earn less in Canada than in the United States? At first glance, no, except that financial incentives do make a difference in career choices. Why would choosing a career as a doctor be any different?  Also take the extended training period post college and the usual debt that comes with it. Additionally, in Canada’s single payer model, as the fiscal year winds down, if the government’s allocated funds are low, reimbursement for care is decreased proportionately, sometimes resulting in work slowdowns--- another term for delay in care.

The most common complaint in single payer systems is the prolonged wait times for care. Being that profit motive is the engine that drives systems to operate more efficiently under capitalistic systems, the more care that can be given, the more rapidly that care will be instituted. The availability of CT scans in the US versus Canada is the most frequently used example. That argument can be expanded to other diagnostics such as getting an arteriogram for angina. Delays are often played down in comparisons between the two systems as only inconvenience. The real difference is often much more--- prolonged morbidity that can lead to further disability or even premature death.

A frequently used argument by those with government run/single payer systems is the lower infant mortality and longer life spans of their populations.  Those comparisons are not valid in the light of this country’s high mix of illegal immigrants and other populations that seek care only when their needs are emergent.

So, what is the answer to Senator Sanders’ concerns if Medicare for All is not? It’s participation by all eligible citizens in a system where by the government and the private sector, both play critical roles.

 The ACA (Obamacare) attempted to address coverage for the uninsured population that could be faced with a life of unpaid debt if they were confronted with enormous medical expenses.

The Individual Mandate clause in the ACA was the Obama administration’s attempt to address this group of about 28 million healthy individuals that did not qualify for one of the federal programs, instead choosing to go ‘bare’.  Unfortunately, the minimal penalty did not sway enough of these individuals to sign up to cover the premium shortfalls in the rest of the legislation. Trump, in one of his first Executive Orders did away with enforcing the penalty for those who elected not to pay the fine. Some of the Republicans, scrambling to reach a consensus on their version of an alternative ACA, have voiced that they are willing to drop the Individual Mandate clause.

Nothing could be more destructive to finding an answer to a long-term alternative solution to the single payer system! Without a buy-in by the electively uninsured, every option, other than a single payer model, will probably fail.

The 28 million uninsured’s monies are sitting on the sidelines. Coupled with the yearly debt they help to accrue when hit by a catastrophic medical or traumatic event, the current situation is unaffordable. According to the American Hospital Association, between 2000 and 2016, hospitals of all types have provided more than $538 billion in uncompensated care to their patients.  

Addressing one change would be to substitute the Cadillac plan in the current ACA for a mandatory catastrophic health insurance plan that would not only cover much of these patients’ insurmountable debts, but protect the caregivers and the taxpayers that either write off the losses or pass it on to the taxpayers.

Currently the debate, to either fix or replace our health care delivery system, is taking place in the halls of Congress. The Democrats want to protect Obama’s signature legislation at all costs. The Republicans support insurance reform and competition to lower premium rates. Both rely on stepped-up federal funding. Sanders’ wants to put it all in the hands of the Feds.

Input from the doctors and their patients seem scanty at best as the large insurers and the hospital corporations have taken over the role as the intermediaries. It doesn’t have to be that way! Collectively, the voters still hold more sway with their elected representatives in Washington than the big hospital corporations and insurers. But it takes the doctors getting off their butts, deciding what kind of delivery system they want and notify their Congressman. Otherwise, someday soon Bernie will be dancing on their graves!





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