Testimony by Dr. Johnathon S Ross, Past President of Physicians for a National Health Program in Support of HR 676
July 31, 2007
Toledo, Ohio
My name is Johnathon Ross. I am an internist. I practice and teach internal medicine at St Vincent Mercy Medical Center and have done so for the past 27 years. I am the medical director for the outpatient adult clinic which serves a center city population that includes a substantial number of poor and uninsured individuals. Every day I see a near miss. Every week I see a wounding. Every month or so I see a death due to our sickness care non-system that leaves 50,000 Lucas County citizens, over a million Ohioans and over 45 million Americans uninsured. A recent Friday morning was a typical clinic session where I work. Here are a few stories from just that single morning. Imagine similar ones day after day for the past 27 years and you will understand why I am here to testify today. I have changed the names for privacy but I did ask each patient if it was ok to tell their story and each agreed.
Tommy is 41. He was making his first visit following bypass surgery after suffering a massive MI. Tommy can’t read or write very well. He was working a low wage job that did not have insurance so he never saw a doctor for well care. That doesn’t matter much now since he lost his job due to his illness. He was very depressed in hospital and was started on medication for his depression and for his heart. Fortunately he was at the clinic with a family member who had paid over $100 for medication to keep him alive until his appointment with us. Thanks to CareNet, a free care program I helped to devise which helps some of the uninsured in Lucas County, he was able to see us in the clinic without charge but there was little likelihood he would be able to pay for follow up with the heart specialists let alone the bills they would soon be sending for his hospital care. One of our nurses who spends hours every day trying to help people get “free” drugs from the pharmaceutical companies looked deflated when we gave her the long list of expensive medication he needed.
Shelly works as a temp at another hospital. She doesn’t have any benefits including health insurance even though she works full time as a nurse’s aide. The irony of a health care worker who is not covered for health care is not lost on me as I see lots of nurse’s aides who work in extended care facilities with no benefits. She was seen in the emergency room for severe stomach pain. She hasn’t seen the bill yet but I suspect her stomach\ pain will get worse when she does. Her stomach still hurts and she had no money for the ulcer medicine they wrote for her. I search the free samples and manage to find about two weeks of medicine. I give her a follow-up appointment and hope for the best. Even if she was covered it can take a month or more to get a gastroenterologist to see my patients.
A clerk tells me that Niles is at the window and he is upset. He is out of medication and needs samples of medication for his blood pressure. He should be covered by Medicare as he is 68. He has a card but the pharmacy says it is no good. He is not sure if it is no good for all or some of his medication. He just knows that he is not supposed to miss it. We have referred him several times to the social security office and they tell him he is covered by his card. There are 50- different plans all with different formularies and there is no time today to sort out again why his card is no good. I tell the nurse to give him samples again and we will try to sort out what is wrong with his card later.
Chris has asthma low back pain and high blood pressure. She is doing ok with her current medication but isn’t sure if her re-application for Medicaid will go through in time to allow her to get the refills that she needs. She says that she might have to “spin down”. She’s not sure what this means but I am. She works a little and may have made too much money this past month to qualify for help and might need to “spend down” not “spin down” to poverty or perhaps she will do both. In any case, she will be out of medicine in about ten days. The last time she missed her asthma medicine she ended up in the ER. I give her one of my last samples of an inhaler just in case and hope I don’t need it for someone else with more immediate needs.
Arthur has insurance. He has Medicaid. This is his third visit for a rash that won’t go away. It seems there are no dermatologists in town who will take his Medicaid HMO. I try to make light of a bad situation and remark that his new private insurance under Medicaid is actually a hunting license. WE get to go hunting for specialists who will accept his plan. We decide to continue our game of musical medicines to see if one will help. At least, he has coverage for his medicines. Welcome to the best health care system in the world.
America and Ohio need affordable guaranteed High quality health care coverage that they cannot lose if they change or lose a job, whether they are rich or poor, whether they are healthy and want to stay that way or whether they are sick and want to get well. Single payer national health insurance or a similar state based plan could accomplish the goals of guaranteed coverage, quality and cost control.
Doctors would get paid for every patient, see malpractice and administrative costs drop. They could maintain continuity of patient care with less non-compliance with expensive but needed therapies. Outcomes and quality would improve. Emergency room overuse and abuse would diminish. Chronic disease management would improve.
For patients, soaring health insurance premiums are the norm and uninsured Americans now exceed 45 million. 80% of the uninsured are working people and their kids. They are not covered by their jobs or cannot afford to buy health insurance when faced with skyrocketing premiums. Managed care, with its restrictions and market competition, failed to cure rising costs but surely created hassles for doctors and patients. Those same self-interested insurers who brought us HMO’s insist that financially squeezing patients will cure the cost crisis. In reality, High deductible health plans and Health savings accounts are just another way that employers shift the cost burden onto employees, whose co-payments and deductibles soar while their coverage sinks. If doctors and patients have problems now with collections, insurance hassles, and continuity of care, just wait until HSA’s with Swiss cheese coverage become the norm. Unfortunately, there will never be an effective market for health care services. Why?
Health care is not an ordinary product that people want. Rather, it is a necessity that they must have. The consumer’s not sovereign. The doctor, not the patient, orders the care. There’s no easy exit from the market for patients. Price does not matter. When critically (and expensively) ill, you buy or die. The most expensive health care is necessary not desired. Even the best physicians are unsure at times what tests or treatments will benefit a patient. Thus, the costs of patient care are often unpredictable. It is this uncertainty and unpredictability that creates the need for insurance in the first place. Asking patients to assume more responsibility for out of pocket costs will not work. Americans already pay the highest out of pocket health care costs in the western world and this has done little to control costs. Research shows that higher out of pocket payments will reduce the number of outpatient visits but these payments fail to increase the appropriateness of the visits. Paying more does not create wiser consumers of health care. To understand the absurdity of using individual market forces to control health care costs, imagine open-heart surgery is on sale. Would you have two? The most expensive surgery or medical care is the least optional, predictable or negotiable. The sickest 10% of patients generate 73% of the health care bills at an average of about $39,000 per person yearly. They will save nothing in their HSA’s. The market for medical services fails these tests of an effective market and will fail in the guise of HSA’s.
Massachusetts is forcing uninsured working families to buy bare bones coverage from private insurers who will likely keep 15 to 40% of premiums for administrative costs and profits. This is hailed as reform but hardly seems wise, fair or efficient. It will leave these families vulnerable to large health care bills that are potentially financially fatal to working families and there seems to be little effort to improve the quality of care we all get under this so called reform.
If market forces cannot work, the proven alternative is a tax financed universal health insurance system. It may seem counter-intuitive that a tax financed universal health insurance program that covers everyone could be less expensive than a health system based on cutthroat competition between private insurance companies that leaves 45 million Americans uncovered. Yet, this has proven to be the case for every other industrial democracy. Recently, Taiwan made just such a switch and again proved it could be done. They covered everyone with little increase in cost. On the other hand, national health insurance, as proposed in HR 676, (Conyers and Kucinich) would replace private premiums with fair payroll taxes. These funds, added to current public spending, would create a single insurance pool adequate to cover all Americans with no added spending. Here in Ohio, The health Care for all Ohioans act would do the same thing for all Ohioans. How can this be true?
In multi-payer systems, complexity yields high administrative costs. Each insurer, hospital and doctor must track of a myriad of contracts, discount arrangements, benefit packages, formularies, limited referral networks, and insurance regulations designed to reduce utilization. Market solutions leave this insurance and billing bureaucracy in place and add the complexity of tracking 300 million individual insurance policies.
Multiple studies confirm that the administrative simplicity of a single universal insurance pool yields hundreds of billions in savings that allow comprehensive coverage for all at current levels of spending. A tax-based public system is simple and efficient. There is simply less work to do. The data from a universal system can be used to track and evaluate care and offers the best opportunity to improve the quality of care.
Health care costs are hurting the competitiveness of our products in the world markets. Despite HMO’s, PPO’s, HSA’s, the FEHBP, CALPERS, small business insurance purchasing pools, high risk individual insurance purchasing pools, we have failed to control our health costs. American business and governmental employers are struggling with the burden of health care costs and despite almost 20 years of experimentation with these different approaches to cost control health care costs are growing at double the rate of the GDP. At the same time, the number of uninsured full time workers has soared by 10’s of millions as premiums have become more and more unaffordable. Several large industries are giving up responsibility for insuring their workers, creating insurance trusts that will be maintained by unions who not surprisingly support national health insurance. The largest U.S. employer, Wal-Mart, has come under severe criticism for its failure to cover its workers. They are targeted with state laws aimed at forcing them to insure their employees or pay special taxes to the state to help cover the uninsured. More business leaders are calling for a national solution. Some have speculated that it must be ideology alone that keeps many business leaders from supporting a national solution.
Business owners should realize that the health care system provides the maintenance on their work force just as other experts provide maintenance on their expensive and complex industrial and business machinery. It makes good sense to get the most comprehensive maintenance system for the best price. More for the same money, value, is what tax-financed universal health insurance system can provide. Those businesses avoiding the cost of insuring their employees are still the recipients of cost shifting. This occurs through higher taxes to fund indigent care and higher prices paid when doing business with companies who continue to insure their employees and pass along the costs shifted to them in the price of their products.
Conclusion
Patchwork solutions such as Medicaid expansions, individual insurance mandates, tax credits or health savings accounts are unlikely to work. They will mainly serve to enrich the insurance bureaucracy. They will fail to control costs, improve Quality and fail to cover everyone. Fundamental reform is needed.
A single payer tax financed universal health insurance system (an improved and expanded Medicare like program such as that proposed in HR 676 and the HCFAO act) will cover all Americans comprehensively at no added cost. It’s good for business and our health. Single payer national health insurance is conservative of the basic structure of the American health care system and in that it changes mainly the financing. It would ease our efforts to improve quality. It is conservative of individual freedom and responsibility in that it allows free choice of provider and eliminates financial barriers to preventive and chronic disease care.
Single payer national health insurance would cover everyone, save lives, save money, and it is the right thing to do. Counter-intuitive or not, even conservatives should support a single payer universal health insurance solution. Financially, they already are.
Johnathon S. Ross MD, MPH
Past President, Physicians for a National Health Program