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Want more choice? Pick single-payer

By Ann Settgast and Elizabeth Frost
Opinion Pioneer Press (St. Paul, Minn.) 07/30/2009

The health care reform debate is reaching a feverish pitch. As physicians, we are troubled by the direction the debate has taken. Whether via a public option or a mandate to purchase insurance, the proposals on the table aim to cover more, but not all Americans. They build on the structure of our broken system -- one that ranks as the most costly, fragmented and bureaucratic in the world.

President Barack Obama acknowledged in his national address last week that a single-payer system, because of automatic enrollment, is the only way to cover all Americans. We agree, and we encourage him to re-embrace this solution to the health care crisis. Single-payer is the only option that will actually work.

Mainstream media coverage of the health care debate is confusing. Conventional wisdom leads us to believe there are only two culprits responsible for skyrocketing costs -- doctors and patients. Doctors order too many unnecessary tests, while patients demand too much care. As doctors, we acknowledge that overtreatment of patients guided by improper incentives occurs, and must be addressed.

There are also patients who overuse care. However, this problem is minuscule compared to well-documented underuse. In its most extreme form, this underuse leads to death for more than 18,000 Americans annually as revealed in a sobering 2002 Institute of Medicine report. Blaming doctors and blaming patients ignores the giant health care elephant in the room: private insurance.

Of every health care dollar spent in the United States, 31 cents is spent on administration (more than double that of other industrialized nations).

This enormous waste comes from our unique multi-payer financing structure based on private health insurance.

So we are wary of proposals that seek to simply expand private insurance. Such expansion may decrease our embarrassing numbers of uninsured, but it will not help the insecurely insured -- a group to which we all belong, even those of us who "like what we have."

Private insurance has been likened to an umbrella that melts in the rain. Consider the study released last month in the American Journal of Medicine revealing that 62 percent of all personal bankruptcies are related to medical bills. More astonishing is that 77 percent of Americans who go bankrupt due to medical bills had insurance when they became ill.

Because it is a business, private insurance has, at its core, the bottom line. In his recent testimony before a U.S. Senate committee, Wendell Potter, former head of communications at Cigna, reported, "Members of Congress and the public have good reason to question the honesty and trustworthiness of the insurance industry. Insurers make promises they have no intention of keeping."

The only way to succeed in the insurance business is to selectively recruit healthy patients or to deny coverage to patients when they become sick. As professionals who strive to make sick people well, we find this model for our system illogical and fatally flawed.

Elimination of U.S.-style private insurance has been a prerequisite to achieving universal health care in every other industrialized nation. One must ask, "What if the rest of the world is right?" Only under single-payer can we eliminate the administrative waste spent on billing hundreds of payers and the sizeable overhead of the private insurance industry.

These overhead dollars are spent marketing, underwriting, lobbying and fighting claims -- none of which makes our patients healthier. Elimination of this administrative waste would save more than $400 billion annually, enough to cover the uninsured and improve coverage for the remainder. There is enough money in the system. We do not need more money -- we need a new system.

As physicians, we are obligated to use evidence-based medicine in our decision-making. The reform debate must be held to the same standard. Ample evidence, including studies by the Congressional Budget Office and the Government Accountability Office, have concluded single-payer can assure universal coverage while saving money.

For those who suggest we would lose choice under single-payer, we ask, choice of what? Choice of insurance plan -- yes. Choice of doctor and hospital -- no. A high-quality system is not one in which our patients choose their insurance plan, but one in which they choose their doctor.

Single-payer is the only reform option that actually expands choice.

Bringing private insurance or a public option to more Americans retains limited provider networks and restricted choice.

For those who say single-payer is socialized medicine and worry that government bureaucrats will suddenly begin making health care decisions, one only needs to remember that single-payer is publicly financed but privately delivered. Medical decisions should be made by patients and doctors alone.

Medicare is an example of a single-payer system.

For those who say competition among insurers is needed to keep costs down, we say the experiment must end. It has been tried, and it has failed.

While it is trendy to refer to patients as consumers who need to exercise more personal responsibility, we believe health care is a public good, not a commodity that can be bought and sold like a flat-screen TV.

For those who ask whether something is better than nothing (i.e., implementation of a public option), we again look at the evidence. Multiple states have tried to patch their systems with piecemeal reforms over the past two decades. None has produced universal coverage while controlling costs.

Given the magnitude of these difficult economic times, including a $1.8 trillion deficit for 2009 and rising unemployment, it is high time to reconsider the most fiscally conservative and financially sustainable option for reform.

 


Ann Settgast and Elizabeth Frost are primary-care physicians practicing in the Twin Cities. Gillian Schivone, a third-year medical student at the University of Minnesota, also contributed to this column. They serve on the steering committee of the Minnesota chapter of Physicians for a National Health Program (www.pnhp.org). Write to them by e-mail at pnhpminnesota@gmail.com. http://www.twincities.com/opinion/ci_12949586?nclick_check=1