An Interview About National Health Insurance

By Ellen R. Hale
Louisville Medicine, Nov 2010

Garrett Adams, MD, MPH, spent 40 years practicing medicine as a pediatrician, as chief of Pediatric Infectious Diseases at the University of Louisville School of Medicine, and as medical director of communicable diseases at the Louisville Metro Department of Public Health and Wellness. In January, he will begin serving as the president of Physicians for a National Health Program, which since 1987 has been the only national physician organization in the United States dedicated exclusively to implementing a singlepayer national health program. As proposed by PNHP, the system would have public funding but private delivery of care. “Under a single-payer system, all Americans would be covered for all medically necessary services, including: doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs,” according to The Louisville Medicine Editorial Board drafted a list of questions for Dr. Adams. GLMS Communications Associate Ellen Hale interviewed him on the board’s behalf.

Q: How did you become involved in promoting a single-payer national health program?

A: In 2003, I read this JAMA article on the “Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance.” I thought, that just makes sense. I went to the website and endorsed it. At that time, there were 8,000 physicians who had endorsed it; today there are 17,000. I began to think about the way medical care had changed during my years of experience. Doctors were taken away from their patients, and I began to realize that the way medical care was being paid for had really intruded into the physician-patient relationship.

A lot of Americans and even some physicians are not aware of the great disparity in the ability to deliver quality health care among the United States and other developed countries. We’re way behind in terms of the efficiency and in terms of quality. And there’s this unjustified idea that we have “the best health care in the world.” It may be true in isolated instances, but overall it’s just wrong. We’re being dragged back by this market-driven, profit-driven system that has really put a damper on our ability to provide quality care for everyone in this country.

Q: What do you hope to accomplish as president of PNHP?

A: We’d like to grow the organization, particularly in the South. One of our goals will be to spread the message of the advantages of a national health system to people who will benefit from it. Some of the worst health statistics are in the South. So these are the people who would benefit from a good national health system. I’d like to recruit physicians to the idea. There’s a lot of education that needs to be done. Our challenge is uphill because the private health insurance industry and the for-profit health industry are opposed to many of the ideas of a national health plan. A lot of their effort is misinformation and propaganda, so we want to try to counteract that with facts. For example, the term “socialized medicine” came about when Harry Truman proposed it. The insurance industry hired an advertising firm, and they came up with “socialized medicine.” That was during the McCarthy era, and people were just afraid. There’s a lot of fear and distrust of government. I’d like to replace the fear with knowledge and understanding and get our government leaders, physicians and the public to understand that we can do better. We’re hurting ourselves by not adopting a simplified system that is in the hands of the people rather than the corporate, profit-making organizations.

Q: How would the proposed national health program be in “the hands of the people” instead of “the hands of the government?”

A: Government is the people. There are American governmental institutions that function very well. Our plan envisages a board, such as the Federal Reserve Board, that would not be run directly by elected officials but more by professionals. Then regional boards would have citizens, physicians and professionals who would make judgments. Medicare in this country has been very successful. There are problems that should be fixed, but it’s made a huge difference in the health of our seniors and also in the financial health of our seniors. Without Medicare, so many people would be totally broke.

There are some institutions that do well as policies change and as the political power changes in Washington. For example, the Centers for Disease Control and Prevention is an outstanding example of an American government project that’s been very successful and effective. There are lots of things we can be thankful for and proud of that come out of the CDC.

Q: Everyone agrees that costs are rising at an unsustainable rate, but getting agreement on solutions to the problem of rising costs is more difficult. What sort of cost-cutting ideas do you think could get widespread public and political support?

A: A national health insurance model or single-payer model is the only model that will control costs. Second to improved quality and improved health care delivery, control of costs is one of the most important advantages of this system. Right away, you gain 30 cents of every dollar that goes into administrative costs. Twenty percent is the usual administrative expense of an insurance company and then the additional 10 percent is the cost of the providers working with the payers. A dermatologist colleague of mine here asked her billing clerk how many plans were represented in their current bills outstanding. It was 287 plans. That’s where a huge amount of expense and time on the part of the physician could be recouped immediately. Medicare, with its faults, has an administrative expense of 3 percent or less. National health insurance would increase it to be more in line with some other developed countries, around 12 percent. The number of billing clerks at Massachusetts General Hospital is about 300. Toronto General, a hospital of equal size, has three billing clerks.

The ability to purchase pharmaceuticals and supplies in volume bulk purchasing would save huge amounts of money. We’re paying roughly 40 percent more here per prescription. The Medicare Modernization Act of 2003 strictly forbade Medicare from negotiating with pharmaceutical manufacturers for volume discounts.

Q: As part of the new health reform law, there are incentives for providers to begin using more and more HIT tools. But to ensure that patients are receiving the most benefits from adoption of the tools, the law requires that providers meet certain “meaningful use” standards. In what ways can providers and your proposed singlepayer program work together to ensure patients are receiving the most benefits from the adoption of HIT tools?

A: The best example is in France where in 1998 they adopted a “carte vitale.” Every citizen has a card. This would be the ideal. It has all the information – the patient’s medical records, X-rays, consultation results and physicals. The mothers of children under 16 years of age carry the card for their children. So they come to the doctor’s office, the doctor swipes the card, and then he has his monitor and he can see all the information. It’s always updated after the visit. Patients can go to any doctor, any hospital, anywhere.

Q: Physicians currently have complaints about Medicare regarding payment and services covered, and getting Congress to permanently fix the SGR formula has been a problem for years. Why was Medicare chosen as the model for the national health program? In what ways would it be improved under the national health program?

A: The defects that are pointed out in that question would have to be corrected. We need higher reimbursements, and we foresee higher reimbursements in a standard formula that doesn’t change. The national health program would provide all comprehensive medically necessary care from birth to death. There are no bills to the patient. All the bills go directly to the NHI (national health insurance), and NHI pays. The bill in Congress that will be reintroduced in January – John Conyers’ House Resolution 676 – provides for payment within 30 days.

I just read that AARP reported that the number of doctors refusing Medicare patients is higher now than it’s ever been. If I’m asking for Medicare for all, then that means the doctors wouldn’t want that because they’re refusing Medicare patients. That’s why we say improved and expanded Medicare for all.

To quote our national coordinator, Dr. Quentin Young: “Medicare is not without its problems, of course. Its benefits package could be richer. It lacks authority to negotiate lower prices with drug companies. The reimbursement rate to physicians could be enhanced and stabilized, instead of depending on an annual cat-and-mouse game with Congress over a flawed accounting formula that only erodes physician confidence in the program … By replacing our crazy-quilt, inefficient system of private health insurers with a streamlined, publicly financed single-payer program, we would reap enormous savings.”

Q: How would a national health program affect physician income?

A: Higher and more dependable reimbursement for primary care physicians; dependable reimbursement for everyone. High-end specialists would probably make less, but they would still do fine. But the primary care physicians would get more, and they would always be paid. They’d have more time to spend with their patients, which is what most of them went into medicine for in the first place.

Q: In a national health program, would physicians still have the right and realistic ability to open a private practice of medicine in a meaningful manner?

A: Absolutely. They just submit their bills. The payment schedules will be adjusted regionally. Within a state, there would be negotiations between representatives of physician groups with the regional board for their payment schedule. Say a school physical exam is set at $60. The patient comes in, gets their exam, the office sends the bill to the NHI, and they get their $60.

Q: Do you foresee any problems with setting protocols for treatment based on the input of a small number of physicians, and then making those protocols the only services that will be covered?

A: No. The concept is very clear that all medically necessary services would be provided. The treating physician makes the choice of what should be done for a patient. Physicians would have muchimproved authority from what we currently have.

Q: Do you foresee any restrictions on a patient’s freedom to make decisions on the manner and scope of their medical treatment?

A: Much less so than now. I see much more freedom of choice for physicians under this program. There’s some evidence to support that claim, and that evidence is in Canada and in France. Those doctors are happy with what they can provide for their patients, and they’re not constricted by pre-approvals from the insurance company. We wouldn’t have to go through the insurance company’s denial management. There’s more freedom for physicians and better ability to prescribe patient’s treatment as they need it.

Q: In a national health program, would individuals have the right to opt out of the system and still purchase private health insurance?

A: No, because that could undermine the system.

Q: How do you foresee the role of restriction of choice in the overall ability to finance health care for all? Won’t it eventually lead either to a two-tier system in which the wealthy are still able to purchase care not available to the average consumer, or conversely to unconstitutional limits on the ability of citizens to spend their money the way they choose?

A: You can’t buy something that is provided by the system. The question presumes that it’s an American right to spend money and buy whatever you want to buy. I guess the answer is that national health insurance does interfere with that so-called right. If it’s not what’s considered medically necessary, then they can buy that. It’s an egalitarian system that provides the best for everyone.

Q: What else would you like Louisville’s physicians to know?

A: I would like to invite fellow GLMS members to go to the website of PNHP to read in depth the answers to all of these questions. I also invite them to join our chapter of PNHP in Kentucky. We have members across the state.

I want this idea to be apolitical. There is a moral premise of providing health care for everyone. This is a simple program. The House bill is 18 pages. Everybody deserves health care. Everybody. Good health care. That’s the bottom line. That’s where we’re starting from.

I like to look around when I’m out in public, say when I walk from here out to my car. I’ll see a dozen people, and I’d like to think each one of them has health care. I get choked up because it’s not that way now. But it could be, and it should be.