Medicare works; open it to everyone

By Larry Donohue, M.D.
The Daily Herald (Everett, Wash.), March 15, 2015

Is our social contract obsolete, only a fond memory of a simpler time? Some, perhaps many, on the political right who embrace a libertarian view hold that their successes are self-made and so should be yours.

As conservatives legislatively seek its repeal and the U.S. Supreme Court again reviews the constitutionality of the Affordable Care Act, or Obamacare, it is possible that we could return to the shame that in this affluent country so many of our citizens could again be without affordable access to even basic health care.

If we could get past polarized political positions, there is no question that Obamacare can be and indeed needs to be improved. Legislative compromises left Obamacare less than it could be. Quality improvement opportunities include:

First, the costs of health care are not optimally curtailed.

There is no question that we should pay for quality of care not quantity of care, as we have traditionally done, easy in concept but more difficult in operation.

The low hanging fruit of cost containment is the administrative costs of our commercial insurers. There is up to 20 percent of the premium dollar going for advertising, high executive salaries and other items that don't contribute to improving health care. But this low hanging fruit is not as easy to harvest as it might be.

Bloomberg Business stated it clearly.

“But the thing that few people talk about, and that no serious policy proposal attempts to fix — the arrangement that accounts for much of the difference between health spending in the U.S. and other places — is the enormous administrative overhead costs that come from lodging health-care reimbursement in the hands of insurance companies that have no incentive to perform their role efficiently as payment intermediaries.”

Second, commercial health insurance rules and regulations introduce expensive-to-administer complexity, not value. Each health insurance plan contractually assembles its own networks of providers, benefits and rules. It need not contract with providers that it judges expensive, despite the providers expertise. An example is Seattle Children's Hospital, a locally cherished and nationally respected health care facility. Several insurers are reported to have not contracted with Children's, citing cost. Their insureds are denied access to these renowned physicians. With pressure from the Office of the Insurance Commissioner, more insurers are now including Seattle Children's Hospital in their networks, but with each contract year the problem can return.

A University of Washington Medical School Professor opined that one of the problems of our health care system is that strategy decisions are now being crafted by masters of business administration rather than by health care professionals. The bottom line trumps the common good.

A second example, arguably the premier cancer research and treatment center in the country, The Seattle Cancer Care Alliance (The Fred Hutchinson Cancer Research Center, University of Washington Medicine and Seattle Children's Hospital) and the largest provider of commercial health insurance in the state, Regence BlueShield, covering some 1.1 million people, have failed to reach contractual agreement, thus denying these 1.1 million fellow Washingtonians affordable access to world-class cancer experts.

A diagnosis of cancer is enough of a psychological assault without adding the additional burden of having to choose between paying for locally available, internationally recognized cutting edge care and risking personal bankruptcy or choosing to forgo potentially life saving state-of-the-art care.

Both of these quality improvement opportunities can be addressed by adopting a “Medicare for all” program to administer health care payment.

The Medicare program is efficient and popular with users. In the heat of argument a few years ago, an impassioned speaker said “Keep your government hands off my Medicare!” Go figure!

The major obstacle to accomplishing these quality improvements is the untoward influence of health care industry lobbyists. More than 2,400 individuals are registered as lobbyists for the health care sector. The National Journal's "Influence Alley" reported that health insurance lobbyists funneled $102.4 million to the Chamber of Commerce during the health care reform debate. Health care industry lobbyists regularly spend $500 million each year influencing Congress.

If the only dialogue is between the lobbyists and politicians, affordable, efficient, quality health care for all will not happen. It is up to us to get involved and make our voices heard. The wisdom of the people can figure it out.

Larry Donohue has worked as a physician with the U.S. Army, UW and Harborview medical centers and a small group practice, served on the governing board of Swedish Medical Center and was an ombudsman and associate medical director for Regence BlueShield. He lives in Seattle. He is also a cancer patient.