The Best of Both Worlds – A Capitalistic Case for a Public Single Payer Option and Private Sector for Health Care in America.

As a family doc geriatrician, I have treated people from literally every arena (medicaid, medicare, private insurance in all it’s variety, and uninsured).  I know first hand the risk of a federally provided program that is over-regulated and that does not actually put money into quality relative to the population’s needs (yes I am talking about Medicare).  I also completely recognize that whether it be a “right” or not, healthcare is a business.  Money is involved, whether at the government level or the private insurer level.  Yet if we truly are a country that believes first and foremost in everyone’s inalienable rights of life, liberty, and the pursuit of happiness, than how can we as a nation not provide some minimum standard of healthcare for all it’s citizens?  What one thing does everyone need to live, to have liberty and be truly free to pursue happiness?  Their HEALTH (mental and/or physical)!  I am not advocating for a single payer system publicly funded that pays for EVERYTHING.  However there are a number of basics that can easily be agreed upon that yes, our government and our taxes should pay for so that everyone in our society can have their best chance at success.  If you want to bring free-market economics into it, then allow for the private sector.  But when people are desperate and feel their lives depend on something (whether they really do or not) they will pay anything, say yes to anything, and ultimately competition and free-market choice just don’t apply.  The American Healthcare system already rations care.  Insurance, private docs, medicaid and medicare all have rules as to what they deem valuable and will or will not do or pay for.  I’d contend however that despite our highly polarized country, there are very basic healthcare and medical needs that Democrat and Republican alike could agree on to be covered for everyone in a nationally funded and provided healthcare system.  Some of these include basic preventative measures like vaccines, pap smears, contraception for women (note I differentiate contraception from abortion……they are different, very very different), basic health literacy education, screenings for treatable chronic conditions and treatable cancers, etc.  Then there are common ailments that are easily treatable (at a certain age) no one expects to get but also should not financially ravage a person or a family if they do, such as an appendicitis, a pneumonia, a traumatic incident or a heart attack.  If the primary panel that determined the type of care needed was made mostly of PCP’s and General surgeons, I’d wager a million to one they’d come up with a bipartisan agreement on what should be covered.  And no, not everything would be covered under a national healthcare system.  Just like in the public school system, not everyone gets a voucher to go to whatever expensive private school they like.

Ok so say we do this.  Who would work in that system?  Most American Doctors are extremely FED UP with the regulations, oppressive burdens of medical school debt, bad technology at our disposal, administrative burdens, medical malpractice, etc that distract from our ability to care and form relationships with our patients.  For this kind of thing to work, we’d have to step outside of our bubble and not be constrained by the many issues of our current private and public Health sectors.  We’d need to take the good things from other countries of comparable standing and be willing to use what could work for us.  Meanwhile we could tap into the amazing resources and technologies we do have in brain power in our own country.  So what could this look like?  Let me tell you.

  1. Scrap Medicare and Medicaid, completely, and start over with a United States National Health System (USNHS).  This would be similar to Medicaid in that it would be a Federal and State program.  Certain minimums would be mandated by the Federal government that would be agreed are basics that must be provided and the current Federal social security tax/medicare federal would essentially become the USNHS tax.  This won’t be enough though for coverage of everyone and therefore allow the States to both administer the plan and levy taxes in whatever ways they feel will work best relative to their respective State needs.  We have 50 vastly different states in this country.  To assume that the needs of one are the same as all is just naive.  Therefore in setting this up, allow for some State autonomy.
  2. Will this be something we can afford to fund with taxes? – Heck yes.  Again it should NOT pay for EVERYTHING.  The USNHS should cover acute, chronic, and preventable healthcare needs agreed upon by experts in medicine and public health (I’d contend mostly family physicians from both urban and rural settings) based on age and likelihood of successful prognosis with treatments.  Yes there will be rationing, as there already IS in every single aspect of healthcare.  However when people find their income is much greater because they did not have to elect for the employer covered private insurance benefits that make healthy people pay for very sick people who over-use the system they’ll find that despite a slight increase in taxes, they’re coming out ahead.    The payment for the physicians in the USNHS and other medical providers should be time-based relative to their expertise and degree level, rather than volume and procedural based.  If payments are time based (like an hourly salary) then physicians are more likely to take the time to explain things, to get a proper history so we don’t just order costly tests, to take the time to talk to other health team members, and to re-establish the sacred relationship between a doctor and patient.  If time-based then we don’t need the Electric Health Records that were built based on cumbersome and business minded ICD-9 or 10 codes.  The USNHS could establish a nationwide EMR created with 80% input from medical providers and 20% from computer coders and engineers that would allow easy documentation the way providers need and want it.  Also, because it would be national, if a patient stays within the USNHS, it would be visible from any USNHS site.  So if they seek care, there would not be more ordering of unnecessary, costly and sometimes risky tests because providers in the USNHS would be able to see results and notes from other providers, even in other states.  Oh also, we would need more meaningful malpractice reform on a federal level.
  3. Who would work in this system and will a time-based salary make people lazy? – If set up correctly, it would be very attractive and no, it won’t make medical providers lazy.  First of all, I am not advocating for almost free medical school education (like many of the countries with socialized healthcare have).  However, we could very easily incentivize people to work for the USNHS if we offered complete loan repayment for those who dedicated at least 4 years (or maybe however many years their residency/fellowship training was) to the USNHS.  If it were a true national program, then there wouldn’t be horrible constrictions on where people would be placed, because likely there would be an opening near where they want to be (currently you can get your student loans paid for if you commit to being placed in literally wherever, often Native American Indian Reservations, Alaska, or the most challenging Federally Qualified Clinics, for at least 4 years after residency).  Also, if the USNHS is set up correctly, many quality family doctors and altruistic health providers would be attracted to the concept of getting the time necessary to establish relationships, educate people about their health and healthy living, and less administrative burdens that I would bet a number of people would stay on with the USNHS despite the overall lower salary paid than the private sector.  There would certainly be more Geriatricians.  And the argument that salaries make people lazy……sorry but no.  No medical providers make it through our physician training system by being lazy.  If they get burned out by our current awful system and start doing less, yeah it’s the system.  Medical providers are not inherently lazy people and salary paying the altruistic ones who work for the USNHS will likely only improve care.
  4. What about Capitalism and the Free Market and Competition and the Private Sector – Good news!  We’re America.  People are easily swayed that they need fancier things, treatments to make them live longer, look younger, look skinnier, or even that just because it’s more expensive it’s somehow better.  And the people want choices!  Why do you think Dr. Oz is so successful?  There will always be cosmetic Dermatologists and plastic surgeons that people will pay for if they have the means.  There will always be fertility specialists offering IVF if you can pay for it.  There will always be someone willing to do your surgery for the right price even if you are risky and it’s not an emergent medical need.  And there will always be doctors willing to keep you alive on machines, or perform a code on your 85 year old Grandma, or offer you chemo they know will not help because you have a strong Faith in God and miracles.  And they will charge you what the market will bear.  And yeah, they’ll have to be better because they will be competing with the USNHS, which will only control costs, improve care, and make for happier Americans all around.
  5. How would this approach support Capitalism, Free market exchange of goods and ideas, entrepreneurship, etc etc etc? – I’m frankly dumbfounded that this isn’t more obvious to politicians and economists.  But then I recall that many politicians and rich business people respond more to the needs big business and big money than the average American working class, rural or urban.  They also are not physicians……or at least the physicians that are on the front-lines of healthcare.  How many of you reading this (I’m hoping I’m getting other views than just medical professionals) have wanted to start your own business, or have an awesome idea that you really think could work, but also have a family to provide for?  How many of you work for an employer who you don’t love, isn’t particularly fair, does not necessarily inspire you, but does provide for basic healthcare benefits so you and your children can get vaccines and basic care if someone breaks a bone or gets an appendicitis?  How many of you know that if you started your own small business it would be successful enough for just the right amount of profit that you wouldn’t qualify for medicaid?  I bet there are a number of you thinking, “yeah, heck yeah, that’s me.”  But, you stay in your corporate big business job and never bring your awesome ideas to our “free market” because your health and your family comes first and you can not take the risk that their healthcare needs and your benefits wouldn’t be met.  So how is this system of no true basic minimum of healthcare met publicly helping capitalism and the “free market”?  It’s not.  It’s helping the already rich corporations solidify their monopoly on ideas and the market.  It’s helping the already billionaires eliminate competition because we are not allowing our true potential to be met.  By trying to force a basic human need, such as minimum healthcare standards, into a private free market capitalistic system, we are actually harming capitalism, the free market, and fostering monopolies.  Did this system make sense at one point?  Yes, it did.  But that was years ago.  Our medical knowledge, treatments, and possibilities and treatable issues have changed drastically.  So it’s time we get up to speed with the times and change too.
  6. How could this be bipartisan? – First of all take a deep breath and try to use reason, logic, and empathy.  Remember the First Amendment that separates church from state.  For a USNHS to be publicly funded, we would need to come up with a compromise of funding non-controversial things.  I will say, abortion and physician assisted suicide should NEVER be publicly funded with our tax dollars.  Contraception for women, physiologic education (currently known as “sex-ed”), hospice and palliative care for terminal conditions should ALWAYS be covered.  If you are someone that insists the medical field do absolutely everything invasive for yourself or loved one despite a dire prognosis or clearly terminal condition because you think it’s God’s will for a miracle……GREAT!  But don’t expect the state USNHS to fund that with American tax dollars.  Miracles are for God, the Churches and religion, not the publicly funded health system.  Pay yourself or get your church to fund-raise.  It’s your choice, it’s a free country.  But basics of coverage will be based on science, evidence, epidemiology, need, and affordability.

In conclusion, don’t let the media, people who know nothing of health and medicine, or those who are medical providers but are also practicing in fields of narrow scopes while making out like bandits cloud your judgement.  We are in dire straights right now in this country and it isn’t sustainable.  We need a real solution and our health is not something that fits into supply and demand economics and free market capitalism.  It just doesn’t work that way.  There is a better way, a compromise of both (Obamacare was doomed from the get-go because to get support from Republicans it had to enmesh the big business health insurance industry as its means to expand coverage……it isn’t working).  I know this probably won’t be read (it’s far too long), that this kind of thing is not in our horizon.  I have good reason to be cynical.  But I can dream.  I refuse, as a woman, mother, Family Physician/Geriatrician, healer, wife, sister, daughter, educator, athlete, granddaughter, Christian, to accept that the status quo is our future.  Here’s to trying!


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