20 July 2007

What should Health Care reform look like?

Faithful reader and devil's advocate Felix writes:

Dear Dr. Shadowfax,

I am confused. You just explained, lucidly and cogently, that idiots like yours truly subsidise the Medicare and Medicaid patients, not to mention the uninsured, so that you can earn enough money in a shift to have a plumber unclog your commode at home.

And then you go on to say, why, Medicaid is so wonderful, let's have more of this?

This is a great point regarding Medicaid and I'd like to riff on it a bit. There's an old adage in Washington DC that "programs for the poor are poor programs," which is to say that they are underfunded with all the negative consequences attendant. Many attribute the success of Social Security and Medicare to the fact that they are endowed across all social classes and that seniors can be relied upon to raise holy hell if any politician tries to touch them, whereas it's well known that poor people don't vote, and there is rarely any electoral consequence for politicians who cut their programs.

But why on earth would you presume that I want Medicaid for all? This seems to be a common misunderstanding among the flat earth crowd who are reflexively opposed to universal health care -- they assume that whatever reformers propose will look like Canada or Britain's NHS or Medicaid or some frankenstein-esque amalgamation of all their worst bits. Either they haven't bothered to read any of the serious proposals or they are deliberately setting up strawmen to bolster their vacuous arguments.

Let me be clear on this point: I favor health care reform which will abolish Medicaid. Medicaid sucks on so very many levels it's hard to explain. The pathetic reimbursements are only its worst feature to me (a doctor) -- the medicaid recipients can tell you in great detail how much it sucks from their side, and state lawmakers and administrators will fill your ears with horror stories from their point of view.

Most damningly, Medicaid fails to fulfill its goal -- to give access to health care to the 'deserving poor' (an arbitrarily defined subset of the actual poor). Sure, beneficiaries have "insurance" but they do not have access. Try finding a PCP who will accept new Medicaid patients. Meaningful access requires coverage which provides meaningful and sustainable reimbursement.

But when you read the health plan advocated by serious individuals, you see that many of them are quite different. Most involve public-private organizations offering community-rated plans funded by premiums collected from insureds, generally with subsidies for low-income persons. Several, including my current favorite, Senator Wyden's Healthy Americans Act, would outright abolish Medicaid. They preserve multiple payors competing against one another, which would prevent a single-payor monopsony depressing provider reimbursements. Plans can even offer different levels of benefits from catastrophic to comprehensive coverage.

You may, should you choose to take the effort to look, note that not a single presidential candidate is advocating a single-payor system. Yet even rational voices like Kevin are obsessed with attacking single payor. Argue against it all you like, guys, but you're wasting your breath. That horse is dead, that dog won't hunt, whatever metaphor you like.

So, Felix, no, I don't want more Medicaid. I want a universal system that covers everybody at the same level (r/t provider reimbursements), so that the shell game of cross-subsidization stops and everybody has access to at least some basic level of real health care coverage.

Thanks for reading.


Anonymous said...

And tnank you for replying, Dr. Shadowfax!

Austria, the land where I was born and grew up, has a two-tiered system. Mandatory insurance for everyone (opting out is allowed if your taxable income exceeds a threshold, and you can show your private insurance policy that overs the mandatory stuff), and on top of the mandatory system, you can make whatever arrangements you like, within your financial limits.

It is not a single-payor system: employees generally are covered by a "regional insurance provider" (one per state), the self-employed are insured by their "guild's" (for want of a better term) company, and so on.

However, all these entities are guaranteed by the fisc, at a cost that is already throttling the national budget.

What I do not understand is why, in this multi-payor system, all those insurers would magically have set the very same low reimbursement rates!

An extra twist is that for most services, the provider is not allowed to charge more than that official rate. A hospital, for instance, may charge me for flowers in my room, but even if I am admitted as a private patient, the hospital administration is stuck with the same loss-making rate that they are allowed to charge to the mandatory insurance plans.

Similarly for doctors: It's either only what the mandatory plan covers, or I can go private all the way. Take for instance: My recent repair to the right acetabular labrum. Aside from the fact that nobody in Austria could have done that arthroscopically yet, I could either have had it covered by insurance and accepted an eight month (!) waiting list for the surgeon; or I could have gone private -- in which case I would have had to reimburse the surgeon, the OR staff, the hospital providing the OR, the anaestestiologist, and the porter who pushed me out the door in a wheelchair, all from my pocket.

No, all this does not mean that multi-payor universal insurance systems are doomed -- but in 39 years in Europe I have yet to see one that is not either terminally broken or driving the country bankrupt. I urge you to be careful what you ask for.

Again, thanks -- and the next time I get run over on my bike, I'll make a point of asking to be delivered into your capable care. I work for "a large software company in Redmond", and the benefits (BCBS has compariatively good reimbursement rates, I am told) may allow you to offer your plumber an extra can of soda when he's done. :-)


Anonymous said...

And please allow me to claim that I do actually know how to spell "anaesthesiologist". My apologies to your gas-passing colleagues!

Graham said...

*Ahem*. Dennis Kucinich supports single-payer.

shadowfax said...


That's why I said that no "serious" person supports single payor. Kucinich is, with respect, a joke, and not the funny kind.


Essential to the success of a multi-payor system is something of a free market. Doctors have to be able to negotiate rates with the payors and to refuse to contract with plans that do not offer reasonable rates. This is the leverage that keeps reimbursement from being set at one low level -- the plans will need to compete to make sure their provider networks are adequate.

For example, there is a large "blue" payor which is the designated insurance co for a certain large software company in Redmond which is notorious for paying the LOWEST rates of any commercial payor in the state, rates on a par with medicare's! So I canceled our contract with this company and we went non-participating for two years. It was an audacious step and caused a lot of controversy in ths hospital, the media, and among patients. Eventually, the "Blue" decided that we were serious and they came back to the table in good faith and we came to an amicable agreement at sustainable reimbursement rates.

You say that in Europe all the similar plans are driving the country bankrupt, but I remind you that we are already spending 50% MORE per capita -- and not even covering everybody.

And may I suggest the Sammamish river trail as a safe car-free place to ride your bike?



Anonymous said...

Dear Dr. Shadowfax,

I am surprised to learn that BCBS is so stingy. A certain large software company in Redmond -- LSCIR -- is self-insured, such that BCBS is only the benefits administrator; given how much money LSCIR throws out the window (or stuffs down the gullet of incompetent drones), I cannot fathom why we cannot pay fair compensation without first being held over a barrel. I really wonder at it.

Oh well, I figure I'll just have to bring the soda for the plumber! :)

The SRT is nice, and I enjoy a leisurely Sunday afternoon noodling along, but since I am not a jerk (or at least try hard not to be), I limit myself to speeds at which the majority of the children near me may survive. For serious biking, I still go out on the roads, and for punishment, there are fortunately any number of interesting hills around.

My email address is felixk@LSCIR -- if you are comfortable divulging where you work (UW? Harborview? I suspect the latter), and when, I'll show up with a nice large pot of paprika csirkes ("chicken paprikash" in English, I think) for the night shift. My late Hungarian grandmother passed down the recipe, and Mom taught me, and I am not a complete failure at it, if I may say so myself.


Matlatzinca said...

Sounds like you, me, and Felix need to discuss this over a 30-60km ride.

Anonymous said...


discuss what? Healthcare might work as a topic (and if we meet Michael Moore, I'll strangle him with the tubing of the insulin pump that I wouldn't be wearing if it were up to him) -- but I'd rather swap recipes. I make a mean dessert, too. I suspect that even Dr. Shadowfax would sell the Democratic Party down the river for a second helping of my Apfelstrudel!

Anyway, felixk@(large-software-company-in-Redmond).com. Until my hip rehab is done (and my left pes anserinus bursitis has resolved), I am limited to 15-17 mph average, but if you are willing to slow down for me, or just go out for a leisurely afternoon on the BGT/SRT, I am game!

If you are looking for other riding partners: There is an orthopod up in Kirkland, Dr. Rolfe, who I understand goes out to ride with a group of doctors. I considered their invitation to join -- what better company for a diabetic to fall off the bike with hypoglycaemia? -- but the schedule didn't work out. I'd be happy to supply his name.


Anonymous said...

Oops, make that last "their names", although Dr. Rolfe will surely be glad to help, too. He is very accommodating in all things, and only some pesky biological facts prevented me from watching my SLAP repair live (one could wish the shoulder were innervated from a level that makes a spinal block possible). Still, the video was neat.


911DOC said...

The earth is not flat... only nearly flat. I have been at up really high in an airplane and I do think that the earth curves at the edges. I think it is more of the shape of a tarpaulin stretched down a bit at the corners with a small protrusion at the center. Careful around the edges... "thar there be monsters."

911DOC said...

and shadowfax, i am not opposed to reform at all. i favor a two tiered system like Australia's. Baseline coverage for all, those of means may bump it up as they see fit. Abolish medicare/medicaid. Absolutely. I do truly believe, however, that when someone says, "I'm from the government, I'm here to help", that you should run away quickly.

shrodingers cat said...

I just googled it and you are right. The earth is round. My whole world is upside down now (or is it inside out). And 911, a two tiered system might well work. But if you want to see a hydra grow out of control, just put more government stiffs into the mix. The NHS is already the third largest employer in the world (behing the Chinese military and the Indian railroads). To meet quotas and make waiting times seem shorter, proceedures are simply canceled. Just imagine how large, immovable, and unmanageable this national "managed care" would become.

shrodingers cat said...

Sorry, added one to many eeees to procedure.

911DOC said...

well said 'cat. would like the whole system to be privately administered with incentives on the adminsitration side which would keep the admin. side as small as possible and allow for firing and hiring outside the 18,000 rules and regs. required to hire and fire a federal employee.