The Health Care Battle Lines

O nemorninglastspringIreachedawatershed in my determined fight for health care finance reform . I was in the middle of a typical clinic, when I met with an old patient of mine whom I had not seen for about two years. Sione Tukuafu (name changed to protect privacy) is a Tongan man whom Ihadcometoknowasweattemptedtodealwithhis diabetes and its complications. In the years I had known him, his illnesshadneverbeenundercontrol.Hehadbeenhospitalizedrepeatedly for diabetic complications, including once for a particularly terrifying fungal infection of the eye that leaves most victims blind. Even the pain and fear provoked by this hospitalization failedtoresultinbettercontrolofhisdiabetes.Soyoucanimagine my surprise when testing done in advance of his visit showed his diabetesfinallyundercontrol! “What happened?” I asked, incredulous. As it turned out, the reason why I had not seen Mr. Tukuafu for some time was that he hadbeeninhisnativecountryforanextendedvisit.Thushismatter -of-factresponse:“HealthcareinTongaisfree.” In the United States, despite my exhortations and Mr. Tukuafu’s own experience of the complications of diabetes, the economic barriers created by co-pays and deductibles had led himhabituallytofailtoproperlycareforhisillness.Theironythat the tiny island nation of Tonga, with few natural resources and little industry, could provide Mr. Tukuafu with free medical care that allowed him to control his diabetes for the first time in years, whileinthisrichcountry hewasunable tocontrolhisdisease, has become an icon for me in my battle to enact fundamental health carereform. In recent weeks, especially, with public hearings beginning in theUnitedStatesSenateandwithPresidentBarackObama’s“Organizing for America” encouraging citizens to gather support for health care reform, the terms of the debate are beginning to becomeclear .Yetthereisgreatconfusion,evenamongsupportersof fundamentalhealthcarereform,aboutthealternativesandissues involved. Single-PayerReform The starting point for most progressives, the gold standard for health care reform, is what has been called singlepayerreform .Essentially,thisdescribesatransformationinthefinancing of health care so that funds are collected from taxes instead of from a mixture of individually paid and employerunderwritten insurance premiums, co-payments, and deductibles, and payment is provided by a single entity. In many respects, proposals for a single-payer system resemble Medicare, but most envision the elimination of the 20 percent co-payment thatMedicarerequires.Mostwouldbefullyfundedbytaxesrather than through a mixture of taxes and individual contributions. These measures are embodied in the following bills: HR 676 (the leadingpieceoflegislation,introducedbyRep.JohnConyers),HR 1200(sponsoredbyRep.JimMcDermott),andS703(introduced bySen.BernieSanders). A single-payer program has special appeal because it would add little or nothing to our nation’s overall health care expenses while providing truly universal care. Although taxes and direct governmentspendingwouldgoup,thiswouldbemorethanoffset by a drop in business and personal expenditures because of the elimination of the administrative waste inherent in our existing balkanizedhealthcaredeliverysystem.Savingswouldappearimmediately from the elimination of advertising, marketing, exorbitant executive compensation ($124 million for United Health Care’sCEOin2004),“product”development,andduplicativecorporatebureaucracies . Beyond the savings from elimination of this corporate waste, a single payer plan would save billions by streamlining the interactionsofproviderswiththeinsurancesystem .Ashighlightedinthe academicjournal“HealthAffairs,”arecentRobertWoodJohnson Foundationstudyrevealedthatdoctorswastebetween$23billion and $31 billion annually while interacting with various health plans, a cost that would be sharply reduced if providers could interactwithonlyasinglepayer . The savings go further still: with a comprehensive national health program in place, there would be no need for Medicare, Medicaid, SCHIP, FEHBP, CHAMPUS, or other categorical health care programs. With the medical component no longer needed, costs of other types of insurance (auto, homeowners, workers’ compensation, malpractice, etc.) would decrease; the scope of corporate human resources operations would diminish; and a central component of labor relations conflict would be resolved . TheRealityofHealthCarePolitics Whether because of inertia, the pull of corporate lobbyistsandtheircorruptingmoney,oraphilosophicalbeliefthat theprivateinsuranceindustryshouldbepartofournationallandscape , all the leading plans to reform our health care system include a prominent role for an ongoing private insurance industry. Although there are several pieces of legislation in the Congress that would bring about a single-payer health finance system, politicalsupportisthin.TheleadingbillintheHouse,HR676,has never had more than ninety-three co-sponsors, while the Senate incarnation,S703,hasnotasingleone. So far, most of the focus on health care legislation has been in The Health Care Battle Lines OP-ED BY AARON M. ROLAND Moving from Yale Law School and legislative politics to a career as a family physician, Dr. Roland’s twenty years on the front lines of medicine have led him back to political advocacy. Follow him on Twitter @doctoraaron. J U LY / A U G U S...