Why Single-Payer Health Care Can't Work

[okarol]

Why Single-Payer Health Care Can't Work
James Anderson  AUG 11, 2009 11:40 AM
Why Single-Payer Health Care Can't Work    
           
      Some say this system would lead to rationing. They're right.

The visceral reaction to the Town Hall meetings on health-care reform leads me to believe that a lot of Americans feel that any single-payer system will inevitably lead to health-care rationing. And I couldn’t agree more.

Way back in the early 1980s, I started out as a pharmaceutical/biotech analyst. Back then, I was frequently asked to talk at small meetings of clients at local offices of the regional brokerage firm that I worked for.

These clients were mostly small-business owners and a big issue was dealing with health-care expenses for their employees. I'd start out the talk with a quote from the retiring first Minister of the UK National Health System. (I've tried googling him and the exact quote, but it doesn’t come up.) The quote is simple, direct, and as pertinent today as it was back in the 1950s and was very simple: "The demand for free health care is infinite." They all got it.

The people protesting now all get it. They all understand that free health care will lead to rationing. Rationing isn't starving to death, it’s “You need a hip replacement -- no problem. But the waiting list is 3 years. In the mean time, limp.” Check out the waiting lists in Canada and the UK, if you don’t believe me. If you want understand real rationing, in the UK, kidney dialysis isn't offered to people above a certain age.

There are simply not enough doctors in the US to allow everyone to have a personal physician. In reality, we do have health care for everyone, but it’s for acute health problems, not chronic problems. If you fall and break your wrist and you go to an emergency room, you get treated whether or not you have insurance. The chronic problems -- diabetes, high cholesterol, high blood pressure, and so forth -- occupy much of the time a family physician spends with patients. Most of these conditions have had significant advances in treatment through prescription drugs, so let’s review some of the breakthroughs from the past 30 years.

The first breakthrough was Tagamet, the first antacid that actually reduced the production of stomach acid. Smith, Kline & French -- now GlaxoSmithKline (GSK) -- won FDA approval in 1979, and the number of people who had to have surgery for stomach ulcers rapidly declined. I believe stomach ulcer surgery was in the top-10 most frequently performed surgeries back the 1970s. You rarely ever hear of one now.

The next breakthrough was in high blood pressure. Two new classes of drugs emerged -- ACE inhibitors and calcium channel blockers. Controlling high blood pressure became much easier with minimal side effects.

The final major breakthrough was statins -- other than antibiotics, the greatest life-prolonging drug class ever developed. Study after study show huge reductions in heart attacks and strokes from the use of statins -- Pfizer’s (PFE) Lipitor, Merck’s (MRK) Zocor and many others.

So, where does that leave us in 2009? All the breakthrough ulcers drugs are over-the-counter. All previously doctor-prescribed, now they can be purchased at your local drug store. The over-the-counter versions were approved at one-half the dosage of the prescription version. Private insurance won’t even pay for these ulcer drugs now. Our current drug-prescription policy in this country is all or none. If you have ulcers, go treat yourself. If you have high blood pressure or high cholesterol, you still need to see a full-blown doctor.

I have one more personal anecdote. A few years ago, taking my Zocor at night, I dropped the bottle (damn child-proof cap!) into the sink. I didn’t think I lost that many pills down the drain, but when I went to get a refill, the pharmacist said it was too early to refill my prescription, despite the fact that she'd never seen a statin abuser. Statin abuser. That comment stuck with me.

There aren't enough family doctors in this country to provide coverage to everyone. But there are many wide disease conditions that really don't require a full-scale examination by a doctor -- at least not initially.

The problem I see is that all levels of any prescription drug still require a doctor’s approval. Why can’t prescription drugs have approval levels? Why can’t we have clinics where a registered nurse or a physician’s assistant prescribe generic drugs at a minimal cost for high blood pressure or high cholesterol? Nobody abuses statins. After the first course of treatment, if it’s not working, then they'd have to see a physician.

To me, this seems to be a way to get coverage to people for the most treatable problems -- problems that if left untreated, would lead to very expensive treatments down the road that we'd all end up paying for.

Clinics could be set up to screen for high blood pressure and high cholesterol. I’ll call them “Chronic Clinics." You go in, get tested, and if you need treatment, for $5-10 you walk out with a 90-day supply of medication. Worst case scenario, you have to go to the drug store. Three months later, you go back. If your problem is under control, you get another 90 days and 3 refills, and you go back in a year.

Expanding the screening for diabetes or possibly glaucoma could also be done, but I'm not sure that a “prescribe and next” policy for those diseases would be as easy or safe as high blood pressure or high cholesterol.

I expect outrage from the American Medical Association if this idea starts to gain traction, but I fully believe that approval levels for prescription drugs could improve the overall health care for the uninsured public at a minimal cost, compared to the trillion-dollar proposals offered by the current bills in Congress.

A version of this article appeared yesterday in the Buzz & Banter section of Minyanville, and I got an email from a doctor and her husband, who happens to be the dean of a medical school. She said that she agreed with the concept, and that it was going to be impossible to ramp up enough new doctors for universal coverage.

That lead me to a final thought. Baby-boomer doctors are going to start retiring just as the baby boomers will start to need much more individual health care. Changes are inevitable for our health-care system, and it won't just be about who's covered, but also who provides it.
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http://www.minyanville.com/articles/MRK-PFE-GSK/index/a/23981

[paul.karen]

Good article.

Also good to see us crazy AstroTurf unamerican, self hating, president bashing, Nazi loving, self loathing Americans seem to have GOTTEN through to the president we dont want this.
He is backing off his proposed takeover of medicare much like he took over the financial field, the automobile field ect ect.

What Americans truly want is simple. tort reform cost controls and oversight.
Not a socialized America..

[Zach]

He is backing off his proposed takeover of medicare ...

But the government does run Medicare.

[Bill Peckham]

He is backing off his proposed takeover of medicare ...

But the government does run Medicare.

Shhhh it's a secrete

[Zach]

Shhhh it's a secrete

 

[paul.karen]

   was a slip i meant Obamacare.  You got me im far from perfect

Bill let me ask you a simple question.
Would you support a tort reform to help fix our healthcare system and do away 100% with the aspects of a single payer system.

[Bill Peckham]

  was a slip i meant Obamacare.  You got me im far from perfect

Bill let me ask you a simple question.
Would you support a tort reform to help fix our healthcare system and do away 100% with the aspects of a single payer system.

Ask people from Missouri if their medical premiums have gone down since their aggressive tort reform. I have no problem with tort reform but it doesn't get us where we need to go.

One idea I've heard on the right but not the left that makes sense to me is to take insurance regulation away from the states and put it under federal oversight while opening up state insurance markets to national organizations. That makes sense to me.

But that still doesn't get you to where our nation needs to be. Healthcare costs kepp doubling every 7 to ten years.

Another problem I've not heard much about is the way Medicaid is split 50/50 (it might be 40/60 not a Medicaid expert by any stretch) state/feds. This creates a framework that encourages bloat - for every dollar cut states get a dollars worth protest for 40 or 50 cents of savings. This has led to bloated Medicaid programs in many states.

This sort of system wide cost shifting is a problem throughout the debate. To cover the uninsured it is said that it'll cost about 100 billion dollars a year but if that was done the savings would go to cities, counties and states that now have to operate ERs as medical care of last resort.

People look at this and say the simplest way to get costs under control would be a single payer system, that is the system I would implement if I was in charge. It's compatible with private insurance in the same way public and private colleges work side by side, in the same market. As a country we're spending 2.5 trillion dollars on healthcare but it is spread between the Feds and the States and insurance companies and people who pay out of pocket. We could do the same job with less money under single payer.

However, single payer isn't on the table. That is disappointing and now in retrospect politically it is clear that is what should have been put forward as one option on the table. If the Republicans won't vote for any reform, even if they thought it would be a good idea (see Grassley's comments to Chuck Todd) then there is no point in catering to their talking points.

This bogey man of rationing is going on right now. Today. People with employer group health plans are denied coverage daily. Denied access to expensive treatments that are available under Medicare. These people with normal EGHP would benefit under a Medicare for all program (single payer) and the people with gold plated EGHPs would still have their gold plated EGHPs

To go back to the original article - that ulcer drug breakthrough happened outside pharma research groups. Pharma research is a joke. Epo and most other meds we seen that have been game changers resulted from underfunded research by a doc who had an idea. Instead of over paying for meds we should fund research directly. Overpaying for drugs - because research by pharma is expensive, or overpaying for hospital care because they provide charity care too is a prescription to running up costs.

One last point. Missing in all this cost analysis is the human toll that illness takes. Everyone on this board knows that price. What is the value of having your parents around, healthier? What is the value of being sick and not worrying how you'll pay for it? What is the value of not having to beg people to not call an ambulance because you know you can't afford it?

[rocker]

I find one really bizarre omission in this article.

The first breakthrough was Tagamet, the first antacid that actually reduced the production of stomach acid. Smith, Kline & French -- now GlaxoSmithKline (GSK) -- won FDA approval in 1979, and the number of people who had to have surgery for stomach ulcers rapidly declined. I believe stomach ulcer surgery was in the top-10 most frequently performed surgeries back the 1970s. You rarely ever hear of one now.

[..]

So, where does that leave us in 2009? All the breakthrough ulcers drugs are over-the-counter. All previously doctor-prescribed, now they can be purchased at your local drug store. The over-the-counter versions were approved at one-half the dosage of the prescription version. Private insurance won’t even pay for these ulcer drugs now. Our current drug-prescription policy in this country is all or none. If you have ulcers, go treat yourself. If you have high blood pressure or high cholesterol, you still need to see a full-blown doctor.

The author seems entirely unaware that one of the OTHER great medical breakthroughs of the last 30 years was the discovery that a majority of stomach ulcers are not "caused by" stomach acid, but by the bacteria Helicobacter pylori.

Antacids are not "the treatment" for most stomach ulcers, antibiotics are.  That is why ulcer surgery has declined.  That is also why many antacid makers suddenly applied for OTC status for their drugs...since these drugs now treat a symptom, and are no longer believed essential to treat the cause, prescriptions dropped off hugely and the profit margin was no longer there.  They had to try to make it up on volume, and these are now marketed as ordinary heartburn drugs, not ulcer treatments.

The author also fails to mention that the same Pepcid you buy OTC today for a few dollars cost many hundreds of dollars as a prescription.

Given that the author is apparently unaware (?) of this enormous milestone in ulcer treatment, and yet makes ulcer treatment one of the centerpieces of the article, it does make it somewhat difficult to take the rest of the article seriously.

[BigSky]

I am not sure that the subject of rationing is actually the boogy man. 

This stuff comes from what was passed in the stimulus bill.  Its when its vague and does not give exact details that lets government justify doing whatever it wants.


The Federal Coordinating Council For Comparative Effectiveness Research ("Federal Council").  (Section 9201 H.R. 1 Version of the Stimulus Bill.)

A fifteen member Federal Council (Stimulus Bill, p. 152.) 
This panel will be made up of Senior federal officials and was funded with over a billion dollars of the stimulus bill.

Stimulus, p. 464:  Federal Council will set cost effectiveness standards. 

Federal officials, not your doctor, could be setting what treatment is effective and worth and what is not.

What is the possible result of this?  Rationing.

[Zach]

Given that the author is apparently unaware (?) of this enormous milestone in ulcer treatment, and yet makes ulcer treatment one of the centerpieces of the article, it does make it somewhat difficult to take the rest of the article seriously.

Excellent point.