STOP single-payer health care NOW

July 13, 2009

I’m sitting here in a hotel room in a Midwest city, listening to Kathleen Sebelius and a few Senators discuss and debate government-run health care with Wolf Blitzer on “State of the Union.” Prior to this segment, Blitzer’s show ran a couple of interviews with ordinary Americans who are out of work and in danger of losing any coverage they may have had. (For those of you who may be unaware, when you are separated from a job in which you were paying for your share of a health insurance plan of any kind, by law the employer must offer you the opportunity to continue to pay for that plan on your own. This is COBRA, the Consolidated Omnibus Budget Reconciliation Act, and it allows the covered to pay 100% of the premiums for up to 18 months to continue the same level of coverage he or she previously had. I’ve participated in it myself a couple of times, having been laid off from jobs four times in my career due to budget shortfalls. It can be expensive, but can also be cheaper in the long run than paying for a catastrophe,  like an auto accident or sudden cancer diagnosis, out of pocket.)  One interviewee said on camera, “We’re the only industrialized nation that doesn’t do this for its citizens….I say, don’t talk about it, do it!

For a couple of years now, I’ve been railing against the prospect of any government-run single-payer plan in this country. If you’re looking for a surefire way to run both the economy and the medical industry in the US right down the shit tubes, this is the best way to do it. Here’s why:

  1. People confuse universal health care coverage with universal health care. To be fair to the politicians and talking heads, for the most part they’re not the ones interchanging the terms. But many citizens are. Just because you have coverage does not mean you will be able to obtain care.  Artificially increasing demand without a concomitant increase in supply increases the value (i.e., the cost) of the item being offered. In both Canada and Britain, the result has been rationing of available medical services. This is tantamount to an increase in cost, the exact opposite of the desired result. The cost increase can sometimes be seen in terms of time rather than money:  Patients wait longer to see a doctor, with sometimes fatal results. (Canada: http://www.patientpowernow.org/2008/03/25/universal-health-care-kills/) (Britain: http://www.dailymail.co.uk/home/you/article-1114446/A-smear-test-saved-life.html, or just do a search on the name “Katie Brickell”) With rationing, because the government is paying for it, the government gets to decide when and what level of care you receive. This, tragically, is how Katie Brickell became famous. Let’s say you’re a 29-year-old female, and you and your doctor know there is a strong history of breast cancer in your family. You want a mammogram, or perhaps even a prophylactic bilateral mastectomy (a scorched-earth solution, but it does happen).  But government guidelines state that women don’t need baseline mammograms until 35. Guess what? You’re shit out of luck. “Oh, but exceptions could be made for compelling circumstances,” you argue. Okay. The compelling circumstance is the knowledge and experience her doctor possesses. This is the way care occurs now. Why do we need an extra layer of bureaucracy to achieve the same end result we now have? Who should decide whether you can have the mammogram: your doctor, you, or some unfireable GS-7  paper-pusher in Washington?
  2. There is already a nationwide shortage of both physicians and nurses.  There were, as of the 2006 census, 800, 547 physicians and 2,417,150 nurses in the U.S. (http://www.census.gov/compendia/statab/cats/health_nutrition/health_care_resources.html) The highest patient-provider ratios, not surprisingly, are in jurisdictions with both large populations and high costs of living, such as Massachusetts, New York, the District of Columbia, and my home state of Maryland, where according to this census there is one doctor for every 415 residents, and one nurse for every 847 residents. This is the third-lowest patient-doctor ratio in the country. On some other message boards I post on, others argue that the solution therefore is to train new doctors. Well, duh! Why didn’t I think of that?! Thinking like that should be in the “No Shit, Sherlock” section of the news. Consider: If there’s already a shortage of doctors, and teaching is one of the lowest-paying, lowest-prestige professions in this country (and it is), does it not also follow that there has been and will continue to be a shortage of medical faculty? (Everything I’m saying about medical education can be extrapolated to osteopathic and nursing education as well, so I’m not mentioning those just in the interest of avoiding redundancy.)  If government takes over all health care, all doctors therefore will be Federal employees.  According to the American Medical Association, in 2007 the average debt a new M.D. graduate emerged from medical school with was $139,517. (http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/medical-student-section/advocacy-policy/medical-student-debt.shtml) Now, if you’re a shiny new medical school graduate, and you’re looking down the barrel of debts that high, or higher, since that’s an average, would you want to accept a government job to pay that off? My guess is not. Most Federal hirees with first professional degrees go in at a GS-11 level, which currently begins at $49,544 at Step 1. Pretty puny, huh? Let’s say we jack them up to a GS-13. Ooo! They’re now eligible for a biiig $70,615 at Step 1. And that’s assuming the government would hire them straight out of medical school with no residency, which is unlikely. Now, we could bring them in on the separate GS schedule for senior-level, scientific and professional employees, which begins at $117,877.  Not bad. Let’s suppose we dump all the new American doctors, as well as the eventual foreign doctors who immigrate here, into that system at that salary, since that’s the only place they can go. Guess who’s going to pay for that? (see #4 below) So, knowing that you’d emerge from medical school with debts like this, and knowing that under a government-run single-payer system, your only career option was a government job, would you pursue that career path? I wouldn’t. Such a plan would actively contribute to a decrease  in the number of adequately trained physicians in this country. Not what we need right now. Nice going government, you just increased demand and decreased supply at the same time.
  3. The sharp decrease in provider supply will lead to an increase in less qualified providers. Some have suggested importing doctors from foreign countries. Okay, sounds reasonable on the surface. We already have many doctors here who got their medical education elsewhere. Let’s take a look at some of the requirements in foreign medical schools:
    France: Medical education in France comprises 3 years of basic medical science at the undergraduate level, followed by 3 years of hospital rotations and a residency of variable length. ( Ann Emerg Med. 1998 Jan;31(1):116-20)
    India: A medical degree in India is an undergraduate degree comprising  the basic clinical sciences and concomitant practical bedside training (http://www.indiaeducation.net/Medical/undergraduate/). Undergraduate degrees in India are three years in length. Graduate medical training can optionally be pursued.
    Russia: A medical degree in Russia is a five- or six-year program, similar to the duration of a pharmacy degree in the U.S., which could be five years for a bachelor’s degree or six years for a Pharm.D, which is currently the degree of practice. (http://www.medical-education-in-russia.com/medicaleducationinrussia.htm)
    Britain: Like India, a British medical degree is an undergraduate degree. Unlike India, however, study can last five or six years.
    Taiwan: Medical study in Taiwan is generally a seven-year program, with the last year being the bedside rotations.
    And those are just some of the most industrialized nations. That’s not counting the infamous “box top” medical schools, whose home countries I do not wish to mention, but if you’re reading this you probably already know whom I’m talking about (I’m looking at you, Ross University).  Here’s my point: No country in the world, not even the UK, has as rigorous a medical education system as the US. Virtually all of these foreign graduates require additional education and certifications, sometimes needing to repeat clinical courses or hospital rotations, to become licensed to practice in the US. And that’s not including the English language courses some of them would need to take. So, despite coming to this country hoping to ease a burden, they actually would contribute to it by needing at least some of the expensive education we require of our homegrown doctors. As well, here’s an oft-neglected aspect of this scenario: Some, including Mr. Obama and Mrs. Clinton, have suggested that the flip side of a single-payer plan be that everyone is required to carry insurance. (Obama backed off on this by suggesting that not everyone,  just every child, be required to have some kind of coverage.) That means that every immigrant doctor coming here hoping to ease the burden would be required to become part of the burden. Stated another way, they too would become mandatory consumers of the plan, before they gain the remedial education necessary to alleviate the burden. Again, this is a great way to cause an increase in demand while reducing the supply, since these new immigrants cannot help increase the supply of doctors until they get licensed and board-certified.
  4. You’re going to be forced to pay for other people’s insurance before you take care of your own family’s needs. This morning, Sebelius stated, “Well, I think we all bear a share of the burden for paying for this.” When she says “we all bear a share of the burden,” she’s basically talking about collective responsibility. That’s communism, folks. It’s the exact opposite of what this country was founded on. Kathleen, look at me and read my lips: NO, WE DON’T. Yes, bitch, I’m shouting. We don’t all bear the burden. Apparently, though, you would like us to. The only way to pay for a government-run single-payer plan is with taxes. In other words, folks, before you pay for your family’s basic needs with your take-home pay, taxes get taken out and used to pay for total strangers. Strangers who may not take care of themselves the way you do. Perhaps strangers whose health is a result of lifestyle choices you don’t agree with. Personally, I don’t care to pay for the medical care of some fat, chain-smoking teen parent who may have been drinking alcohol when she was pregnant, and her child(ren), in, oh, say, Alaska. Fuck that. I could see a situation where a taxpayer with religious objections to, say, alcohol consumption would resent being forced to pay for the coverage of alcohol-related illness. (Extrapolate that to AIDS or abortion and you can see the shitstorm brew right before your eyes.)
    “But other industrialized nations do it!” Yup.  And their take-home pay is much less than ours. The countries I hear touted the most as models of universal care, Sweden and Denmark, take a much bigger chunk out of paychecks to pay for that universal, single-payer plan they have.  A Danish take-home check is about 45% of gross wages earned. Forty-five percent. Sweden, 52%.  http://blog.canadianbusiness.com/take-home-pay-in-oecd-countries/, also http://www.fool.co.uk/news/Comment/2004/c040224e.htm
  5. Do you still really want a government-run cradle-to-grave health care system? And do you not mind paying for others? If so, fine. Move to Europe. Leave me and my paycheck out of it.

    (Post hoc 9/12/09: A poster to the comment boards at http://www.washingtonpost.com tipped us off to this insightful article in the Atlantic Monthly: http://www.theatlantic.com/doc/200909/health-care And I’m not just saying insightful because he agrees with me. He has the experience and economics chops to back it up.)

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