A Bowlful of Vinegar
In “A Spoonful of Sugar” [Feb. 13], his review of Paul Starr’s book on healthcare reform, Bernard Avishai says I have been “hammering away” supporting policies insurance plans could use to control costs. Not so. I have never championed such marginal remedies, because I believe the main causes of the US system’s excessive costs are elsewhere—in its commercialized investor-owned organization and in its incentives to maximize income. For-profit private insurers generate huge unnecessary costs, as does the fee-for-service system.
I advocate replacement of private insurers by a public, tax-supported single payer, and replacement of fee-for-service by prepaid universal entitlement to comprehensive care in a not-for-profit system. The elimination of billing and collecting avoids excessive overhead costs and prevents the rampant fraud afflicting the present insurance-based system. But it also requires providers to accept global payment, reimburse physicians largely with salaries, and support multi-specialty groups in which primary care doctors collaborate closely with specialists. Organized care like this outperforms private practice and is expanding.
Avishai and Starr dismiss the possibility of such transformation, but a rapidly growing number of physicians are choosing employment in multispecialty groups, and physicians’ support of major reform is gaining. Furthermore, employees insured at work now realize how badly the system is broken when they must contribute more to their medical costs and receive fewer benefits. They, too, may soon be ready for major change.
The Affordable Care Act took a step toward reform by expanding and improving coverage, but it still relies on private insurance and fee-for-service, so it will not control rising costs. We should not give up on the further reforms so urgently needed.
ARNOLD S. RELMAN, MD, professor emeritus of medicine and social medicine, Harvard Medical School; former editor, The New England Journal of Medicine
New York City
Bernard Avishai portrays progressive critics of Obama’s healthcare bill as hopelessly naïve and out of touch with political reality. But intimate acquaintance with medical reality drove the criticism from us and our 18,000 colleagues in Physicians for a National Health Program who advocate single-payer. As doctors, we’re too cognizant that the plan will leave 23 million uninsured and thousands dying each year from lack of coverage; do nothing for our insured patients with coverage so skimpy that serious illness would lead to bankruptcy; strip tens of billions from safety net hospitals; and let medical costs continue to skyrocket, leaving Medicare and public workers’ coverage open to savage cuts. Whatever its political merits, the bill is a failure in medical terms.
If anything’s naïve, it’s Avishai’s faith in cost savings from generalizing the Mayo Clinic model (Mayo shuns uninsured and Medicaid patients—and Medicare at some clinics—and was dropped from two big insurers’ networks because of its high costs) and from standardized and computerized billing. Computer firms have been promising paperwork savings for forty-six years (see the 1966 video at youtube.com/watch?v=t-aiKlIc6uk), but they haven’t materialized. He also seems unaware that hospital billing has been standardized and computerized for years (they all use the same ICD coding system, the UB82 billing form). As our studies in The New England Journal of Medicine have shown, single-payer reform could eliminate about $400 billion wasted annually on insurance overhead and billing paperwork; the reforms Avishai lauds will save bupkis.