My former chief of medicine, and the former editor of the prestigious New England Journal of Medicine, Dr. Arnold Relman, said that “our health policies have failed to meet national needs because they have been heavily influenced by the delusion that medical care is essentially a business.”
All efforts over the past forty years, both on federal and state levels, have made this assumption, that medicine is a market in the classical economic sense. And this assumption was fortified by the monetization of health care with the establishment of Medicare and Medicaid in the 1960’s alongside the growth in employment-based health insurance. The resultant explosion in the number of physicians, the growth in basic and applied research, the development of new drugs and surgical devices and court rulings applying anti-trust law to physicians and hospitals, reinforced the sense that this brave new world was a “medical-industrial complex.”
The Affordable Care Act, now called, both honorifically as well as pejoratively, Obamacare, is a private market-based attempt, modeled on the Massachusetts plan first introduced by a Republican governor, to repair the current broken model. We are working to reduce the 47 million uninsured in this country, 770,000 who live in Maryland. Medical cost inflation has slowed to 1%, the lowest in 50 years. Beginning this January 1st, once the system is repaired and online, major changes will be enacted, making the private insurance market more equitable and less risky for most. States that participate will be able to expand Medicaid, and also experiment themselves with public options. Costs to individuals will be capped, insurance company excesses reined in, spending on marketing and administrative costs capped, community centers expanded, preventive care emphasized, the Medicare “donut hole” filled. A lot of good will be done, for those residents in states which have joined the system.
What we do not have is Medicare for All or a public option.
- We still spend 17% of GDP on health care, twice as much as our closest allies, and have much poorer health as measured by many statistics.
- We do not have real competition, or more than a hope that increased private competition and greater use of technology will bring down costs.
- We do not have a no-fault malpractice system which would free physicians from practicing defensive medicine.
- We do not yet have an alternative to fee-for-service care.
But it’s a start.
The ultimate goal, which we can encourage with leadership here in Maryland, is a national, tax-supported universal system with the state as a single payer - “Medicare for All.” Vermont is instituting such a plan, with California close behind. Taxes are not evil; they are the cost of doing the people’s business in a civilized society.
Universal coverage would allow physicians to retain their autonomy but with incomes now derived from the non-profit model of pre-paid health coverage for all. They would be relieved of the burden of paperwork and petty bureaucratic control, and would be subsidized to transition to an all-electronic record-keeping system (EMR) which would improve the quality of care, including the development of electronic patient health records (PHR).
Private insurance companies would continue to provide benefits for elective procedures not covered under the basic policy, and physicians would be free to provide those same services, as they now do.
Surveys show this is what the large majority of Americans wants, including nearly 60% of physicians as well. Businesses, too, would benefit by un-tethering from the competitive necessity to compete by providing health insurance, about which they know little. We need to encourage everyone - consumers, physicians, nurses, hospitals and insurers - to bring such a plan to fruition.
I will begin by sponsoring legislation to offer a public option here in Maryland, beginning with coverage options for state active and retired employees, Medicaid, and the new high-risk pool. Maryland has long had a unique Medicare waiver, allowing us to become the nation’s only all-payer hospital rate regulation system. Now, under the Affordable Care Act’s Innovation Center, we are leading the nation in payment reform by paying for hospital care on a per capita, rather than a fee-for-service, basis.
Maryland can lead the nation in providing quality, affordable health care to all its citizens. It will take some political courage to start down this road, but the destination is well worth the journey.