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 have made progress in reducing the 47 million uninsured in this country, 770,000 who lived in Maryland. Medical cost inflation has slowed to 1.68%, the lowest in 50 years. The private insurance market has become more equitable and less risky for most. States that chose to participate, including Maryland, have expanded Medicaid, and can still, if they choose, experiment with public options. Costs to individuals have been restrained, 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 has been done, for those residents in states which have joined the system.
Until this year, that is, when the assault of the morally bankrupt Republican Party attempted, time and again, to “repeal and replace” the ACA. They failed, awakening millions of Americans to their ongoing banditry, and a sudden appreciation of the government’s concern as manifested in Medicaid. No one thought that program was popular, but it is.
Now the Republican tax bill threatens the ACA, as well as the imposition of severe cuts to Medicare beginning next year.
Still -- What we do not have is Medicare for All or a public option.
- We spend 18% of GDP on health care, $3.3 trillion, 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.
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.” 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.
But what can we do, now, in Maryland? When Vermont attempted to institute a state single payer plan, which requires the employer-based plans to be folded into it, they ran into the marketing problem of convincing both consumers and businesses that the “taxes” (actually, premiums) that consumers would pay to the state would be less than the premiums they and their employers pay now, with the employer tax benefit included. Such a plan would free business from the burden of providing a product for which they are unqualified, frees them from reducing wages to offer that benefit, allows the consumer the freedom to change jobs without financial penalty, and would result in lower net costs overall. But since the voter would not see the loss of insurance premiums and the rise in wages as connected to the increase in taxes, which have become anathema since the Republicans started down the road to plutocracy, that roadblock killed the effort.
In the meantime, we can join in the movement to care for those residents who don’t qualify for Medicaid, and can’t afford premium ACA policies. The process is called the “Silver Switcheroo,” which would drive federal funds into the basic Silver benefit plans, and we can augment it by piggybacking the state on top of the existing law. This would greatly benefit the Maryland treasury, and would also be less costly than instituting a “Medicaid-for- All” plan, which would work for consumers, but cost the state much more.
I will do what I can to change the culture, and message to the voters of Maryland that the best plan is the plan in use throughout the post-industrialized world. As we work towards Medicare for All, I will do what I can to protect Maryland from further attacks from the Republican kleptocrats and fascists on the Hill and the White House to gut our communal health care. It will take some political courage to start down this road, but the destination is well worth the journey.