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.”

But is medical care a business, an industry? Nobel economist Kenneth Arrow has written about the “uncertainty” inherent in medical services. There can be no freedom of choice for a frightened, sick patient who knows little about medicine. There is no “Consumer Reports” for medical care, and even if there were, there would be no time to choose in many cases. Patients, therefore, depend on professional licensure which is a non-market mechanism. And there are other non-market mechanisms at work, including strict educational standards limiting physician supply, insensitivity to price, and, most importantly, the physician’s ethical obligation to put the patient’s welfare above her own profit.

The current market model is simply broken. We spend 17% of GDP on health care, twice as much as our closest allies, and have much poorer health as measured by many statistics. In spite of this payout, we have 47 million uninsured in this country, and 770,000 in Maryland. The cost is rising 7% per year, as most people with insurance are aware, with some policies growing in cost by 20-25% per year. In 2005 my personal, individual Carefirst policy cost $15,000!

We are all being held hostage to the Republican mantra that the market is the solution to every problem, and that personal choice will resolve this crisis.

So what can we do? We can experiment, using the federal system to put in place test projects as we now have in Illinois and Massachusetts. We can provide to all people the choices currently available to members of Congress. We can forbid the use of “pre-existing condition” exclusions so dear to the insurers. We can mandate that policies become truly portable. But given the failure of market-based solutions, including the introduction of HMOs over the past twenty years and the new health savings accounts more recently, we must go farther and work to replace the current inadequate system in its entirety.

We have taken valuable small steps during the past two years, led by Delegate Heather Mizeur, but those steps are just a beginning. The next step, which we can implement here in Maryland, is to expand the Maryland Children’s Health Program (MCHP) to cover all children, and extend the age of eligibility to thirty. That would close the gap for young adults who are no longer covered by their parents’ or their college’s policy but who cannot receive benefits when they begin work. We can overhaul medical malpractice, replacing it with a “no-fault” system, so that physicians will no longer fear lawsuits and will be able to learn from mistakes, and patients will be promptly compensated for their injuries, regardless of cause. Preventive medicine must be emphasized, particularly with respect to the prevention of obesity, which has now reached as far back as infancy, and evidence-based research should be accelerated. We can aggregate our drug purchases here in Maryland and drive costs down until we can revise the deeply flawed Medicare Part D and provide such purchasing power for the country as a whole.

But 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. We would not be paying rapidly increasing premiums nor covering all the hidden costs now present with 47 million uninsured, which makes the current chaotic system highly inefficient and reduces America’s global competitiveness. There would be no uninsured, and 22+% of every insurance dollar would not be wasted on marketing and other administrative costs. Doctors would 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 which would improve the quality of care. 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. We need to encourage everyone - consumers, physicians, nurses, hospitals and insurers - to bring such a plan to fruition. I have already heard that such a plan is “communist,” coming from people who have never met a communist, don’t know what communism is, and were born after communism imploded. It’s time we stand up, speak the truth loudly and clearly, and take back our state from those people.

In summary:

• Universal health care - beginning with children and young adults
• Complete patient choice
• Electronic record-keeping
• No-fault malpractice expediting payments to patients and encouraging physician education
• Serious emphasis on preventive medicine
• Leadership to move America to a single payer system supported by general revenues - “Medicare for All”
  
  • Universality
  • Continuity throughout life; coverage tied to people, not businesses
  • Affordability and sustainability through use of general revenues
  • Access to quality care
  • Greatly reduced bureaucracy for patients and physicians