Scum of the Earth, Continued

05/25/2011 12:35 pm ET
  • Deane Waldman Physician, systems theorist and award-winning author

Two prior posts - "Who gains from billing?" and "Insurance companies = "scum of the earth?" - have finally gotten people to speak up. Many just vented and that is okay as long as we differentiate emotional catharsis from constructive dialogue. The thoughtful comments demand exploration.

"What insurance companies do is not what we want," wrote one Commenter. True, as patients. Insurance companies are, however, doing exactly what we want, as stockholders. Why do virtually all large pension plans own insurance stocks? Because they make money for you in your retirement.

Someone emphasized that a single payer has the power to negotiate and as individuals, we do not. Another scoffed at the "freedom to negotiate" position of Candidate McCain. It was suggested that negotiating leverage could control costs. Not true. It might control expenditures. Only the consumers - that is you and me as patients - by their behaviors and by their choices, only the patients can control costs.

(If you want an example of how a single payer can control "costs," look at what the Italian government has done. It has negotiated so-called "fair prices" for drugs and in so doing, it has virtually destroyed its own native pharmaceutical industry.)

Do you smoke cigarettes? Do you exercise regularly? How much do you weigh? Ever go to the ER with because of a fever or a rash? (Neither is an "emergency.") YOU generate unnecessary costs that everyone must pay. Negotiations will not change that.

The big issue among commenters was the presumption that, since I questioned the single payer concept, I was recommending self-financing of medical care, that is, no coverage of any kind. This would mean that no one would get care because no one could afford it. The commenters are wrong and right. Wrong: I never suggested that people should pay all their medical bills out of pocket. Right: under the "no-coverage" scenario, only the top 0.1% of the population could pay for needed medical care. For the record: me, my family, and every doctor and nurse I know is in the 99.9% group.

Several respondents wanted money entirely out of the equation. "Americans should have cradle-to-grave healthcare with no charge," wrote one person. Okay. No charge, but there still will be costs. Who pays? How much? Are there any limits? And most important, who will control those costs and how?

The financing of healthcare cannot be separated from the rest of the system. Systems thinking has given us one absolute certainty: you can never, ever, ever, ever, ever, ever [Did you see the movie Martian Child?] change one part of a system without having effects - many unintended and painful - on other parts of the system.

I hate being the naysayer. I prefer to put forth my positive recommendations rather than say what is wrong with the other guy's idea. BUT, all these suggestions about what to do - expand the VA system; implement a single payer system like Canada or Taiwan; adopt the Oregon Plan - presume that we know and that we agree about what healthcare should do. We do not - we neither know nor agree. That is why we need a nation-wide discussion: to achieve consensus on what healthcare should do. Only then can we talk about how.