Friday, November 17, 2006


Diversions and Deceits

Politicians, especially those lacking both spine and scruples, tend to avoid dealing with, or even talking about tough problems by diverting the public to another problem. An example of this is the nation's health care system. The system is broken. Hospitals are being forced to close their emergency rooms because they don't have the money to treat all the uninsured patients who use emergency rooms as their only source of health care.

There are several things that can be talked about and proposed as partial solutions. For example, we can talk about the meager funding that public hospitals receive from cash-strapped local governments. We can talk about the scandal of the large and growing number of people who don't have and can't afford health insurance. We can talk about establishing a single-payer organization to provide health insurance to all residents, with premiums adjusted to the person's income and a subsidy from government to make up the difference. There are other things we can talk about.

What do the spineless, unscrupulous politicians say? Many of them change the subject to the broken immigration system. The overcrowding of emergency rooms is a consequence of the great number of illegal, poor immigrants who have come here for low-paying jobs and free public services. Get rid of them and the emergency rooms will no longer be overloaded with freeloaders. Of course, there's no practical way of getting rid of all of the illegal immigrants. There are way too many of them. However, they make a convenient scapegoat. Illegal immigrants don't vote and don't have much money. They do not represent a political obstacle. More money for hospitals means less money for the police, fire protection, and other local government services. The public will become angry if the police or fire departments have to be cut back. A single-payer health insurance entity will be bitterly opposed by the insurance companies now in the profitable business of selling health insurance policies. Insurance companies can raise huge sums of money for political campaigns against those politicians who have the courage to advocate a change that will reduce the profits of the insurance companies.

I recently listened to an argument on a news broadcast. A man was complaining of the very high cost of the American medical care system. Our nation ranks in the 70's among the industrial countries in terms of the cost of health care and the benefits receive. That is, our costs are high and the benefits low compared with 70 or so other countries (e.g., Canada, England, France, Japan, Germany, Sweden, etc.). The interviewer asked the man whether he would favor a single-payer system, such as the one in Canada. The man replied that this country is not yet ready for that reform. What has to be done first, he said, is reduce the cost by eliminating some of the unnecessary tests and other medical procedures that American doctors prescribe and perform.

I don't know whether the man was a politician. However, what he said sounds to me like a diversion. The man did have one suggestion worth considering: let more care be performed by the primary care physician and less by specialists to whom the primary care physician now refers his patients. The man stated that too few medical students go into primary care compared with the number that go into specialties.

So, let us consider that suggestion. First, let's follow the money. Primary Care physicians have a financial incentive to refer their patients to specialists. If you've ever tried to make an appointment with a specialist yourself, you have to fill out a questionnaire about your health and the name of the doctor who recommended you to this specialist. The Primary Care physician gets a kick-back from the specialist. The more recommendations, the more kick-backs. Also, the more business for the specialist. Eliminating the practice of the kick-back would take away one incentive to refer a patient to a specialist.

Others (not the man in the interview just cited) have said that physicians try to avoid doing procedures that subject them to the risk of malpractice lawsuits. A physician might refer a particular patient to a specialist so that the specialist would have to risk the malpractice suit. A physician might refer a healthy by hypocontriac patient to a specialist for fear of being sued for not making the reference. The real problem in any such case is not the malpractice suit itself but the insurance premium the physician or the specialist pays to cover the possibility of a judgment.

Some politicians have attempted to reduce the damage awards for malpractice by imposing legal limits on the size of the award, particularly punitive damages. Nobody in office has dared go after the insurance companies for setting their premiums to cover their losses from bad investments rather than on a realistic estimate of future costs due to malpractice lawsuits.

I don't know how the Canadian system works in detail. It seems to me that the single-payer system might also provide insurance for the participating doctors. A doctor who was deemed to be guilty of malpractice could be dropped from the list of physicians eligible to receive payment for services provided.

I leave this rant half-done. I invite comments, especially from those who disagree with me.
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