February 2006


In 1993 when President Clinton appointed his wife Hillary to head a committee to develop an all inclusive Health Care System, he did not expect a result that would enrich the insurance industry and exclude 47 million Americans.  Most European and Asian nations insure their citizens with reasonable success, but ironically, the United States, wealthiest and self advertised as the most advanced nation in the world still harbors 47 million citizens bereft of health insurance. England and Canada have single payer systems; Germany’s Health Care System inherited from Bismarck  over 100 years ago, modified by war and occupation still serves the nation through an inter linked series of Districts that form a national pool to which the wealthier contribute monies in order to subsidize the poor. East Germany when ruled by the Soviet Union had universal health care. The French enjoy a system similar to our Medicare except that everyone, not just those over 65 years of age is insured.


After months of arduous study, Hillary in conjunction with some of the “best” brains of the Public Health intelligentsia produced 1000 pages of complex plots and plans that was deemed unworkable and klutzy enough to be turned down by a Congress dominated by Democrats. Even now, 13 years later, she is derided for failing in the mission. But she didn’t fail entirely, because the plan became a model and signal to the insurance industry that a national fabric of HMOs in private hands would find little opposition by Congress, nor by the Administration, and certainly not by the insurance industry. The failure of congress to legislate the Hillary Plan gave free rein to the private sector, which launched the mess we have now.  As things stand, the HMOs, independent of the government, and draining funds that could better be used elsewhere, have created an ad hoc system guided by the mantra of Managed Care, which stands for Best Care for the Lowest Cost, (sort of an oxymoron, isn’t it?). The HMOs embracing Managed Care immediately bastardized the principle by establishing set aside funds, a pool of bucks to be paid to the doctor, minus money subtracted for each procedure, lab test or referral that the doctor orders. In other words, a monetary incentive or bribe of the primary care doctor to do less, render less care. Under HMOs and Managed Care the cost of medical care was supposed to be controlled and restrained. There were no savings becaue money ordinarily designated for heath care wne to salary the insurance industry.


In the US the wealthy can buy insurance, the very poor, the aged and prisoners get it for nothing. But people unlucky enough to be hard working and not too poor, sometimes labeled “Medically Indigent” more often than not cannot afford it.  


Hospital charges are so inflated that they invite chuckles of disbelief.  But the charges are really fantasies that are adjusted downward by Medicare and HMOs to a reasonable fraction of the bill. But the catch is that the uninsured, those who have the least available cash, must pay the full amount. This burden falls on self employed hard working people, often tradesmen, blue collar, or people in families holding several jobs in order to subsist; often the people without whom the country could not survive.


For years the AMA bleated repeatedly that  the government was out to Socialize Medicine, and “Socialized Medicine” was bad because it deprived people of their choice doctors. Doctors joined the chorus. Surprise! The AMA was right. We have been Socialized, not by government as the AMA anticipated but by enterprise. And guess what? The HMOsinsured do not provide a choice of doctors, except of course, for those in the restrictive panel offered to the insured patients.  All doctors are not equal, and under the present system, patients are deprived of the specialists that might best suit their needs.


The public is disenchanted, many are disenfranchised, doctors are disillusioned, reimbursement is sluggish, malpractice insurance is high and services that are reimbursed poorly tend to be discarded. For something as simple as urinalysis patients are referred to laboratories and costs are out or sight.   


 But there is a solution. Let the public choose.


The government ought to establish a Single Payer system, not to replace the HMOs, but to compete with them. A system that would care for all citizens rich or poor, the costs of which would be prorated according to the income of the client. It would be a system to which new medical graduates might want to gravitate.   It could be attached to the Veterans, the Public Health Service, or some other agency.


Marketplace capitalism embraces competition as something that levels the playing field between buyers and sellers. A Single Payer system competing for patients would force HMOs to pay attention to patient care rather than costs, and patient care generally would improve as HMOs develop models and practices that would force the single payer system to sharpen its medical practices. A “Single Payer System” competing with HMOS would assure that every American was insured for Health Care. It would have the potential to provide  the best care independent of cost. It could provide for cross referral between systems to gain certain efficiencies. It could correct inequities in the present system. Basically the two systems side by side, Single Payer and HMOs  could work as a self correcting  homeostatic feedback system.


Hooray for thermostats and cybernetics.