Making a Case for a Single-Payer System
MANAGED CARE March 1999. ©1999 Stezzi Communications
A Conversation with Quentin Young, M.D.
Leaving health care in the hands of a market groping for direction is feeding a public outcry that this physician says is...
Quentin Young, M.D., is careful to point out that he doesn't oppose markets or organized health care systems. But Young, national coordinator for Physicians for a National Health Program, thinks that combining the two to create a market-based health system has been a disaster. He points to turmoil among for-profit health care companies and increased public sentiment for tighter regulation of managed care as signs that the current system is heading for a fall. He believes a single-payer plan should replace it.
Young's views are grounded in more than 40 years as a practicing internist, including a stint as chairman of the internal medicine department at Cook County Hospital in Chicago. In 1980, Young founded the Health and Medicine Policy Research Group as an advocate for poor and medically underserved residents of Chicago. He is immediate past president of the American Public Health Association.
A long-time activist, Young recently shared his thoughts on health reform with Senior Contributing Editor Patrick Mullen.
MANAGED CARE: After the Clinton health plan failed in 1994, a lot of politicians concluded that large-scale health reform is impossible.
QUENTIN YOUNG, M.D.: That is the prevailing wisdom.
MC: Another piece of prevailing wisdom today is that market-based health care is here to stay. What's your view of those two premises?
YOUNG: I believe both are flawed. We at the Physicians for a National Health Program advocate a national single-payer health system. Regarding the notion that this country can't have such a program, I defend the argument that we can't have anything but. It's the only solution, because of problems created by the transformation of health care into a corporate-dominated sector. I feel that we're on the eve of the failure of marketplace strategies.
YOUNG: There remain only three issues: cost, quality, and access, and the system is failing on all three. More than 43 million Americans lack health insurance, and a larger group has such poor insurance that a serious illness would wreck them. Those numbers are going up by an average of 125,000 per month. This was predictable. As costs went higher and competition got greater, it became less attractive for employers to cling ideologically to being the center of finance for health care. The paradox is that business, because of its honest and profound mistrust of government and its hostility to taxes, has clung to a task that is unique to America. In every other industrial democratic country, health care, on one level or another, is the responsibility of society, and usually that means government.
MC: Why are you confident that single payer would work here?
YOUNG: We have a spectacular health work force, with nine million of the best health workers at every level: scientists, technicians, specialists, doctors, nurses. The one major flaw is that we way overshot in training specialists. So physicians are 70 percent specialized, 30 percent primary care, and that's a burden. The case can be made for 60 percent primary care and 40 percent specialists, but certainly 50/50. There are all sorts of costs associated with the excess. Everything specialists do costs more. Just as anteaters eat ants, specialists do what they were specially trained for. It's a self-fulfilling arrangement that is very costly to the system. That phenomenon was one of the large stimuli for managed care replacing the old laissez-faire system. We certainly have the money for universal coverage. In 1997, the last year for which figures are complete, health care spending in this country reached $1,170,000,000,000. That is $4,005 for every person in the country, more than any other nation. The next country is Switzerland, at $2,400 per capita. Germany spends $2,300 per capita. Canada, with its universal system that has its flaws, spends $2,200.
MC: How is the present system irrational?
YOUNG: The irrationality is essentially a definition of the power of the forces that, for economic or ideological reasons or both, like the way things are. My thesis is that we're in a time of gathering dismay with the current system, a kind of a protophase.
MC: How is the dismay playing out?
YOUNG: First, the rush toward oligopoly, toward combinations of bigger and bigger companies, some of which have fallen of their own weight. Take these physician practice management organizations. Their collapse is a fantastic thing. It isn't as though we had a bad storm last week. Practices were disrupted. Organized medicine and the profession as a whole largely created the conditions for this catastrophic event in American health care. Then there is the accumulating, almost cascading public dismay with the system. The turning point came when the mainstream press ceased writing as if HMOs and the marketplace solution were foregone and immutable. Press coverage changed to something quite different, to a frontal critique. It started with the gag clause. A doctor with a gag on his face on Time magazine's cover is the kind of thing that captures the public's imagination. Since then, the press coverage has been harsh, although I don't necessarily think unfair. There's no more sense that managed care is inevitable or is the highest form of human health endeavor.
MC: Yet the political debate today is over ways to fix managed care. I don't sense much of a debate over broad national reform.
YOUNG: The main form of political protest has been the so-called "patients bill of rights," which is on the national agenda and a form of which I understand is in every single state legislature. Lawmakers pass a reform or a series of things, like giving women two days in the hospital after a delivery or 36 hours after a mastectomy. Even though I identify with those efforts and support them, they are not solutions. It's one of the bad fallouts from this whole era. It's a mistake to have 50 state legislatures and the federal government rewrite each state's Medical Practice Act, which says that medical practice standards are defined by the profession. That's a profoundly important professional ethic. There are characteristics of the medical profession besides having an M.D., such as peer review and guaranteeing a standard of practice. I would argue that the profession has honored many of these crucial social compacts, these commitments to society. Peer review and discipline of our colleagues who are incompetent or venal or criminal — and all those kinds exist — have only laterally gotten any attention, largely because of consumerist demands. That failure to guarantee the product was a prelude to the managed care event, as was the huge number of unnecessary operations as recently as the early 1980s. These elements clearly were grist for the managed care mill. Even as harsh a critic of managed care as I can say managed care plans had every reason to assault that misconduct and, to the extent possible, eliminate it.
MC: In your view, where did managed care head down the wrong path?
YOUNG: The fatal event was in the operation of the HMO Act during the Reagan years. It opened the doors to venture capital and corporate investment in health delivery, notably HMOs and hospital chains. From an investor's point of view, it was like a gold mine waiting to be tapped. The health system was very bloated, had no controls, and was inefficiently run. Most of the doctors who ran it were notoriously poor business people. Hospitals were run on a cost-plus basis, so the more inefficient they were, the more money they made. These arguments are legitimately made by many managed care proponents and I can't resist that part of the argument. They are absolutely right, but I hasten to point out that it doesn't make sense to put it in the marketplace.
MC: Why not?
YOUNG: Just as I don't oppose organized prepaid medical systems, I don't oppose markets. You'd have to be pretty doctrinaire and probably blind not to notice how market-based economies, product development, and production have spectacularly benefited this country. But in health care, based on my experience, it just doesn't make sense. Say the people who own the company, the investors or their designated executives, hire a prudent and efficient manager. The manager's goal, again putting the best face on it, is to deliver the best product for the least dollars to the clients, who usually are the employers who bought the health plan. The employer has an interest in a happy and healthy work force. On the plus side, a for-profit health plan is going to do more or less what the not-for-profit prepaid group practices did: Give the best product for the least amount of expenditure.
MC: And on the minus side?
YOUNG: Enter venture capital, and the people who have taken their hard-earned money and put it at risk. In keeping with the basic laws of Adam Smith, they want maximum profits. The pressures, then, are toward what can best be summed up as denial of care. The ways you do that vary greatly and are getting ever more sophisticated. There are some basic ways. One, you avoid sick people. That's documented in the experience with Medicare HMOs. Data underscore how people joining Medicare HMOs use less of the system even though they pay the median annual expenditures in their region. Another remarkable fact is that people who leave the HMOs become much higher utilizers. The system works to get rid of high utilizers. That is elementary good sense when the bottom line is what you're looking at. But it's the exact opposite of what a health system should do.
MC: How has market-based medicine changed patient-physician relations?
YOUNG: The biggest thing that I deplore is that it has adversely transformed the terms of engagement in the consultation room. This has happened in a very brief period. We're talking about 20 years max of high HMO reality. I'm invoking my long years of practice in Cook County Hospital Clinic, in my own practice in a middle-class neighborhood in Chicago, and in the variety of other venues where I've worked. There was, in that one-on-one environment, almost invariably an optimistic, hopeful, friendly, even affectionate mood. The doctor had your interest in mind and was going to try to help you — not always, not invariably, but that was the prevailing mood. That has been transformed. I don't mean 100 percent, but I do think that there's a growing feeling among patients that the doctor's interest can somehow become contrary to theirs. That is to say the doctor will make money or be rewarded for withholding care. I'm not arguing that it's universally true.
MC: But patients feel that it might be true.
YOUNG: That's right. That's what intruded. In the early days of the debate, the marketeers had a model of the health care consumer as kind of a kid in a candy store. The argument was that if you don't put economic barriers in front of them, they'll want everything. They'll want to have their appendix out every day, and prenatal care before they've become pregnant. The reality is, people don't like health care. If you're going to the doctor when you're sick, there's apprehension, there's nervousness. Did I have a heart attack? What's he going to be like? Is he going to hurt me when he examines me? If the patient learns happily that things are going to be all right, there are still those needles and tubes and X-rays. Thank God, we doctors have convinced the public that health care may be a way of achieving health, or at least diminishing illness and relieving pain and suffering. That's the basis of the compact between doctors and patients. The notion that people, if given a chance, would become gluttons for health care, was just fictional, up until recently. That has changed. Now we have patients actually demanding things because they think you're keeping them from them.
MC: So the bond of trust that patients have for physicians is being frayed.
YOUNG: The irony is that what the market people were saying all the time has come true — thanks to them. They created the aura and the structure of denial. You can't go to a consultant until you get approval from somewhere.
MC: How do you think a single-payer program would change that?
YOUNG: First, you would get rid of the absolutely useless mountain of paper that has inflicted the American health system. That mountain was growing even before the marketplace thing, just from the plethora of insurance companies and their motivations to be accurate or to avoid payment or whatever the purpose. Making this system work requires that an enormous work force be dedicated to nonproductive work that costs somebody something. Eliminating that would be a huge saving, not to mention the saving in Sturm und Drang.
MC: When Canada's system is held up as an example, its critics respond by pointing to such things as long waits for elective services. The argument boils down to the view that it does not work there, and it would not work here.
YOUNG: The first downside is one you didn't mention. It's the abuse that's inherent if doctors get paid for everything they do. All you have to say is, "I saw Jimmy Jones and did this and that for him. Send me the money." In this case, I would hope physicians would take responsibility, the absence of which contributed to the imposition of managed care. Also, in a single-payer system, a doctor who is gaming the system is taking money out of all his honest partners' pockets, because there is only so much money. So the colleagues would have an economic motivation, in addition to ethical and professional ones, to prevent that. The system would work to prevent it.
Say you have a physician — we'll just arbitrarily set some criteria — a GP in Calgary, with a panel of 2,000 patients. The age, gender, and illness profile of each patient is easily computerized, and would predict how many electrocardiograms that doctor should do, how many hospitalizations, and so on. Let's use the example of electrocardiograms. If he does a lot of ECGs, he makes a lot of money. Let's say the profile suggests he does 350 a year. Two months into the year, he has already billed for 150. For that kind of variation, he might be called by the Health Ministry and told, "You seem to be running a little high. Do you have an explanation?" I am told that on occasion he or she can end the discussion right there. "I admitted 10 people to the hospital with arrhythmias and they need frequent ECGs and I can document this." If there is not a satisfactory answer, the doctor is invited to meet with a group of his peers appointed by the medical society of Alberta. It's not an inquisition or a grand jury panel. He will be reviewed by GPs who are, we hope, leaders of their profession. Every two or three weeks, they meet and listen as doctors make their cases. They can conclude that a case is reasonable or unreasonable. Let's say they find he made some blunders. He's not shot. They know him. These are his peers. He is urged to take a refresher course in ECG, or maybe get more consultation from his colleagues. The point is that there are prudent ways to control a great deal of the excess we see now, mostly using professional peers.
MC: Let's talk a bit about the politics of health reform, past and present. Give us your post-mortem on President Clinton's reform effort.
YOUNG: Clinton's finest moment, possibly his only fine moment, came when, before both houses of Congress, he held up his pen and said, "I want you to send me a health care bill and I tell you I will not sign anything that is not universal." It was exciting, no matter where you stood, because he seemed to be putting the maximum weight and prestige of his office behind that commitment. And then nothing happened. It was almost a handbook on how not to get a popular mandate. You do not take 500 people, most of them government employees, and put them behind locked doors to come up with a 1,370-page monstrosity. You can't wisely write a bill on such an enormous area with so much detail. Every page invited another set of opponents, and Clinton got them.
MC: What did you think of the bill's content?
YOUNG: The idea had grandeur but it was wrongheaded. I had a lot to criticize about the actual bill. We at Physicians for a National Health Program were critical of it from the beginning. Our single-payer proposal has a simplicity that was starkly absent from Clinton's proposal. Mrs. Clinton was asked why she didn't support single payer. She responded, knowledgeably but wrongly, that it's the best way but it's unfeasible politically. There's a huge irony in that. How feasible was their laboriously put together plan? It couldn't even get out of committee.
MC: How could the Clintons have done things differently?
YOUNG: Instead of working from the premise of feasibility, the president and his wife and the congressional leaders could have had a strategy for victory, by backing the single-payer bill introduced by Rep. Jim McDermott. It had 95 cosponsors in the House, and I would venture the president's support would have picked up another 50 or 60. It would have been defeated in the House by about 235–200 or something like that. In the Senate, with five sponsors, it might have gotten 10 votes. We would have come to the 1994 elections with a very different script. Here's a president who promised universal health care. His bill was defeated by a coalition of Republicans and conservative Democrats, thanks to lobbying by the insurance industry and the American Medical Association and all the rest. Clinton could have said in 1994, "This is it, American people, I want you to give me a Congress that will pass this bill." Rather than the 1994 debacle for the Democrats, he might have gotten a mandate for national health reform.
MC: But that didn't happen. What's your political road map for reform today?
YOUNG: Increasingly, I think we're going to get universal coverage in one or two states, and they may not be the most liberal states, however you define that. Here in Illinois, we have a tailwind behind a proposal to enact a constitutional amendment, the Bernadin Amendment, which is not a commitment to single payer, but to universal coverage. Joseph Cardinal Bernadin [the former Catholic archbishop of Chicago], a highly regarded cleric who died quite graciously from a terrible pancreatic cancer in 1996, wrote and preached extensively on the health matter. He addressed, by invitation, the AMA House of Delegates, Harvard Medical School, and others, and he wrote magnificent pastoral letters on it. Obviously, he wrote from a moral and ethical viewpoint, but also from a good old-fashioned health policy viewpoint. He said, to roughly paraphrase, that health care is so vital to human dignity that society has a responsibility to find health care for all people. In other words, health care is a human right. A lawyer who was at a memorial on the first anniversary of Cardinal Bernadin's death teased a version of what I just said into a proposed amendment to the state constitution.
MC: What would push states to enact universal coverage?
YOUNG: As much as I'd like it to be, change won't happen out of altruism or high moral purpose. It will happen out of stern economic necessity and stern health care need. We're going to see an intensification of the failings of the present system. These include failing to actually deliver care, and the result, for instance, will be that you get a lawsuit because the mastectomy wasn't done in time because the lump was ignored. Look at how many major companies have backed off of Medicare HMOs. Not least is the debacle that's assaulting the hospital chains, with Columbia/HCA in the lead. They are still looking at indictments charging billions of dollars of fraud. This is not peanuts, where you just settle and go on. These are destabilizing events. The change will be political in part. You wouldn't need 250 people elected to Congress on the basis of this issue, but you would need 20 or 30 to win for it to become an issue. Pressure for health reform, a kind of maturing of the reform demand, which was a kind of a wail in the wilderness, is now becoming politically pertinent.
MC: Thank you.